Daniel K Sokol

What is a Surgical Complication

In preparing for a lecture on the ethics of surgical complications, it became apparent that confusion exists about the definition of a ‘‘surgical complication.’’ Is it, as one medical website states, ‘‘any undesirable result of surgery?’’ [1]. In the European Journal of Surgery, Veen et al. [2] provide a more elaborate definition: ‘‘every unwanted development in the illness of the patient or in the treatment of the patient’s illness that occurs in the clinic’’ [2]. An esteemed historian of science suggests yet another definition in a recent volume on surgical complications: ‘‘a complication, in any sphere of endeavour, is something out of the norm, and the product of extraneous and unexpected factors’’ [3]. Such is the discrepancy in definitions that Rampersaud et al. [4] declared in 2006 that ‘‘presently, there is no clear or consistent definition of a complication in the surgical literature.’’ Much research in surgery aims to reduce the risk of surgical complications. However, until we have a stable and agreed definition of what counts as a surgical complication, we cannot reliably compare different studies to discover what best reduces the chance of surgical complications [5]. Therefore, the topic is more than mere pedantry; defining surgical complications will help us with the broader question of how to improve surgical practice. A basic PubMed search returned nearly 800 articles with the phrases ‘‘surgical complications’’ or ‘‘surgical complication’’ in the title. But unlike the sources above, many articles on the subject do not define surgical complications at all. A complication for one author may not be so for another. In Lewis Carroll’s Through the Looking Glass, Humpty Dumpty declares ‘‘When I use a word, it means just what I want it to mean’’ [6]. Mr Dumpty’s subjective approach to language is best avoided when dealing with an issue as common and significant as surgical complications. The website’s definition, ‘‘any undesirable result of surgery,’’ captures an essential part of a complication: it must be undesirable. There is no such thing as a good surgical complication. The definition, although pleasingly simple, is nonetheless inadequate. An unsightly operative scar is undesirable but not necessarily a complication. As Clavien et al. [7] have noted, a surgical scar is generally considered a sequela, i.e., an adverse outcome inherent to the procedure. To avoid conflating surgical complications with sequelae, we can appeal to the notion of expectation:

Update on the UK law on consent

Last week’s case of Montgomery v Lanarkshire Health Board has important implications for doctors

“First do no harm” revisited

Following the dictum means balancing moral principles

Meeting the ethical needs of doctors

We need clinical ethicists in addition to other measures A sound knowledge of medical ethics is essential to the good practice of medicine. This belief underlies the integration of medical ethics into the teaching of medical students, the proliferation of articles and textbooks on the subject, the increasing number of clinical ethics committees in NHS trusts, and the BMJ s new series on medico-ethical problems in everyday practice.1–5 These are all indications that medical ethics constitutes an important component of medical practice. But even more conclusive evidence exists that doctors need help with ethical problems. The BMA receives several thousand enquiries each year from concerned doctors confronted with ethical issues.6 No doubt many more doctors do not make use of the BMAs services through lack of time or embarrassment. Some doctors, especially if junior, may not wish to rock the boat by pointing to an ethically dubious practice. House officers, for example, may not feel comfortable obtaining consent from a patient for an unfamiliar procedure, but they may feel even more awkward raising the issue with a consultant. Others simply fail to identify the ethical problems pervading their day to day …

Consultation activities of clinical ethics committees in the United Kingdom: an empirical study and wake-up call

Objective: To identify the consultation activities of clinical ethics committees (CECs) in the UK and the views of CEC chairpersons regarding such activities. Methods: An anonymous, password-protected online questionnaire was sent by e-mail to 70 CEC chairpersons. The questionnaire contained 14 items. Results: Of the 70 CECs contacted, 30 responded (a response rate of 43%). There has been an almost fourfold increase in the number of CECs in the past 7 years. Over half of the CECs that responded had considered three or fewer active cases and three or fewer retrospective cases in the preceding year. Eighty percent of chairpersons felt that the number of active cases considered by their committee was too low. Seventy percent of CECs had rapid response teams. Aside from low consultation caseloads, chairpersons identified a number of concerns, including education and training of members, composition of CECs, low profile and lack of funding and support. Although most respondents believed there is a need for clinical ethics support in the NHS, many noted the limited use of the services, even after efforts to increase the visibility of their CEC. Conclusion: Despite a sharp increase in the absolute numbers of CECs across the UK, the number of cases considered by the majority of CECs is low. The findings presented here suggest we must reflect on the reasons for such low caseloads and pause to consider whether the committee model is most appropriate for the UK context.

The death of DNR

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A crisis of confidence

With regards to confidentiality, there is a discrepancy between what appears on the pages of professional medical guidance and what occurs at the coalface

Ethics of Surgical Complications

Whatever the place or period, surgical complications have been an inevitable part of surgical practice. It is not surprising, then, that studies on various aspects of surgical complications are plentiful. A PubMed search returned nearly 800 articles with the phrase ‘‘surgical complication’’ and its plural form in the title. However, despite the importance and prevalence of the matter, there is at present no agreed definition of a surgical complication [1]. Published definitions of the term range from the straightforward (‘‘any undesirable result of surgery’’) to the more elaborate [2, 3]. In this article, we propose to use the following definition, which, although unwieldy, captures more accurately the attributes of a surgical complication. 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 [4].

Ethical dilemmas in the acute setting: a framework for clinicians

Nearly all healthcare professionals will encounter ethical dilemmas in their work but rarely get any training in how to resolve them. Using a real case, Daniel Sokol and colleagues illustrate a structured approach to ethical analysis

Rethinking ward rounds

If you were a patient, would you prefer your medical team to use an ethics checklist?