Volume 17, Number 3, September 2005

Ethics, Etiquette, and Surgical Training

Ethics is at the heart of surgical practice. The dependence of patients on the technical knowledge and integrity of surgeons means that a bond of trust between surgeon and patient is required. From earliest times, various legal systems have incorporated a certain degree of regulation of surgeons. The Hippocratic Oath (4th century BC) indicates the early concern of the profession to regulate itself by laying down basic standards of conduct, not only between doctors and patients, but also between teachers and pupils.

In the ensuing centuries, mostly influenced by the principles of humanism that dominated the practice of medicine, traditions of etiquette in public and private life gradually evolved, and the criteria of professional conduct, which established a physician's position in society, was crystallised. Towards the end of the 18th century, the role of physicians in dealing with disease in individuals as well as population groups (as in the great epidemics) led to the drafting of codes of professional conduct. In 1803, Thomas Percival of Manchester published his seminal work
Medical ethics or a code of institutes and precepts adapted to the professional conduct of physicians and surgeons, thus laying the foundations for modern medical ethical standards.1

We presently live in a period of change of ethical and moral consciousness. In 1947, the Declaration of Geneva was formulated by the World Medical Association, with attendant declarations on particular aspects of ethics such as abortion, research, and torture and other inhuman treatment. Since then, there has been an increased rate of scientific discovery and better communication with the public. This has engendered a growing need for the profession to be aware of society's evolving views on all medical advances and developments, and has also necessitated the promulgation of ethical guidelines reflecting safeguards to patients' well-being and interests, with regular updates of codes of ethics and conduct.
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In the process of evolving codes of medical ethics, a shift in emphasis has occurred. In Percival's work, there was an overriding concern for doctors' conduct towards each other rather than towards patients' needs and status.1 The above-mentioned change in emphasis prompted reinterpretation of Percival's work as 'medical etiquette' rather than medical ethics.

In today's world, medical etiquette refers to the set of moral principles that guide members of the medical and dental professions in their dealings with each other. The basis of a good relationship between members of any profession lies in mutual respect and understanding. Contrary to the view that etiquette is an introspective approach that aims to protect the profession against external challenges, the interaction of members of the medical profession directly impacts on the welfare of patients who straddle the gap between their different skills and services.

The classic ethical issues concerning surgeons today include the ethics of human and animal experimentation, informed consent, abortion, organ transplantation, and euthanasia among others. Less commonly addressed, but nonetheless important, issues relate to the ethics of learning from patients.3 This question is relevant both at the undergraduate level4,5 and at the surgical residency level.6 Although it is generally acknowledged that study modules on bioethics are useful in surgical training,7,8 they have yet to become part of the surgical training curriculum in many specialties.

For the past 3 decades, the medical profession has been under pressure due to changes in society's expectations, and an increase in litigation is but one of the manifestations. Although some of the criticism might be warranted, the majority of conflicts and consequent litigation are avoidable through appropriate surgeon-patient rapport, a subject aptly covered in Professor Edwin Hui's contribution in this issue of the Journal.9

Nabil Samman
Editor-in-Chief
Asian Journal of Oral and Maxillofacial Surgery

References
1.
History of medical ethics. In: The handbook of medical ethics. London: British Medical Association; 1984:9-10.
2. Principles of medical ethics. www.ama-assn.org/ama/pub/category/2512.html
3.
Shooner C. The ethics of learning from patients. Can Med Assoc J 1997;156:535-538.
4.
Cohen DL, McCullough LB, Kessel RW, Apostolides AY, Alden ER, Heiderich KJ. Informed consent policies governing medical student's interactions with patients. J Med Educ 1987;62:789-798.
5.
Knapp MB. Legal implications of clinical supervision of medical students and residents. J Med Educ 1983;58:293-299.
6.
Siegel JH. Surgical training, quality surgical care, and informed consent. Bull NY Acad Med 1980;56:433-452.
7.
Downing MT, Way DP, Caniano DA. Results of a national survey on ethics education in general surgery residency program. Am J Surg 1997;174:364-368.
8.
Wenger NS, Lin H, Lieberman JR. Teaching medical ethics to orthopaedic surgery residents. J Bone Joint Surg Am1998;80:1125-1131.
9.
Hui EC. The patient-surgeon relationship (part I): its professional nature and moral implications. Asian J Oral Maxillofac Surg 2005;17:151-156.

Asian J Oral Maxillofac Surg. 2005;17:149-150.
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