Thought Leader on Surgical Ethics

Under the leadership of Peter Angelos, MD, PhD, the University of Chicago teaches surgeons how to navigate the ethical quandaries distinct to their field

Peter Angelos, MD, PhDPeter Angelos, MD, PhD

It was supposed to be a routine parathyroidectomy. But, not long into the procedure, the young surgeon found a suspicious nodule in one of the lobes of his patient's thyroid. Without delay, he removed the lobe and sent it to the lab for analysis. The results were called directly into the operating room: Cancer.

The logical next step would have been to remove the remaining lobe. But Peter Angelos, MD, PhD, checked himself. This was not without ramification. There was a small chance the patient, a minister, would be left permanently hoarse. He'd need replacement thyroid hormone for the rest of his life. Would the patient sanction the procedure? It hadn't been among the contingencies discussed before the surgery. Angelos left the operating room to consult with the patient's family.

The minister's family was adamant that he wouldn't want Angelos to proceed -- not without discussing it with him first.

Angelos was concerned, but heeded the family's wishes. The minister was thankful Angelos hadn't pressed ahead. "I told him he needed another operation," Angelos recalled. "He said, 'I understand, but I'm glad no one made that decision for me.'"

The ultimate outcome of the case -- removal, without complication, of the patient's entire thyroid (albeit after a second operation) -- was unremarkable in view of what had been discovered. But more than 15 years later, Angelos looks back on the ethical questions that were posed along the way.

As chief of endocrine surgery at the University of Chicago Medicine and professor at the Pritzker School of Medicine, Angelos, 50, is a world-renowned expert in the surgical treatment of disorders of the endocrine organs, such as the thyroid and parathyroid, including cancer. Procedures like parathyroidectomies are his bread and butter. But as the Linda Kohler Anderson Professor of Surgery and associate director of the MacLean Center for Clinical Medical Ethics, Angelos also directs the first program in the nation dedicated to the study of surgical ethics. Each year, under his aegis, the University teaches a cohort of residents, fellows and mid-career surgeons how to navigate the ethical quandaries distinct to surgery.

Peter Angelos, MD, PhD, speaks in March 2012 as part of the Named Professor Lecture Series
Peter Angelos, MD, PhD, speaks in March 2012 as part of the Named Professor Lecture Series. The audience included Kenneth S. Polonsky, MD, Dean of the Biological Sciences Division and the Pritzker School of Medicine and executive vice president for Medical Off airs at the University of Chicago, and Mark Siegler, MD, director of the MacLean Center for Clinical Medical Ethics and executive director of the Bucksbaum Institute for Clinical Excellence.

The case from the 1990s encapsulates several of these issues. For starters, Angelos' decision to excise the lobe on which he found the nodule is grounded in the distinct nature of informed consent in surgery, in which patients sign pre-operative form explicitly empowering the surgeon to exercise his professional judgment. On the other hand, Angelos balked at removing the second lobe, seeking counsel from surrogates for the patient before proceeding, underscoring the imperative to respect the autonomy of an anesthetized patient who cannot express his own wishes. Finally, the possible side effect of lifelong hoarseness, an especially bitter blow for a patient whose livelihood relied on his voice, crystallized the gravitas of surgery's defining act: opening a person up while they are incapacitated to re-engineer their organs -- an action both drastically restorative but inherently risky.

This coupling of great power with grave responsibility is captured in an oft-cited remark by sociologist Charles L. Bosk, PhD'76, MA'74, in a landmark study of how surgeons manage mistakes, "Forgive and Remember," written while he was a graduate student at the University. "When the patient of an internist dies," Bosk wrote, "the natural question his colleagues ask is, 'What happened?' When the patient of a surgeon dies, his colleagues ask, 'What did you do?'"

And it's a reason why, as Bosk noted, "postgraduate training of surgeons is above all things an ethical training." Of all the mistakes trainees might make, particular opprobrium is reserved for "normative errors" -- those involving ethical breaches such as covering up an error -- Bosk wrote. "Subordinates are harshly disciplined when they violate the ethical standards of the discipline. They are promoted and accepted into the ranks as colleagues on the basis of their ethical fitness."

Still, Angelos deems the concept of surgical ethics as a distinct field of study "revolutionary."

While traditional training of surgeons has been tacitly ethical, surgical ethics represents an effort to reframe issues that historically have been approached as matters of professionalism or surgical judgment in explicitly ethical terms.

"This gives surgeons a new language with which to talk about things and an awareness of the influences that ought to be shaping their decisions," Angelos said. "Being a better surgeon is not just about being technically better. It's about appreciating the implications of what we do in the OR."

A 2011-12 fellow credits the surgical ethics program with "completely changing the way I think."

The University's surgical ethics fellows undergo intensive instruction in philosophy and ethics. To help them tie philosophical and ethical principles back to real life, they are immersed in practical case studies and participate in an ethics consultation service, offering counsel to faculty members confronting ethical dilemmas in their everyday work.

Karen M. Devon, MD, a 2011-12 fellow, credited the program with "completely changing the way I think." She has returned to the University of Toronto, where she is an assistant professor of surgery, to institute a surgical ethics curriculum for residents there.

Angelos is raising questions and opening up a dialogue, said Bosk, now professor of sociology and medical ethics at the University of Pennsylvania. "It's a great thing to watch."

Recasting issues in ethical terms opens up more of a dialogue with patients, a critical function as patients become more involved in decision-making, Angelos said. "If a patient is really sick, whether to put them through an operation is a question of surgical judgment. But it also has ethical aspects because it needs to take account of their desired outcome."

The distinct way innovation is introduced in surgery is another core focus of the program.

Whereas new drugs must demonstrate efficacy through strictly regulated trials and secure FDA approval before they may be generally prescribed, the development of novel surgical protocols frequently has occurred independent of such controls.

Dr. Angelos with a patient
Peter Angelos, MD, PhD, an expert on endocrine surgery, talks with patient Jeffrey Guylay of Sun Valley, Idaho, at a postoperative checkup.

"Take any surgical standard of care we now have -- appendectomy, cholecystectomy, hepatectomy, neurosurgery, the great developments in thoracic and cardiovascular surgery, laparoscopic surgery, minimally invasive surgery and on -- and trace them back, you find they are the result of professional self-regulation, innovations surgeons have made with oversight from their colleagues," said Mark Siegler, MD, the Lindy Bergman Distinguished Service Professor of Medicine, director of the MacLean Center, and a long-standing member of the American College of Surgeons' ethics committee.

Moreover, extending some of the checks and balances governing innovation in other branches of medicine, such as placebo-controlled studies, to surgery is challenging, Angelos has written. In a 2003 paper in the American Journal of Bioethics, he noted, for example, that sham surgery, the surgical version of a placebo, is an invasive procedure with real risk, and that it entails a considerably more elaborate pretense than simply administering a sugar pill in a drug study -- factors that make it difficult to use more than sparingly.

But in a field in which iterative "tweaks" on established procedures or adaptations to accommodate physical differences between patients are commonplace, it may be unclear when an action constitutes outright experimentation for which explicit patient consent must be sought, Bosk, Angelos and others have observed.

Such uncertainties place formal ethics instruction at a premium, Angelos said.

Angelos' background may make him uniquely qualified to provide this.

"This gives surgeons a new language … and an awareness of the influences that ought to be shaping their decisions," Angelos said.

His first encounter with philosophy and ethics came as a teenager through a class he took at the local State University of New York campus in upstate New York, where he grew up. "The concept of studying actions and that some were better than others was powerful," he recalled. Angelos was hooked.

Inspired by his physician father, he gravitated toward medicine while still in high school. Spurning offers from both Harvard University and the Massachusetts Institute of Technology, Angelos enrolled in the combined six-year BA/MD program at Boston University, where he soon felt the pull of surgery, his father's specialty.

But he kept up his interest in ethics, making philosophy his undergraduate minor. After Angelos completed his bachelor's degree, he decided to continue his study of philosophy by pursuing a PhD.

Yet he struggled initially with how to apply his philosophical training to surgery.

A formative influence in connecting the dots was David L. Nahrwold, MD, former chief of surgery at Northwestern University, where Angelos did his residency.

S. Peter Angelos, MD, Peter Angelos, MD, PhD, and Mark Siegler, MD (left to right)
Peter Angelos, MD, PhD, introduces two men who influenced his career trajectory: his father, surgeon S. Peter Angelos, MD, left, and Mark Siegler, MD.

As a young surgeon in the early 1960s, Nahrwold landed a fellowship in the lab of renowned physiologist Morton I. Grossman, MD, PhD, at the University of California, Los Angeles. "What I observed as a surgeon in a physiology department was that when [Grossman] would get together with professors from other disciplines, they'd generate ideas they could never have come up with on their own," he recounted.

In charge of admissions to the surgical residency program at Northwestern, Nahrwold made it a point to look out for nonconventional applicants who could bring knowledge from other fields to surgery.

"I thought Peter could be an enormous resource for surgery in this country if he persisted and everything was orchestrated to get him on the faculty someplace."

There was the small matter of the PhD though. Angelos had yet to finish it. His dissertation, "The Moral responsibility of the Physician: A Philosophical Examination," had been deemed "too applied"; he'd been asked to rewrite it. Now, he was entering the notoriously grueling surgical residency program designed to steel trainees to the rigors of surgical practice.

Nahrwold arranged for Angelos to devote the residency's research year to retooling his dissertation. To that end, Angelos enrolled in the clinical medical ethics fellowship program at the MacLean Center.

Angelos finished his residency (Northwestern) and PhD (Boston University) in 1995. He then completed a yearlong fellowship in endocrine surgery at the University of Michigan. Nahrwold recruited him to Northwestern immediately after.

Angelos is "ideally suited to launch the new field of surgical ethics," Siegler said.

At Northwestern, Angelos built a busy surgical practice and devised an ethics curriculum for surgical residents that became an early model for how ethics teaching could be undertaken in a surgical residency. He rose to become associate professor of surgery and chief of endocrine surgery.

But something nagged at him.

"We'd meet maybe once a year, and always return to the question of how he could better incorporate his training and interest in ethics into his clinical work," recalled Siegler.

Angelos' acceptance in 2006 of a professorship at the Pritzker School of Medicine with an associate directorship in the MacLean Center offered him a platform.

But Angelos and Siegler had something more in mind. "As we'd talk over the years, what came to us was the idea of developing this field of surgical ethics that had hardly been examined before, and establishing the first program in the nation at the University," recounted Siegler.

A history of surgical ethics

The program Angelos established builds on a long-standing tradition of innovation in what would now be considered surgical ethics at the University of Chicago.

"It's become a part of our daily activity to put things in an ethical framework," said Jeffrey B. Matthews, MD, chair of surgery at the University of Chicago Medicine.

For example, the way surgeons ethicists at the University of Chicago approached the first U.S. living-donor liver transplant in 1989 is considered an exemplar of responsible, thoughtful surgical innovation. Though living-donor liver transplants are widely accepted now, at the time there were concerns that the procedure could become "the first operation with a 200-percent mortality" -- donor and recipient, Siegler recounted in a 2007 lecture. The University embarked on two-plus years of due diligence, consulting widely and formulating robust protections for living liver donors. This process culminated in the publication of a paper in the New England Journal of Medicine three months before the first living-donor liver transplant was performed. The paper presented a new ethical model to analyze surgical innovations before they are introduced. This scrupulousness ultimately cost the University of Chicago the prestige of being the first in the world to perform the surgery, noted Siegler, a prime mover behind the deliberations and co-author of the journal article. But it was instrumental in establishing the procedure in surgical practice, he said. "It was the Chicago protocol series of 40 cases that allowed the world to learn the techniques, to modify them and go forward."

While not as visible to the outside world, innovations introduced by Angelos to the way surgeons work at the University of Chicago Medicine could have similarly far-reaching effects.

Once a month, surgeons now fold an ethics discussion into the mortality and morbidity conferences they hold weekly to review difficult cases.

"This is truly unique," said Devon, the former fellow. "The idea of having a bunch of surgeons discussing medical complications and including cases where an ethical issue is the focus is more progressive than you might imagine. It has become part of the surgical culture at the University of Chicago."

The innovation has been a lever for embedding ethical considerations into surgical practice more generally. "It's become part of our daily activity to put things in an ethical framework," said Jeffrey B. Matthews, MD, the Dallas B. Phemister Professor of Surgery and chair of surgery.

Angelos' personal example also has been pivotal in this. In 2011, his colleagues nominated Angelos to receive the Pritzker School of Medicine's Faculty Physician Peer Role Model Award.

"He's articulate, approachable, curious and not judgmental," said Matthews. "I've seen the discussion of ethics get sanctimonious; Peter is very non-judgmental. He's nuanced and helps people think through problems. It makes the program feel real, not theoretical."

This equanimity was on display the time Angelos' father watched him in action during his early days as a surgeon. Angelos was directing a procedure in which a resident was using a laparoscope when a "sudden flood of blood" appeared on the monitor, obscuring the view, recalled S. Peter Angelos, MD. "The resident said, 'Dr. Angelos, you've got to get over on this side, so you can take care of this.'"

"Peter said, 'Now, you're a surgeon, you're going to learn how to do this. Just take 10 seconds to get your wits together.' He walked her through things, but didn't take over. He was patient, didn't yell or lose his temper, and he didn't get excited about a misadventure."

This comports with the vision Siegler and others had in the 1970s, which led to the creation of the MacLean Center: a new breed of "clinical" medical ethicist, who would bring a practitioner perspective to an ethics field then dominated by non-medical professionals. "Clinical ethicists have to demonstrate they are practitioners involved in the clinical mission, and Peter does that in an exemplary way. His clinical skills and judgment, technical abilities, and relationship with his patients are all of the first order," Siegler said. "He was ideally suited to launch the new field of surgical ethics."

Paternalism no more

The doctor-patient relationship has undergone transformation over the past half-century. In a 2008 World Journal of Surgery paper, Peter Angelos, MD, PhD, cites the results of surveys conducted 14 years apart at Chicago's former Michael Reese Hospital, polling physicians on whether they informed patients of a cancer diagnosis. In 1961, 88 percent said they did not; in 1975, 98 percent said they did. The shift illustrates the demise of so-called "paternalism" -- what was once viewed as well-intentioned discretion ("saving patients from themselves") now is viewed as overweening professional condescension.

Medicine on the Midway cover

This story originally ran in the Spring 2013 issue of Medicine on the Midway, a publication of the University of Chicago Medicine and Biological Sciences Division.
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