Complications, Errors, and Surgical Ethics

In their article titled The Ethics of Surgical Complications, Adedeji and colleagues explore the ethical dimensions of surgical complications [1]. Although there are numerous ways that one could explore the ethical aspects of such complications, these authors have used the four widely known ethical principles of respect for autonomy, beneficence, non-maleficence, and justice as the prism through which to consider surgical complications. Through this line of analysis, we see how general principles can be applied in specific situations to help guide surgeons’ behaviors. The authors have done an excellent job of showing the relevance of the ethical principles for guiding action. They have also shown how focusing on a specific aspect of surgical ethics, such as complications, can help define the surgeon’s proper role. Critical to the entire manuscript is the definition of a surgical complication. The authors accept the definition of ‘‘complication’’ that was recently proposed in the World Journal of Surgery: ‘‘A surgical complication is any undesirable, unintended and direct result of surgery affecting the patient, which would not have occurred had the surgery gone as well as could reasonably be hoped’’ [2]. Using this definition of a surgical complication, the authors begin with the principle of respect for autonomy to explore the implications for surgeon behavior. It is immediately apparent that in order to respect the autonomy of patients, surgeons must disclose the possibility of complications when they obtain the patient’s informed consent. The authors go on to emphasize that respect for autonomy also requires that complications, when they occur, must be disclosed to patients. Although the definition of a surgical complication does not carry with it any concept of error, the authors do raise this important issue when they state: ‘‘a surgeon who has made a mistake may attempt to disguise it by calling the error a surgical complication, thereby relying on the inference that this eventuality is inevitable. This is deceptive and paternalistic.’’ I agree that to suggest that an error is merely a complication would be misleading. However, it is not clear from the article how errors and complications are actually related. We will return to this issue below. The authors then turn to the principle of beneficence and explore the implications for surgeon behavior in applying this principle. The importance of ensuring the appropriateness of surgery can be derived from beneficence—that is, doing good for patients. Furthermore, the maintenance of a surgeon’s skill and knowledge is required by the principle of beneficence. The authors also suggest that a surgeon’s responsibility to address the material needs of the health care system can also be derived from the principle of beneficence. This issue may be of greater concern to surgeons working within a national health system. Finally, the important concept of surgical innovation is even addressed as being an essential aspect of furthering the good of patients. The principle of non-maleficence, or avoiding harm, is next addressed. The authors suggest that many aspects of avoiding complications such as exercising good judgment, recognizing the limits of one’s competence, infectioncontrol measures, and quality improvement programs can P. Angelos (&) Department of Surgery and MacLean Center for Clinical Medical Ethics, The University of Chicago, 5841 S. Maryland Avenue, MC 4052, Chicago, IL 60637, USA e-mail: pangelos@surgery.bsd.uchicago.edu