For surgical trainees interested in an academic surgical career, the surgeon-scientist pathway is established as the occupational model for scholarly contributions and academic advancement. Trainees devote years of training in basic/translational science or clinical research to develop the requisite skill set, build collaborative relationships, and position themselves for an established academic niche. But what about trainees who are primarily interested in studying and contributing to the ethical dimensions of their surgical responsibilities, such as “Have I performed the right operation?” or “What is the right thing to do for this patient?”1,2 “Is this the right policy to manage this limited resource?” Although clinical data, the outcome of research trials, and surgeon experience and judgment help inform the “right” treatment for a given disease process, patient contextual factors, such as surgical patients’ end-of-life care preferences, conflicts between patient autonomy and the surgical team, beneficence, justice, and societal issues that arise from the emergence of new technologies, require a level of background knowledge, moral reasoning, and decision-making that challenges the judgment and analytic capacity learned in standard surgical training and bioethics education.

These subjects are of interest to the fields of bioethics,3 clinical ethics,4 and the burgeoning field of surgical ethics.2 Although most medical students have some instruction in medical ethics, little attention is given to carefully considering ethical behavior and decision-making during surgical residency or fellowship training. This situation presents a challenge for surgical trainees who wish to devote at least part of their careers to addressing ethical issues unique to the practice of surgery. Specifically, few surgical ethics training programs exist. In this paper, we present a brief overview of 2 fellowship programs in the United States that offer specialization in surgical ethics. We suggest that this specialization is highly valuable for the surgical trainee pursuing ethical questions associated with surgery and that the surgeon-ethicist version of the academic surgeon-scientist will be increasingly valuable to the wider field of surgery in the years to come.

THE DEVELOPMENT OF THE FIELD OF BIOETHICS

Ethical patient care has been a concern since at least the days of Hippocrates (460–377BC);5 however, the explicit study and practice of ethics within biomedical research and medical decision-making has only recently emerged. Since its inception in the 1960s, the field of bioethics has addressed important issues pertaining to the care of surgical patients (eg, organ transplantation6 and the definition of brain death7). Health care professionals now have access to technologies and advanced devices that have improved the ability to diagnose, treat, and monitor disease. Developments, such as xenotransplantation, robot-assisted surgical platforms, extracorporeal membrane oxygenation, and implantable devices, have also introduced new ethical considerations for surgeons, though the ethical challenges of surgical patient care are not limited to the new/novel technologies and techniques of surgery. The routine yet crucial responsibilities, including the informed consent process, disclosure of adverse events, disparities in surgical care, and navigating shared decision-making, deserve continuing attention and ethical analysis. Given the breadth and number of bioethical topics and issues, more formal bioethical education is warranted.

Clinicians and nonclinicians have been trained in the field of bioethics through doctoral, master, and fellowship programs, but rarely has the field of surgery or the role of the surgeon been the primary subject of an educational program. There has been a rapid increase in the number of educational opportunities in bioethics since the 1980s. Two programs have recently emerged with a specific focus on ethical issues distinctive to surgery. The limited number of formal programs belies the growing interest in surgical ethics. Although there are collectives of educators and experts in the field at the 2 institutions that have formalized training in surgical ethics, there is an increasing number of surgeons interested in the intersection of ethics and surgery. The increasing availability of remote collaboration and learning brought about by the coronavirus disease 2019 pandemic has allowed surgeons from across the country and the world to meet regularly to discuss ethical issues. Consequently, the learning opportunities for surgical ethics education, which have traditionally been available in-person only, may soon become more widely accessible and affordable for trainees. Scholarships, such as the Cardiothoracic Ethics Forum Scholarship and the American College of Surgeons (ACS)-MacLean Center Surgical Ethics Fellowship, can assist trainees in funding surgical ethics fellowship opportunities.

THE PURPOSE OF SURGICAL ETHICS EDUCATION

Formal training in surgical ethics can equip trainees with research methods for identifying and analyzing the relationship between surgical practice and ethical decisions. Formal training in ethics introduces trainees to the discourse of ethics that is foundational for facilitating both formal and informal discussions of ethical cases. Surgeons with explicit training in ethics can serve as a resource for surgical colleagues and trainees in analyzing and approaching ethical challenges, which is likely to be more utilized than a formal ethics consultation given the mutual trust and understanding among surgeons. Not surprisingly, when one of the authors conducted a survey of attending general and subspecialty surgeons at an academic tertiary medical center, the findings showed that surgeons prefer to discuss ethical dilemmas with other surgeons. In this survey, 64/81 (79%) of attending surgeons who responded preferred handling ethical dilemmas through discussion with surgical colleagues (Fig. 1).

Figure 1:

A survey of 64 surgeons at an academic medical center demonstrates surgeons are more likely to discuss an ethical dilemma with a colleague than to obtain an ethics consult or deal with it alone.

It is likely that surgeons with ethics training are not inherently more ethical surgeons in practice,8 just as surgeons with formal training in education are not necessarily more adept at teaching. It is reasonable, however, to expect that surgeons with formal ethics education will be better equipped to apply moral reasoning to clinical and research ethics challenges, to evaluate ethical dimensions of health care policy and national guidelines, and to empirically study and lead discussions on ethical issues.

CURRENT OPPORTUNITIES FOR SURGICAL ETHICS EDUCATION

Recognizing that there may be more programs in surgical ethics training, we describe 2 surgery-focused ethics fellowships: the ACS-MacLean Center Surgical Ethics Fellowship and the Washington University in St. Louis School of Medicine Department of Surgery’s fellowship in Surgical Ethics.

Since 2015, the MacLean Center for Clinical Medical Ethics at the University of Chicago has sponsored a joint surgical ethics fellowship program with the ACS.9 This program, headed by Dr Peter Angelos, is open to surgical attendings, residents, or fellows interested in identifying and resolving ethical dilemmas that occur in caring for surgical patients. The MacLean Center has a historic reputation for being involved in the first live-donor liver transplantation in 1989. The MacLean Center continues to further the field of surgical ethics by addressing complex ethical questions, such as those raised by surgical innovation, informed consent, organ allocation, and care of living donors. The MacLean Center’s Surgical Ethics Fellowship is dedicated to preparing surgeons to conduct empirical research in surgical ethics. By combining research methods utilized in adjacent fields, such as clinical epidemiology, health services research, and decision science, fellows analyze and discuss the ethical considerations of both clinical surgical practice and academic research. The fellowship program is a 1-year part-time program, which starts in July and consists of a 5-week, full-time summer intensive clinical ethics course delivered on-site, followed by in-person weekly meetings on Wednesdays through May. The structured curriculum includes seminars, lectures, clinical ethics consultations, and case conferences. Fellows are also involved in the local ethics consultation service and are expected to design and carry out a surgical ethics research project.

The surgical ethics fellowship offered by the Center for Humanism and Ethics in Surgical Specialties at Washington University of Medicine in St. Louis is unique in its location within the Department of Surgery.10 This program, founded in 2019, is directed by Dr Piroska C. Kopar, who is also the president of the Consortium for Surgical Ethics, a national nonprofit organization dedicated to the academic integrity of ethics research and education in surgery, and Dr Douglas E. Brown, a surgical ethics specialist. The aim of this 1-year, part-time program is for fellows to obtain the skills to perform clinical ethics consultations and to conduct surgical ethics research that enriches the discipline of surgery. The fellowship runs from September to June and consists of in-person didactic sessions, engagement with readings and written reflections, and participation in teaching of undergraduates, medical students, residents, fellows, and faculty. Core faculty and international guest lecturers at the Center for Humanism and Ethics in Surgical Specialties program stress the importance of identifying, and reflecting on, the ethical tensions in surgical practice that sometimes present as paradoxes, such as the unique balance of risk and benefit that occur when surgeons must “cut to heal” and “hurt to cure.”

These 2 surgical ethics fellowships are focused on preparing surgeons to tackle existing, new, and evolving ethical issues in surgery. To be sure, all surgeons will continue to confront ethical issues in their careers, and these issues are likely to become more diverse and numerous as surgical advances and research initiatives expand. For surgeons interested in delving into the ethical considerations of their specialty, formal training in surgical ethics offers education in the discourse and methods that will enhance career participation in surgical ethics through empirical research, education, and improvement in ethical surgical care.

REFERENCES 1. Conley J. Have I performed the right operation. Arch Otolaryngol Head Neck Surg. 1986;112:385–387. 2. Angelos P. Surgical ethics and the future of surgical practice. Surgery. 2018;163:1–5. 3. Jonsen AR. The birth of bioethics. Hastings Cent Rep. 1993;23:S1–S4. 4. Siegler M. Clinical medical ethics: its history and contributions to American medicine. J Clin Ethics. 2019;30:17–26. 5. Romankow J. Hippocrates and Schweitzer—comparison of their concepts of medical ethics. Arch Hist Filoz Med. 1999;62:245–250. 6. Jonsen AR. The ethics of organ transplantation: a brief history. AMA J Ethics. 2012;14:264–268. 7. A definition of irreversible coma. Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. JAMA. 1968;205:337–340. 8. Aeon. How often do ethics professors call their mothers? Aeon Essays. Accessed March 2, 2023. https://aeon.co/essays/how-often-do-ethics-professors-call-their-mothers 9. The MacLean Center for Clinical Medical Ethics. ACS-MacLean Center Surgical Ethics Fellowship. Accessed January 17, 2023. https://macleanethics.uchicago.edu/fellowship/surgical_ethics/ 10. Fellowship in surgical ethics. Accessed January 17, 2023. https://chess.wustl.edu/fellowship/