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KEY POINTS

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  1. The physician should document that the patient or surrogate has the capacity to make a medical decision.

  2. The physician discloses to the patient details regarding the diagnosis and treatment options sufficient for the patient to make an informed consent.

  3. Living wills are written to anticipate treatment options and choices in the event that a patient is rendered incompetent by a terminal illness.

  4. The durable power of attorney for healthcare identifies surrogate decision makers and invests them with the authority to make healthcare decisions on the patient’s behalf in the event that they are unable to speak for themselves.

  5. Surgeons should encourage their patients to clearly identify their surrogates early in the course of treatment.

  6. Earlier referral and wider use of palliative and hospice care may help more patients achieve their goals at the end of life.

  7. Seven requirements for the ethical conduct of clinical trials have been articulated: value, scientific validity, fair subject selection, favorable risk-benefit ratio, independent review, informed consent, and respect for enrolled subjects.

  8. Disclosure of error is consistent with recent ethical advances in medicine toward more openness with patients and the involvement of patients in their care.

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Dedicated to the advancement of surgery along its scientific and moral side.

June 10, 1926, dedication on the Murphy Auditorium, the first home of the American College of Surgeons

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WHY ETHICS MATTER

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Ethical concerns involve not only the interests of patients, but also the interests of surgeons and society. Surgeons choose among the options available to them because they have particular opinions regarding what would be good (or bad) for their patients. Aristotle described practical wisdom (Greek: phronesis) as the capacity to choose the best option from among several imperfect alternatives (Fig. 48-1).1 Frequently, surgeons are confronted with clinical or interpersonal situations in which there is incomplete information, uncertain outcomes, and/or complex personal and familial relationships. The capacity to choose wisely in such circumstances is the challenge of surgical practice.

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Figure 48-1.

Bust of Aristotle. Marble, Roman copy after a Greek bronze original by Lysippos from 330 b.c. [From http://en.wikipedia.org/wiki/File:Aristotle_Altemps_Inv8575.jpg: Ludovisi Collection, Accession number Inv. 8575, Palazzo Altemps, Location Ground Floor, Branch of the National Roman Museum. Photographer/­source Jastrow (2006) from Wikipedia (accessed April 8, 2014).]

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DEFINITIONS AND OVERVIEW

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Biomedical ethics is the system of analysis and deliberation dedicated to guiding surgeons toward the “good” in the practice of surgery. One of the most influential ethical “systems” in the field of biomedical ethics is the principalist approach as articulated by Beauchamp and Childress.2 In this approach to ethical issues, moral dilemmas are deliberated by using four guiding principles: autonomy, beneficence, nonmaleficence, and justice.2

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The principle of autonomy respects the capacity of individuals ...

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