The Latin expression primum non nocere (“above all, do no harm)” is perhaps the most misattributed, misunderstood, and misused expression in medical ethics. It is usually attributed to Hippocrates, yet it appears nowhere in Hippocratic writings. The closest ancient statement is probably “To help, or at least, to do no harm,” which appears in the Hippocratic corpus, in Epidemics, Book I, Section XI. The specific phrase primum non nocere is, in fact, not of ancient origin at all, but has been attributed to the seventeenth-century physician Thomas Sydenham [1]. The phrase was first used by a surgeon, L.A. Stimson, MD, in the late nineteenth century, and was in common usage by the turn of the century [2].
A more substantial problem with the Latin phrase, however, is that it advocates the impossible. Virtually every medical encounter, diagnostic procedure, or treatment is harmful to a greater or lesser degree. The expression is particularly inappropriate in the context of surgery, because surgical interventions nearly always begin with traumatic injury to the patient in the form of an incision through skin or mucous membrane. A more appropriate aphorism for both surgery and medicine would be: “Above all, do more good than harm.” An expression of this kind might be considered by some surgeons to lie at the heart of surgical ethics, but I believe it to be a corollary to the foundation of all medical ethics, as stated in the American Medical Association Code of Medical Ethics: “A physician shall, while caring for a patient, regard responsibility to the patient as paramount” [3].
A recent study compared the surgical with the medical literature, looking at the subject matter of the papers published in 12 surgical and 15 medical journals. The authors found, among many thousands of articles, that substantive discussion of an ethical issue could be identified in 2.7% of articles found in medical journal articles and in only 0.6% of those found in surgical journals; that is, ethical matters were discussed more than four times as often in the medical literature as in the surgical literature [4]. Why do surgeons consider ethical issues less frequently than other physicians in their publications and, presumably in their professional meetings? One well-known surgical educator put it this way: “The difference between surgeons and internists is that surgeons practice ethics, while internists mainly talk about it” [5].
Regardless of its origins, the gap may be narrowing, at least in cardiothoracic surgery. In recent years, there has been increasing interest in discussing ethical issues in both the CT literature and at CT meetings. Some of this has been due to the efforts of the Ethics Forum, which was established in 1999 for the purpose of encouraging education in ethical issues for cardiothoracic surgery. It comprises members of The Society of Thoracic Surgeons Standards and Ethics Committee and members of The American Association for Thoracic Surgery Ethics Committee. From 2000 to 2005, members of the Ethics Forum published 113 articles on ethical topics in the surgery literature, many of which are touched upon in this issue of the Thoracic Surgery Clinics.
The issue is divided into three sections: Clinical Ethics and the Surgeon at the Bedside; Bioethics in Health Care Policy; and Biomedical Research Ethics. The section on Clinical Ethics and The Surgeon at the Bedside begins with Jones, McCullough, and Richman discussing consent (“Informed Consent: It's Not Just Signing a Form”). They review the fundamentals of informed consent, how the requirements for consent are best met, and the process of consent under special circumstances, such as compromised or limited capacity to make decisions, dealing with conflicting professional opinions, surrogate decision making, and the flip side of informed consent for surgery: informed refusal.
Jay Jacobson (“The Effect of Patients' Noncompliance on Surgeons' Obligations”) explores the circumstances under which surgeons have specific obligations to care for noncompliant patients, as well as suggesting ways to identify such patients and to work with them effectively to make the relationship less onerous.
Reynolds, Cooper, and McNeally (“Withdrawing Life Sustaining Treatment: Ethical Considerations”) describe the difficult and morally troublesome aspects of withdrawing life support. They suggest ways to manage withdrawal of life support appropriately, through understanding the limits of treatment, expertly using palliative measures, communicating clearly with patients and families, and carefully orchestrating controllable events with compassion.
Francis Lee builds upon the preceding paper in his discussion of withdrawing life support in a special context: that of futile care (“Postoperative Futile Care: Stopping the Train When the Family Says ‘Keep Going’”). After pointing out the difficulties in the definition of futile care, he discusses the conflicts that may arise when a surgeon believes that further life support should be withdrawn because it is not medically indicated and the family disagrees; describes how to negotiate conflict by discovering and understanding the values that drive the family's viewpoint; and asserts the ultimate irrelevance of fears about lawsuits when making decisions in the context of conflict.
In his article “Ethical Issues in Patient Safety,” Lucian Leape brings us up to date on the current status of a field he virtually created over 25 years ago—dealing with medical and surgical errors and injury to patients. He begins with the ethical imperative to prevent errors and injury insofar as it is practical, then describes the necessity to search for new methods to prevent recurrences when errors are made, the ethical and practical necessity to be honest and open in dealing with patients, and taking responsibility both as individual surgeons and as a profession for ensuring that our surgical colleagues practice competently.
The section on Bioethics in Health Care Policy begins with a discussion of one of the major problems with public policy in the nation: how to provide health care for uninsured patients. John Goodman applies the do-no-harm principle to this problem in his article “Solving the Problem of the Uninsured” by showing the harmful effects of some of the nation's health care policies and suggesting ways to fix the system by converting some of those harms into goods.
Virtually every aspect of hospital practice and office practice has been affected by the implementation of HIPAA regulations over the past few years. Peter Angelos, in his article “Compliance with HIPAA Regulations: Ethics and Excesses,” describes the well-accepted ethical foundations upon which most of the regulations are based, and attempts to quell the anxiety that many surgeons feel about disclosing patients' private information, fearing transgression of legal requirements that may subject them to substantial penalties or lawsuits.
The first transplant of a kidney was accomplished in December 1954, between identical twins. Living donors now provide several organs other than kidneys for transplantation, such as lobes of livers and lungs. In their article “The Ethics of Living Donor Lung Transplantation,” Wells and Barr describe the special ethical considerations that are engendered by the risks of these procedures, which can be substantially greater than those of kidney transplantation.
In his article “Conflicts in the Surgeon's Duties to the Patient and to Society,” Neil Farber describes a wide range of conflicts surgeons face between their obligations to individual patients and their broader obligations to society. He provides a model of analysis that may help in creating guidelines, as well as a mechanism that surgeons can use in balancing competing values when making a decision under such conflicts.
Grant and Iserson analyze the impact on patients of gifts to surgeons from pharmaceutical and device manufacturers. In their article “Who's Buying Lunch? Are Gifts to Surgeons from Industry Bad for Patients?”, they present a strong case based on a great deal of indirect evidence that patients are indeed harmed by gifts to physicians from industry. They suggest that banning such gifts would not completely resolve the ethical problem, and they suggest a different, more effective solution.
In the section on Biomedical Research Ethics, Franklin Miller looks at aspects of surgical research that are distinct from those of other kinds of biomedical research. In his article “Ethical Issues in Surgical Research,” he discusses such issues as the fuzzy boundary between innovative surgical practice and surgical research, the special problem with control groups in surgical trials, and nettlesome issues of informed consent for surgical research.
Haavi Morreim discusses the differences between clinical trials of surgical devices and drugs in her article “Surgically Implanted Devices: Ethical Challenges in a Very Different Kind of Research.” She uses the AbioCor, a totally implantable heart replacement device, to highlight the differences between device trials and drug trials, such as much smaller numbers of subjects, incremental innovation within device trials, and limited possibilities of double-blinding, randomization, and placebo controls. She demonstrates convincingly that research on devices is, indeed, “a very different kind of research.”
In presenting this collection of articles, we hope to achieve several goals: to stimulate CT surgeons to think analytically about their decision-making processes; to show that ethical considerations inform and motivate us in virtually every aspect of our day-to-day professional activities; to demonstrate that ethical thought and deliberation have a crucial role to play in developing health care policy; and to highlight the special characteristics of clinical trials in surgery that make them in some ways unsuitable for the theoretically ideal methods of research that we learned in medical school. In striving for these goals, we hope in some small way to help surgeons to increase the first and decrease the second objective in the not-so-ancient aphorism “Above all, do more good than harm.”
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