ETHICAL DILEMMAS IN SURGERY AND
UTILIZATION OF HOSPITAL ETHICS CONSULTATION SERVICE: A SURVEY
Jennifer A.T. Schwartz, M.D.
Post-doctoral Fellow
NIH Dept of Bioethics
Eric A. Singer, M.D., M.A.
Clinical Fellow
Urologic Oncology Branch, NCI
Mentor: Marion Danis, M.D
Background: “Ethical problems routinely arise in the hospital and outpatient practice setting, and
ethics consultation services have become commonplace in health care institutions to assist staff and
patients in resolving ethical dilemmas or disputes. Indeed, hospitals in the United States
are mandated to maintain some mechanism to resolve ethics issues, and the scholarly literature has
largely encouraged development of these resources. Furthermore, criteria for educating and training
consultants and for standardizing the process of consultations have been published. Despite this
endorsement of ethics consultation, little empiric evidence exists about the use of ethics consultation
or its perceived effectiveness. Studies evaluating consultation services indicate to date that persons
who request consultation are reasonably satisfied, and 2 controlled studies in the intensive care
setting suggest that automatic ethics consults for patients at great risk of dying provide some benefit
to patients and clinicians, and may optimize resource use. However, all these studies are restricted to
single institutions. There has been little systematic study of the kinds of ethical dilemmas
{[surgeons]} confront, the kinds of dilemmas referred for consultation, the effectiveness of ethics
consultation, barriers to the use of ethics consultation, and {[surgeons]} satisfaction with the
resolution of ethical dilemmas. Accordingly, a… survey of U.S. {[surgeons]} {[will be]} conducted to
address these questions.” (DuVal, Clarridge, Gensler, Danis)
Objective:
1. To identify the frequency of ethical dilemmas that surgeons have encountered in their
practices in the past year.
2. To characterize the utilization of hospital ethics consultation service by surgeons
3. To recognize barriers to surgeons’ use of ethics consultation services
Methods:
Design: 32 item questionnaire
Setting: Online Survey
Participants: Surgeons contacted through the ACS e-mail distribution list
Population: 72,600
Sample Size: 1052 (95% CI; +/- 3% margin of error)
Estimated Response Rate: 34%
Sample Size (with compensation for estimated RR): 3156
Incentive: 1 CME credit upon completion of survey
Hypothesis: Respondents who report encountering a greater number of ethical dilemmas will
report a greater number of ethics consultations (if service is available to them).
QUESTIONNAIRE
Your answers are completely confidential. The information from this study shall not be presented or
published in any way that would permit identification of any individual. Your answers will be
combined with other answers for statistical analysis. Your participation in this interview is entirely
voluntary and you may withdraw at any time. If you would like to participate in this study, please
sign below.
____________________________
Signature
______________________
Date
Demographic Information:
A1. How many total years have you been a practicing surgeon (include time spent in
residency and fellowship training)?
__________________
A2. Please select one of the following:
□ Male
□ Female
A3. Have you had sub-specialty fellowship training?
YES, (field)__________________
NO
A4. Are you board certified?
YES, (field)__________________
NO
A5. Which of the following best describes your current surgical practice?
a. Solo private practice
b. Group private practice
c. Employed by hospital
d. Employed by health system
e. Employed by government
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f. Other_____________________
A6. Where do you perform the majority of your operations?
a. Community hospital
b. Government hospital
c. Academic medical center
d. Ambulatory surgical center
e. Other_________________________
Ethical Dilemmas:
For Items B1 - B17 please answer the following:
In the past year many times have you been in a situation in which...
B1. Rules for third party payment prevented you from proceeding with your preferred course
of treatment?
a. 0
b. 1-2
c. 3-4
d. 5 or more
B2. A patient requested a costly intervention (which you believe will have very little benefit)?
a. 0
b. 1-2
c. 3-4
d. 5 or more
B3. You felt pressure to misrepresent a patient’s condition in order to help the patient gain
medical interventions not otherwise covered by the patient’s health plan?
a. 0
b. 1-2
c. 3-4
d. 5 or more
B4. A pharmaceutical company or device manufacturer has offered you a generous gift (or
other incentive) that you were concerned could cause a conflict of interest?
a. 0
b. 1-2
c. 3-4
d. 5 or more
B5. You had a concern about a colleague being impaired from fatigue, drug or alcohol use,
illness, personal crisis, or other issue?
a. 0
b. 1-2
c. 3-4
d. 5 or more
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B6. You experienced competing commitments between a family or personal obligation and a
professional obligation such that you had to choose one to the exclusion of the other?
a. 0
b. 1-2
c. 3-4
d. 5 or more
B7. You felt uncertain about the validity of the informed consent obtained from a surgical
patient?
a. 0
b. 1-2
c. 3-4
d. 5 or more
B8. A patient's cultural or religious views conflicted with your proposed course of treatment?
a. 0
b. 1-2
c. 3-4
d. 5 or more
B9. You felt unsure of the best course of action when the duty to maintain confidentiality of
patient information conflicted with another duty (such as mandatory reporting or protection of
another party or public welfare)?
a. 0
b. 1-2
c. 3-4
d. 5 or more
B10. You were involved in the decision to limit or withdraw life sustaining treatment of a
terminally ill patient?
a. 0
b. 1-2
c. 3-4
d. 5 or more
B11. An adult patient’s capacity for decision-making with respect to their own health was
uncertain or impaired?
a. 0
b. 1-2
c. 3-4
d. 5 or more
B12. There was significant disagreement among family members/caregivers on the proper
course of treatment for the patient?
a. 0
b. 1-2
c. 3-4
d. 5 or more
B13. Your preferred course of treatment conflicted with institutional policies, federal
regulations, or other laws?
a. 0
b. 1-2
c. 3-4
d. 5 or more
B14. You were asked by a patient how many times you have performed a specific operation
and felt pressure to exaggerate your experience?
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a. 0
b. 1-2
c. 3-4
d. 5 or more
B15. You were concerned that a colleague or trainee was planning to perform or did perform
a procedure for which he/she was not appropriately credentialed?
a. 0
b. 1-2
c. 3-4
d. 5 or more
B16. You were asked to exclude trainees (fellows/residents/medical students) from
participating in the intraoperative care of a patient at a teaching hospital at a patient’s or a
family’s request?
a. 0
b. 1-2
c. 3-4
d. 5 or more
B17. You felt that a surgeon’s innovative operative technique would be better described as
“experimental” rather than “standard of practice”?
a. 0
b. 1-2
c. 3-4
d. 5 or more
B18. Please describe an ethical dilemma that you experienced in the past year, how you
solved it, and the outcome:
Ethics Consultation:
C1. Is there a process for requesting an ethics consultation at your primary practice site?
YES
DON’T KNOW
NO
C2. How many ethics consultations were you involved in over the past year (initiated by you
or another member of your primary team)? If “NONE” go to Item C4.
NONE
#_________
C3. On a scale from 0 to 10 (where 0 is not useful at all and 10 is extremely useful), how
would you rate the usefulness of the most recent ethics consultation you requested?
0
1
2
3
4
5
6
7
8
9
10
5
C4. If you have not requested an ethics consult in the past year, what prevented you from
doing so? Please select all that apply.
a. I was unsure if it would have been appropriate to request an ethics consult.
b. I don’t know how to request an ethics consult.
c. I believe an ethics consult would have created more problems than it would have
solved.
d. I didn’t needed guidance from an ethics consultant concerning patient care.
e. I didn’t have time to wait for an ethics consultation when I was making decisions
for patient care.
f. Ethics consultants don’t have enough practical clinical experience for their
recommendations to be useful.
g. I didn’t have access to an ethics consult service
h. Other_______________________________________________________
C5. Which of the following would make it more likely that you would request an ethics
consultation in the future? (Please select all that apply).
a. If I had access to an ethics consultation service.
b. If the consultation process were faster.
c. If ethics consultants could offer more specific/useful recommendations.
d. If the ethics service did a better job of advertising its available services.
e. If the ethics consultation team were more experienced in regard to ethical issues
that often arise in surgery.
f. If the ethics consultation team had more clinical experience and knowledge
regarding surgical patients.
g. Nothing would increase my likelihood of requesting an ethics consultation.
h. Other_______________________________________________________
Comments regarding this survey:
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References:
A National Survey of U.S. Internists’ Experiences with Ethical Dilemmas and Ethics Consultation. G
DuVal, B Clarridge, G Gensler, M Danis. Journal Gen Int Med. March 2004. Vol 19. Pp 253-9.
Fast Facts on US Hospitals. American Hospital Association. www.aha.org
Ethical Issues in Clinical Surgery. MH McGrath, DA Risucci, A Schwab. American College of
Surgeons. 2007.
Physician Characteristics and Distribution in the US. DR Smart. Pp 1-5. 2010.
Physician Specialty Data: A Chart Book. AAMC Center for Workforce Studies. August 2006.
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