The Uncomfortable Ethics of a Surgeon’s Shadow

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STUDENT VOICES | CHYNN ETHICS PRIZE SECOND-PLACE WINNER
By Michael Bub

Family gatherings for the holidays are one of those things that most everyone has to deal with. Those who get excited for these annual events are few and far between. Most of us just view them as an opportunity to visit with that one aunt, uncle, or cousin whose company you enjoy while avoiding the others who ask the same questions with feigned interest every year. On Easter Sunday of 2017, however, one of those usually pointless conversations bore fruit, presenting an exciting opportunity. After answering the typical “What year are you again?” and “What are you studying”-esque questions from my second cousin’s husband (I won’t even attempt to entitle that familial relationship), he asked me if I had any ideas in the works concerning how to boost my ever-relevant future medical school resumé during the upcoming summer. With little vigor I responded that, ideally, I hoped to work or volunteer in a hospital-type setting or possibly even shadow a doctor to begin filling the long list of requirements necessary to have a fighting chance of getting into a decent medical school. He halted my apathetic train of thought, offering a suggestion that finally changed my outlook of him as simply the born-on-third-base son of a name partner for one of the largest firms in St. Louis. A client of his happened to be a surgeon at one of the leading hospitals in the metropolitan area, specializing in neurosurgery, a particular interest of mine.

I recall the first patient the most vividly. Two months had passed, and I had met Dr. Moore (name changed) that morning before his first scheduled appointment. As I tried to make myself as small as possible sitting in a corner of the room atop a small stool, a thirty-something blonde woman entered the room. Before she could take her seat, Dr. Moore gave her a quick rundown of who I was, why I was there, and asked if she would mind me sitting in on her visit. She paused, noticing me, so I sat up, smiled, and gave a slight wave. Another moment passed before she muttered, “That’s fine”. Fine. This was day one, hour one, and I had already received  my first taste of uncomfortability. In the moment, I only felt uneasy as it seemed like the patient was displeased with my presence; not until later did I consider the ethics of my intrusion. I was a first-year college student with virtually zero medical experience, yet I sat there and was somehow allowed to listen as Dr. Moore asked this stranger, whose voice trembled as she replied
from the intense nerve pain she was experiencing in her shoulder, some very personal questions. Yes, she had been informed of my presence before the doctor-patient interaction began, but not prior to her visit. Was she really supposed to tell a seemingly good-intentioned 18-year-old to leave the room because his presence bothered her?

The Belmont Report, a set of general guidelines for research ethics, addresses issues such as these under the principle of Respect for Persons, which can further be broken down into an acknowledgement of a person’s autonomy and the requirement to protect those with diminished autonomy (Belmont Report 4). One might assume all of a doctor’s patients are autonomous persons, but, based on the individual’s specific circumstance, they may not be. Take the mid-thirties woman for example. When healthy, she would likely be considered an autonomous person. However, at the time during which Dr. Moore asked her consent for me to shadow her visit, she was experiencing so much pain that she could hardly speak. The Belmont Report states that “some individuals lose [the capacity for self-determination] wholly or in part because of illness” and that “Respect for … the incapacitated may require protecting them … while they are incapacitated” (Belmont Report 4). This individual had endeavored to make an imperative visit to address chronic, debilitating pain and was instead approached by an esteemed surgeon asking her permission to allow a stranger to sit in on her appointment. While I am certain Dr. Moore wished no ill-will, individuals in vulnerable situations like this woman’s must be protected, and ethical standards such as these elucidated in the Belmont Report must be considered.

Further ethical issues were revealed upon entering the Operating Room. Etiquette within the OR is well-known among those following career paths in the medical field, and even the general populace has certain ideas about the requirements from popular culture. Everyone wears scrubs from head to toe, face masks, and preferably comfortable shoes. What most people do not know, however, is that a stringent ethical code also exists among those who work within the confines of the OR. The code includes ensuring that patients are informed “about staff members who will be a functional part of the surgical team” as well as clearly and concisely “informing patients … about the process of overlapping, sequenced, [or] multidisciplinary surgeries” if applicable (Holt). Prior to my experiences within an operating room, I was not privy to this information. Informed consent is vital when performing surgery on an individual. Unfortunately, “Patients are, in general, woefully lacking in information and understanding about who, specifically, is participating in their surgical procedures, and what role each participant will play” (Holt). I witnessed five or six surgeries throughout my summer shadowing Dr. Moore and only once was I introduced to the patient prior. For the other four or five instances, there was no indication that patients were aware of my attendance of their operations.

The mere presence of a prospective medical student within the operating room with essentially no role to play may seem insignificant to some, but envision yourself as the patient. During the surgeries I observed, the patients’ pre-surgery gowns were usually removed after sedation, leaving each individual completely bare for a short period of time. Would you have no qualms with a random 18-year-old hovering over your unclothed body for seconds at a time as the rest of the OR staff prepared the next steps? For some, and especially for those unaware of this unqualified individual’s presence, this circumstance may be considered an acute invasion of privacy and a violation of the Belmont Report’s principle of Respect for Persons.

For this reason, informed consent is yet again a necessary step in the pre-surgery process. No aspect of an operation in which a human person’s life hangs in the balance should go unattended. A patient should have a complete knowledge of every facet of the procedure, including an awareness of each individual that will be present during the surgery. Unfortunately, patients almost universally sign the surgical informed consent document on the morning of their surgery in the preoperative area, which “usually does not allow for further discussion of concerns and questions that the patient have developed since the last visit” (Holt). The integrity of this process is further jeopardized upon the realization that “the patient has likely not slept well the night before, may have awakened much earlier than usual, is probably hungry and thirsty, and is very nervous about what is to occur” (Holt). Much like the first patient whose visit I shadowed
with Dr. Moore, those undergoing surgery are in no position to consent to matters of such magnitude under these unfavorable conditions. As such, the signing of this document in essence means nothing if the patient’s awareness remains inadequate.

A curious undergraduate student simply seeking to gain some pre-medical experience as well as a few shadowing hours to buff a resumé may seem harmless. Yet, the ethics involved in allowing such an individual to sit in on physician-patient interactions and surgeries unannounced should be considered carefully. The unease I experienced while sitting idly by as an otherwise healthy woman was nearly brought to tears describing the difficulty she endured simply raising her arm to get a box of cereal down from a high shelf that morning was certainly not unfounded, so imagine how she might have felt regarding my presence. By the conclusion of this woman’s visit, Dr. Moore had suggested surgery as a possible option, with the patient convinced it may be the only plausible solution. Patients such as this woman who are strong candidates for surgery along with those involved in the pre-surgery and operational process are at their most vulnerable. Consequently, measures must be taken to provide these individuals with the utmost protection from potential breaches of the ethical standards delineated in the Belmont Report, such as failing to prioritize the thorough and legitimate consent of those with a lessened capacity for self-determination.

Works Cited

The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects in Research.

Holt, G. Richard. “Ethical Challenges in the Operating Room.” ENTtoday, 14 Oct. 2016,
http://www.enttoday.org/article/ethical-challenges-operating-room/.


Michael Bub ’20, a student in Fordham College Rose Hill, is majoring in biological sciences and was awarded second place in the Fordham University Center for Ethics Education 2019 Dr. K. York and M. Noelle Chynn Undergraduate Essay Prize in Ethics and Morality.

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