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Treat without discrimination, whether labelled ‘pauper’ or ‘to pay’
Before delivering the Ravi Pillai Memorial Oration titled ‘Ethics, the Law & Cardiothoracic Surgery’, Consultant Cardiothoracic Surgeon Dr. Panna A. Gooneratne gave a glimpse as to who Dr. Pillai was.
“What I learned from Ravi was not only surgical techniques, but also to think on my feet and deal with unexpected situations skilfully. He used to say to me, ‘Be like a swan. Serene on the surface but paddling like hell underneath’,” said Dr. Gooneratne, who had gone as the first Sri Lankan overseas Registrar in Cardiothoracic Surgery to the John Radcliffe Hospital in Oxford, United Kingdom (UK) in 1989.
This Senior Consultant Cardiothoracic Surgeon who has retired after a long service at the Sri Jayewardenepura General Hospital, is currently Consultant – Clinical Governance & Electronic Health Records at a private hospital. He was among Dr. Pillai’s five Sri Lankan trainees in the UK.
Having worked with Ravi until January 1992, he says that Ravi knew the background of cardiac surgery training in Sri Lanka and took him under his wing to train him and make him fit to go back and disseminate the expertise and knowledge gained in the UK.
When Dr. Gooneratne started working at Sri Jayewardenepura General Hospital, Ravi had brought a cardiac team from Oxford for two years, to help develop the unit.
It is with much emotion that he reminisces how he and Ravi played for the John Radcliffe Hospital cricket team and even won a trophy once. “Our association was more than a mentor-mentee connection. He was my friend.”
With regard to ‘Ethics, the Law and Cardiothoracic Surgery’, Dr. Gooneratne says ethics is defined as “the moral principles that govern a person’s behaviour or the conduct of an activity”. It is simply “doing the right thing” as regards to moral obligations, benefit to society and fairness to individuals. It is the set of moral principles that govern a practice.
Explaining how ethics had developed around the world, he said that the Sri Lanka Medical Council published guidelines for ethical conduct in 2003 and a revised edition in 2009.
On how this is relevant to cardiothoracic surgery, he went onto say that cardiothoracic surgeons typically perform extremely complex surgical interventions on very sick patients. The training almost entirely focuses on the clinical and technical skills required. In his time, medical ethics as a concept was never even discussed. Thankfully, this was changing and his previous academic institutions, the Colombo Medical Faculty and the PGIM now had courses on medical ethics.
With ethics and litigation going hand in hand, he said that ethical violation could be medical negligence by way of unintentional harm by an act or omission of it. It could be medical malpractice when negligence is intentional. It could also be financial fraud or research fraud.
Dr. Gooneratne said: “There are three criteria that must be satisfied for a healthcare worker to be found guilty of medical negligence – a duty should have been owed; this duty should have been breached; and that breach must have caused death or injury.
“There is, however, recognition that even if we do everything correctly, things can go wrong. What ‘doing everything correctly’ looks like is determined by the level of training we are expected to have received. Of course, these criteria apply to the government and private sectors in equal measure.
“If a healthcare worker is found guilty of medical negligence, the penalty may be compensatory or punitive. The extent of compensation could be based on lost income, including projected losses. Punitive damages could be professional, for instance being struck off a national medical register, or legal, for instance imprisonment in the case of malpractice.
“So how do we make sure that we do the right thing and in doing so, do right by our patients and stay on the right side of the law,” he asked, exploring the different types of ethical considerations at play.
According to him there are seven key ethical considerations that affect cardiothoracic surgeons and medical professionals – informed consent; auditing; innovation & research; conflict of interest; dilemmas; stress; and honesty.
To improve ethical considerations in cardiothoracic surgery in Sri Lanka, Dr. Gooneratne recommended that senior practising surgeons should be involved in ethics training for new doctors. Such training could be through refresher training in ethics for junior cardiothoracic surgeons.
There should also be a consistent method of measuring quality that is accessible to all cardiothoracic surgical units in the country, he said, happy that the first steps had been taken in establishing a pathway to quality assessment. This could then lead to a process of regular performance reviews for surgeons, to ensure good professional standing in the sector.
Dr. Gooneratne wound up with a poignant quote from a poem by Rudyard Kipling, modified by the late Prof. K. Rajasuriya.
“If you can bear in mind that you are dealing With human life and not with ‘cases’, pray, If you can treat them without discriminating Whether they are labelled ‘pauper’ or ‘to pay’.”
Here is the full text of the Ravi Pillai Memorial Oration 2024 titled ‘Ethics, The Law & Cardiothoracic Surgery’ delivered by Dr. P.A. Gooneratne, Consultant Cardiothoracic Surgeon (SJGH; Retd.)
& Consultant: Clinical Excellence and EHR Implementation (Hemas Hospitals) at the Annual Academic Sessions of the Association of Cardiothoracic & Thoracic Surgeons of Sri Lanka
Introduction
I came to know Ravi in December 1989 when I was appointed as the first overseas Registrar in Cardiothoracic Surgery at the John Radcliffe Hospital in Oxford. Ravi knew the background of Cardiac Surgery training in Sri Lanka and he immediately took me under his wing to train me as a Cardiac Surgeon fit to go back to Sri Lanka and disseminate the expertise and the knowledge that I had gained in UK. I worked with Ravi until January 1992, and I am happy to say that I fulfilled his wishes.
Ravi trained a total of 5 Sri Lankan Cardiac Surgeons at Oxford. Whenever he came to Sri Lanka, he would contact his trainees and ask how they were getting on. When I started working at Sri Jayewardenepura General Hospital, Ravi brought a Cardiac Team from Oxford for 2 years running to help us develop the unit at SJGH.
What I learned from Ravi was not only surgical techniques, but also to think on my feet and deal with unexpected situations skilfully. He used to say to me, “Be like a swan. Serene on the surface but paddling like hell underneath”. He introduced the system of fast tracking to Oxford and used to do 6 operations per day in the 2 theatres shuttling between the 2.
Every Friday, a day he did not operate, he would do a grand ward round, discuss and view angiograms of next week’s cases, participate in the journal club and invite all those not on call or not in the theatre for lunch at the closest pub. If I was going, he would never fail to ask Saro, my wife to join us…and he would never allow us to pay. Finally, we said if he did not allow us to share the bill, we would not come the next time. He agreed reluctantly.
Ravi and I also played for the John Radcliffe Hospital cricket team. He would finish the list on Wednesday and both of us would be at the grounds by 5.30 p.m. On one occasion we even won a trophy. Our association was more than a mentor-mentee connection. He was my friend. It gives me great pleasure to deliver the 2024 Ravi Pillai Memorial Oration, on the topic of “Ethics, The Law and Cardiothoracic Surgery”.
Definition and Timeline of Medical Ethics
Ethics is defined as “the moral principles that govern a person’s behaviour, or the conduct of an activity”. Expanding it further, it is simply “doing the right thing” as regards to moral obligations, benefit to society and fairness to individuals. It is the set of moral principles that govern a practice.
If we are to trace the timeline of medical ethics, it was in around 400 BC that Hippocrates laid down an oath, which in summary states: “I will use my power to help the sick to the best of my ability and judgement; I will abstain from harming any man by it”. This oath was taken by all embarking on the practice of medicine up to the 19th century. Sadly it is not so now.
The first book on medical ethics in the Arab world was published in 800 AD. This book also contains the first documented description of the peer review process. Then in 1847, the American Medical Association was founded, and the first modern code of medical ethics was drafted.
In 1947, the Nuremberg Code was established during the post-WWII Nuremberg Trials. During these trials, medical doctors were accused of Nazi human experimentation and mass murder under the guise of euthanasia. The Code stressed the importance of voluntary consent. Twenty years later, the Helsinki Declaration on ethical principles for medical research involving human subjects was adopted by the WMA General Assembly.
Despite the existence of this declaration, in the early 1990s, the prioritisation of quantity over quality at the Bristol Royal Infirmary in the UK led to a mortality rate for paediatric cardiac surgery on children under 1 that was double the national average. Partly in response to this scandal, the NHS established a national framework for clinical governance in 2001.
Closer to home, our own Medical Council published guidelines for ethical conduct in 2003, and a revised edition was published in 2009. So how is all of this relevant to Cardiothoracic Surgery? Cardiothoracic surgeons typically perform extremely complex surgical interventions on very sick patients. Our training for this line of work focuses almost entirely on the clinical and technical skills required, and we build our courage and confidence through experience and interaction with our mentors and peers. However, at least in my time, medical ethics as a concept were never even discussed. Thankfully this is changing, and both my previous academic institutions, the Colombo Medical Faculty and the PGIM now have courses on medical ethics in their curricula.
Relationship between Law and Cardiothoracic Surgery
Ethics and litigation go hand in hand. Ethical violation could be medical negligence by way of unintentional harm by an act or omission of it. It could be medical malpractice when negligence is intentional. It could also be financial fraud or research fraud.
There are three criteria that must be satisfied for a Health Care Worker to be found guilty of medical negligence. First, a duty should have been owed. Second, this duty should have been breached. Third, that breach must have caused death or injury. There is, however, recognition that even if we do everything correctly, things can go wrong. What ‘doing everything correctly’ looks like is determined by the level of training we are expected to have received. And of course these criteria apply to the government sector and private sector in equal measure.
If a Health Care Worker is found guilty of medical negligence, the penalty may be compensatory or punitive. The extent of compensation could be based on lost income, including projected losses. Punitive damages could be professional, for instance being struck off a national medical register, or legal, for instance imprisonment in the case of malpractice.
Relationship between Ethics and Cardiothoracic Surgery
So how do we make sure that we do the right thing, and in doing so do right by our patients and stay on the right side of the law? For the remainder of this presentation I’m going to explore the different types of ethical considerations at play. Some of the examples are based on my own experiences, whereas others are taken from publicly available literature.
There are seven key ethical considerations that affect cardiothoracic surgeons, and medical professionals in general.
Informed Consent
I mentioned earlier that patient consent featured heavily in the Nuremberg Trials. Informed consent is where the patient recognises that surgery is beneficial to their quality of life, but fully understands the risks involved and is aware that there may be a risk of death or long-term disability. It is the surgeon’s responsibility to provide the patient with whatever information they need to be able to make an informed decision. However, the patient must also be aware that all clinical decisions are at the discretion of the surgeon. This is especially important nowadays, given the ease with which patients can consult ‘Dr Google’.
When I was an SHO at the Cardiothoracic Unit of General Hospital Colombo, now NHSL, when a patient arrived at the ward, the nurse would ask the patient to sign on the side of the admission sheet to say that they give consent for surgery. The patient too signed the paper without asking any questions and with no knowledge of the surgery. Now the nurse should not have been the one to request consent, as they lacked the clinical know-how to advise the patient. And the patient shouldn’t have so readily signed something that they didn’t understand. Thankfully nowadays, patients have more agency. Additionally, I can confirm that at Hemas Hospitals, the patient consent forms include all three languages, so that a patient can provide informed consent regardless of their vernacular. I trust that this is common practice at all hospitals.
To give you another example, I recall a 63-year-old female patient who presented to SJGH with an aortic aneurysm extending from the ascending aorta up to the aortic bifurcation. Three months after carrying out an Elephant Trunk procedure as the first stage of the correction, I offered her the repair of the rest of the aneurysm as the second stage. Following our discussion regarding the risks involved, she declined the operation as she didn’t want to endure the trauma of further surgical intervention. If I am to quote her, she said “අනේ දැන් ඇති නේ මහත්තයෝ”, or “now that’s enough”. I respected her decision and made arrangements for medical management. She received regular check-ups at the clinic for a year and passed away two years after that.
Our discussions included the patient’s family, as they too were affected by what she was going through. I also made a point to refrain from using technical jargon with all my patients, as this would only be a barrier to their understanding. Regrettably, I didn’t routinely practise the third point on this slide, but I believe that asking the patient to explain what they’ve been told is an excellent way of ensuring that consent is truly informed. Something else we can do to help our patients make the right decision is show them the EuroSCORE result for their case.
Another facet that we need to consider is the emotional toll cardiac illness can take on the patient and their family. It is therefore our duty to be respectful of their concerns and address them properly, irrespective of whether we think they’re significant or not.
Auditing
The report on the public inquiry into the Bristol Royal Infirmary scandal I mentioned earlier talks of clinicians keeping records and carrying out audits of their cases, but not doing so in a systematic, professional manner with a focus on continuous improvement. The purpose of auditing should be to formally analyse performance in terms of quality of outcomes, identify shortcomings and make changes to improve results.
An example of a suitable auditing mechanism is the Morbidity-Mortality meeting. I didn’t get a chance to implement these meetings during my tenure at SJGH, however I have been able to establish them in a non-cardiac context at Hemas Hospitals. In these meetings, Medical Officers and nurses present complicated cases in which they’ve been involved to an audience consisting of consultants, hospital management and other health care workers. Attendees engage in an open discussion to identify potential areas for improvement, either at a personal or institutional level.
Innovation & Research
Cardiac surgeons, particularly those focusing on paediatrics, are great innovators in the correction of complex Congenital Heart defects. Examples include the Jatene procedure for the correction of TGA, which superseded the Senning and Mustard approaches and the Norwood procedure, which is used to correct the previously untreatable hypoplastic left heart syndrome. Elsewhere in cardiac surgery, the Ozaki technique offers reconstruction as an alternative to replacement in the treatment of aortic valve disease. Technological innovations in virtual and augmented reality are also providing surgeons with immersive digital environments in which to improve their surgical skills. However, as with all aspects of cardiothoracic surgery, surgical innovations are high risk, and therefore, they must be peer reviewed and adhere to strict ethical guidelines.
When presenting the medical ethics timeline to you earlier, I mentioned that the Helsinki Declaration was adopted by the World Medical Association in 1967. The declaration contains 32 principles relating to medical research ethics, ranging from informed consent and confidentiality to regulatory compliance and dissemination of results. The Council for International Organisations of Medical Sciences has worked with the WHO to produce guidelines for the implementation of these principles, especially in low-income settings such as ours, since the 1980s…the most recent being the 2016 International Ethical Guidelines for Health-related Research Involving Humans.
Unfortunately, despite the establishment of these guidelines, ethical violations in medical research continue to occur. One of the more high profile cases relating to our field is that of Paolo Macchiarini, a disgraced thoracic surgeon in Sweden, who circumvented ethical approval processes for his so-called ground-breaking artificial tracheal transplants and misrepresented the outcomes of these operations in multiple publications. In late 2023, a Swedish court found him guilty of gross assault of his patients, and sentenced him to 30 months in prison. His misconduct as a medical professional as well as other troubling details about his private life have been explored in a recent Netflix documentary as well as in other dramatizations.
Conflict of Interest
In the 18th century, the Scottish physician Dr John Gregory identified the potential for conflict between patient care and financial gain from surgery in his paper, “Lectures on the Duties and Qualifications of a Physician”. These concerns have only grown, and in the early 2000s, a perceived lack of transparency in disclosure of surgeons’ financial dealings with medical device manufacturers led to the Cleveland Clinic in the USA modifying their Conflict of Interest policies. Whilst receiving remuneration for providing quality patient care is appropriate, it is important that this income generation is transparent and does not cloud clinical judgement.
Dilemmas
Cardiac surgery is inherently complicated. Unfortunately, it gets even more complicated when decisions have to be made regarding prioritisation of recipients of treatment. So let me give you a few hypothetical scenarios. You have two patients on the heart transplant waiting list. One is an upstanding member of the community, involved in public service. The other is a convicted criminal. Your clinical judgement alone dictates that the latter is in more urgent need of the donor heart, and you know that you should treat all patients alike, regardless of who they are or what they have done. But morally, how comfortable are you with that decision? Let’s consider another one – you have two patients in critical condition, both in need of intensive care…but the ICU only has one bed free. How do you decide who gets the bed? The final scenario is not hypothetical at all – in the case of Charlie Gard, who was born with an extremely rare terminal genetic disorder, there was a prolonged legal battle in which the patient’s parents and the medical team at Great Ormond Street Hospital argued over the best course of action – to explore experimental treatment in the US, or for life support to be switched off. The reality is that whilst there may be a legally binding solution, it is extremely difficult to find a solution that is satisfactory to all involved.
Stress
Cardiothoracic surgery is a gruelling activity – there are long periods of standing and operating with intense concentration, which is both physically and mentally draining. A 2014 study on chronic stress and coping amongst cardiac surgeons reviewed existing literature and found that cardiac surgeons were at a much higher risk of burnout than surgeons in other fields. Burnout is a physical and mental breakdown due to prolonged overwork and stress and it affects not only the surgeon, but their families and their patients. It is therefore imperative that surgeons strive to achieve a healthy work-life balance and find positive ways of coping with the stresses of the job.
Honesty
The final ethical consideration is honesty. It is important that a surgeon is honest with their patient with regards to the possible clinical outcomes so that the patient entrusts the surgeon with their life having understood their clinical state. It is also important that we recognise that any clinical record or insurance claim form we sign as surgeons could be presented as evidence in future legal proceedings, and we may be called upon to clarify or defend what we have written. Finally, it has to be recognised that surgeons, being human beings, have limitations, and whilst we are in the business of saving lives, we are not infallible.
Closing Remarks
In the spirit of being honest, I must confess that whilst I was practising as a cardiothoracic surgeon, this type of presentation would’ve been completely outside my comfort zone. Like many of you, I’m sure, I was more comfortable focusing on the facts and figures and technical aspects of surgery. However, I hope the examples I’ve presented here have gone some way to demonstrate that in a lot of situations, a safe pair of hands is not good enough. And what I’ve presented is just the tip of the iceberg – unfortunately I’m sure many of you would be aware of other situations where those providing care have been found wanting.
So what can we, as a professional community, do about it? I’d like to close with some recommendations for improving ethical considerations in cardiothoracic surgery in Sri Lanka, based on my almost 50 years of service as a doctor.
Recommendations
Firstly, senior practising surgeons should be involved in ethics training for new doctors, perhaps through refresher training in ethics for junior cardiothoracic surgeons. This would ensure that junior surgeons are familiar with current and relevant ethical case studies and their legal ramifications, and consultants are familiar with the nature of the ethical training being undertaken.
There should also be a consistent method of measuring quality that is accessible to all cardiothoracic surgical units in the country. I’m pleased to say that this council has already taken the first steps in establishing a pathway to quality assessment of cardiothoracic surgery in Sri Lanka. This could then lead to a process of regular performance reviews for surgeons, to ensure good professional standing in the sector.
Now these are just three recommendations that I personally feel would help improve ethical compliance at key points in the professional journey of a cardiothoracic surgeon. I hope this presentation serves as food for thought so that we can work together as a professional community to further improve the quality of cardiothoracic care in Sri Lanka.
Conclusion
Finally, I leave you with an excerpt from a poem originally written by Rudyard Kipling, and modified by the late Prof. K. Rajasuriya.
“If you can bear in mind that you are dealing
With human life and not with ‘cases’, pray,
If you can treat them without discriminating
Whether they are labelled ‘pauper’ or ‘to pay’.”
(The full text can be found in the SLMC’s Ethics Guide I mentioned previously.)
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