“The greatest danger mankind faces is not from the bad forces per se, but from those apparently good men, who collaborate with the bad knowingly or unknowingly.”

– Venkatesan Sangareddi –

During a recent semester at the Seoul National University (SNU) Graduate School, I developed a new lecture series titled “Debates on surgical ethics” for postgraduates majoring in Surgery. I am not a specialist in surgical ethics, but I am very interested in education and ethics, and enjoy reading the articles published in the section “Surgical Ethics Challenges” in the Journal of Vascular Surgery (JVS), edited by Dr. James W. Jones [1,2]. Therefore, I designed a practical lecture series for young surgeons to introduce many ethical issues encountered in daily practice, discuss personal experiences and ideas on specific issues, and uncover hidden ethical problems in the surgical field.

The lecture plan describes the course as follows: “Surgical techniques and devices have been rapidly developing and advancing in recent years. However, current medical ethics cannot address the delicate issues that arise with novel advanced surgical treatments. We aim to collect data on modern surgical ethics involved in various clinical scenarios and discuss the pros and cons of each topic. These debates will clarify the concept of future surgical ethics and help develop guidelines for surgical ethics. After providing the related texts and materials, debates will be held by students in the roles of moderator and those arguing for the pros and cons of a particular viewpoint, under the supervision of a facilitator professor.” The lecture series was held every Thursday afternoon and included various ethical issues with the following titles: 1) Surgical ethics concerning endovenous varicose vein (VV) treatment; 2) Turf war: Ethics of professional territorialism; 3) Surgical tourism; 4) Ethics of live surgery demo or broadcast; 5) They decide who lives and who dies; 6) Ethics of organ donation and transplantation; 7) Industry and surgical innovation; 8) Ethical price of stardom and show doctors; 9) Operative over-scheduling; 10) The question of an impaired surgeon dilemma; 11) Discovering over-treatment; 12) Who should protect the public against bad doctors?; 13) Refusal of life-saving treatment in the aged; and 14) Ethical problems specific to surgery. Many of the titles were benchmarked based on the JVS Surgical Ethical Challenges and other articles [3,4].

However, only eight students enrolled in the class. I changed the roles of the presenter of a specific issue allowing for free discussion with the participants, and every student was encouraged to speak about their experiences and ideas on that issue. We enjoyed the weekly Thursday meetings more than expected. Similar to the film “Tuesdays with Morrie”, I enjoyed every “Thursday with surgical ethics students” for the last four months. After the final class, I conducted an anonymous survey on the lecture course, and most postgraduate students gave positive feedback. One student wrote “Thanks to the materials provided, I discovered something new in the field of ethics. In particular, for the first time, I read an interesting article entitled ‘They decide who lives and who dies’ [5]. I then read several similar articles. It was also interesting to read about the personal problems of doctors, such as alcoholism. Thank you for this interesting course.”

Arguably, the most interesting lecture topic that was chosen for discussion was “impaired surgeons’ dilemma”, which dealt with the personal problems of surgeons with regard to drug and alcohol abuse and impaired skills in some novel techniques. This is not an easy issue to discuss, especially in a highly hierarchical society such as the field of surgery, especially in Korean culture. Drinking is very popular among surgeons in the sociable society of Korea. We shared our experiences with drinking surgeons, which included some of us, and found no serious events to date. However, we agreed that strict guidelines are needed to prevent seeing a patient or guardian when a doctor has consumed alcohol, even if the doctor intended to help them. Instead, they should discuss with the on-call doctor, give advice, and have the on-call doctor speak with the patient or guardian. This is especially important when the surgeon is the only vascular surgeon in the hospital.

The second topic of interest was endovenous treatment (EVT) of the VVs. This year, members of the Korean Society for Vascular Surgery (KSVS) were happy to note that the largest number ever of fellows applied for vascular surgery. However, this can be interpreted as bubble of a popular path towards opening a private clinic for VV surgery or arteriovenous fistula intervention. As mentioned before [6], the ethics of many VV centers in this country are questionable. The issues of unethical practice on VVs can be diverse: 1) questionable credentials of VV doctors; 2) excessive unnecessary and inaccurate venous Doppler tests; 3) unnecessary EVT procedures on normal saphenous veins; and 4) excessive costs for EVT. Therefore, it is essential to teach surgical ethics to new vascular fellows through the initiative of the KSVS.

Another topic of interest was live surgery, which is very popular in the field of vascular surgery. Because endovascular interventions have a relatively short operation time and include many options for selecting devices and techniques, and because expert panels can advise optimal options for a specific case, live endovascular demonstration is a prerequisite for a successful vascular meeting. However, as mentioned before [7], live surgery involves many ethical problems, and recorded live demonstrations can be a good alternative for education without jeopardizing patient safety. I believe it is time for the KSVS to devise guidelines for dealing appropriately with these important live surgery demo-related issues and to collaborate with international societies to find a global consensus.

The Oxford Dictionary defines ethics as moral principles that govern a person’s behavior or the conducting of an activity [8]. Ethics and morals have similar meanings, and both deal with the principles of right and wrong. The key difference is that ethics concern rules from an external source, and morals are based on each person’s own principles around right and wrong [8]. Surgical ethics deals with the moral principles of surgeons performing invasive procedures, sometimes called minimally invasive procedures, on patients’ bodies. Surgeons are essentially doers, rather than thinkers or speakers. Surgical decision making often results in immediate obvious and occasionally painful outcomes. Surgeons need not only practical wisdom but also great skill as craftsmen [9]. Meanwhile, vascular surgery patients are frequently old, fragile, stubborn, indocile, and sometimes near or below the poverty line. Therefore, there are many ethical issues to discuss and study in various clinical scenarios.

In recent years, research ethics have become more stringent, and every study should be approved by the Institutional Review Board. Every postgraduate school student should enroll in a course on biomedical research ethics at SNU. However, surgical ethics is not taught sufficiently enough because of a lack of experts in this specialized field. Vascular surgeons are often busy with clinical work, exercising new devices and instruments, teaching residents and fellows about open or endovascular surgeries, and performing clinical and basic research. Only a few are interested in surgical ethics. Medical ethics professionals excel in teaching medical or research ethics, but they are not familiar with the complex clinical scenarios encountered every day in the vascular clinic and operating room. Therefore, we vascular surgeons should teach surgical ethics to young surgeons, possibly in collaboration with medical ethics professionals.

The missions of the SNU College of Medicine are: 1) to foster warmhearted leaders who respect principles; 2) to be a leader in medical science by performing innovative research; and 3) to realize a healthy society through participation and social services. The missions of the KSVS should be similar in the field of vascular surgery for the sake of patients and surgeons.

Seung-Kee Min has been the editor-in-chief of Vasc Specialist Int since 2019.