The AAS Ethics Committee held its first annual Artwork and Essay Contest in 2021 – the topic for the essay contest was “What is the most challenging ethical issue, personal or professional, you have encountered in the COVID era?” The winning essay and artwork were selected by the Ethics Committee and will be published in the October issue of the Journal of Surgical Research. But we also want to share many of the powerful entries we received for this contest, so look for more of these essays to post as blog articles between now and the 2022 ASC – thank you to everyone who participated in the contest!
Krista Haines, AAS Committee Chair & JJ Jackman, AAS Executive Director
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Becoming a Fellow of the American College of Surgeons (ACS) declares intent to practice the art and science of surgery with honor, integrity, and excellence as stated in our Fellowship Pledge. The COVID-19 pandemic has pushed our specialty to the brink. We are tasked to uphold standards while being asked to perform the impossible. Our Pledge tells us there are clear rules by which to abide. However, these are now getting blurred.
I pledge to pursue the practice of surgery with honesty and to place the welfare and the rights of my patient above all else. I promise to deal with each patient as I would wish to be dealt with if I were in the patient’s position, and I will respect the patient’s autonomy and individuality.
The patient must come first. Altruism in healthcare providers is revered but, in this pandemic, such altruism can mean our death. We are having to fight the urge to care for a patient in extremis until the layers of appropriate Personal Protective Equipment (PPE) are in place. Some centers are changing resuscitation techniques to minimize exposure. When healthcare workers are dying and seconds matter, do patient welfare and rights truly come first?
I further pledge to affirm and support the social contract of the surgical profession with my community and society.
The College has worked tirelessly to respond with support through rapid development of best practice guidelines, dissemination of Just-In-Time learning modules, and advocacy to mitigate economic losses. Surgeons have responded by assisting in hot spots or leading efforts within their own hospitals. When the ACS called to limit surgical cases to conserve critical resources, we looked to our own practices. Can cancer operations wait without compromising outcomes? What level of debilitation is acceptable to ask someone to tolerate for the sake of the public health response? When faced with a patient in tears from pain, how do you say “I’m so sorry. I can’t right now. You’ll have to wait.” Are we supporting our social contract?
The social contract is not one sided. Many surgeons are devastated by reports of blatant violations of shelter-in-place orders. Interpersonal violence is on the rise with many major cities seeing spikes in firearm-related injuries, stabbings, and intimate partner violence. There have been reports of hoarding of PPE and price gouging. At the same time, many in society have answered our social contract resoundingly. Hospitals have seen an outpouring of support through meal trains, donations of hand-sewn masks, letters and videos from school children, and blood and plasma donations. For these, we are eternally grateful.
I will take no part in any arrangement or improper financial dealings that induce referral, treatment, or withholding of treatment for reasons other than the patient’s welfare.
With the limitations on non-essential surgeries, hospitals and practices across the country are facing crippling economic losses. We do not know the final toll these actions will take on surgical practices. Some are receiving administrative pressure to keep operating, placing surgeons in the terrible position of trying to do the right thing for the public health response or risking severe financial strain and possible job loss.
The ability to pay should never determine if someone receives access to critical medical care. The ability to survive has now become a factor in this decision moving beyond medical futility into the realm of resource allocation. As surgeons trained in triage through mass casualty incidents, we have been asked to develop such allocation guidelines. It is a terrible thing to face a patient and say “someone else is more likely to survive with this resource.” The substantial good of the many must surely outweigh the marginal good of one when resources are pushed to exhaustion. But such decisions are not made without moral injury. The mental health of our profession must be a priority as we begin to heal ourselves after this pandemic.
Upon my honor, I declare that I will advance my knowledge and skills, will respect my colleagues, and will seek their counsel when in doubt about my own abilities. In turn, I will willingly help my colleagues when requested.
This is where we, as a surgical community, have excelled. Impromptu groups have popped up, sharing information from the frontlines. Intensivists passed on tricks on sedation protocols and ventilator management. Minimally-invasive surgeons shared ideas on viral filtering for laparoscopic cases. Oncology circles suggested guidelines on who could wait. We were all navigating new territory together. Now, we are charged with turning anecdotal reports into evidence-based medicine. We need to make sure we capture this experience, so we can be more prepared for our next challenge.
I recognize the interdependency of all health care professionals and will treat each with respect and consideration.
Surgeons are stepping into atypical roles to fill needs as they arise. We are all in, and we expect our institutions to be all in with us. Many systems have done a tremendous job shifting resources to areas of most need and allowing for disaster credentialing. Other surgeons have suffered the stress of administrators that appear to be more concerned about mitigating financial losses over the safety of personnel. Some are being told PPE is expensive and access is limited, or we do not have enough for all so no one should have them. They are being asked to cover high-risk units while also suffering crippling pay cuts. Many are out there working harder than ever and being told what we are doing is worth less than before.
We are Fellows of the American College of Surgeons. We exemplify and develop the highest traditions of our ancient profession. We live in strict accordance with the College’s principles. In the face of the COVID-19 pandemic, we have been stretched to the brink; we have made impossible decisions. We have placed ourselves in harm’s way for the welfare of our patients, so that we may emerge on the far side of this crisis battered, but with our oath intact.