A person can decide what is right or wrong based on the ethical principles that guide them. It is a subfield of philosophy that conducts an intellectual examination of the complexity of human morality [1]. Medical ethics rules serve as a guide for actions and decisions that have a clinical impact on patients. A particular branch of medical ethics defines certain moral conundrums and concerns that are unique to surgeons. Due to its many distinct characteristics, surgery calls for a special ethical approach. The patient's body is penetrated during surgery, which is invasive and painful before healing.

Surgery-related decisions are frequently made in the shadow of ambiguity [2]. Given how quickly the field of surgery, particularly robotic surgery, and other cutting-edge techniques, is developing, the surgeon is being presented with more and more difficult ethical dilemmas [2].

As surgery, particularly robotic surgery and other cutting-edge techniques, develop quickly, the surgeon is forced to deal with more and more difficult ethical issues [2]. This essay's goal is to outline the ethical dilemmas that contemporary surgeons face in their field.

The Practice of Surgical Ethics

In addition to being in charge of surgical ethics, the surgeon has a duty to safeguard the patient's well-being. According to Namm [3], the origins of surgical ethics can be found in Egypt and Mesopotamia. The application of ethics to a situation that is specific to the practice of surgery is defined as surgical ethics [4]. Surgical ethics has distinct objectives and traits that support the surgical discipline [3,4]. By virtue ethics, duties and rights, and appeals to specific kinds of principlism, surgical ethics is not dissimilar from general medical ethics [4]. Mc Cullough defined the scope of surgical ethics as the procedural nature of surgery to cause psychological and physical damage, which may modify general ethical principles like justice, rights, equality, and virtues [5].

Modern surgery, according to neurosurgeon Anne-Laure Boch, is the setting where science and knowledge are combined to form technoscience. Technology and science must advance in tandem for technoscience to exist. The goal of medicine is to advance scientific and technological advancements in the surgical field during the 20th century. Ethical principles must guide surgeons in surgery, medicine and the operating theatre.

According to Ann-Laure Boch, surgical ethics incorporates three major realities of surgery: 1) well-done work as the body is considered an object; 2) ethics of action as surgery is oriented not towards speculation but towards action; 3) ethics of relationship in which the human relationship is important and the technical prowess of surgery would be futile, without this relationship [6].

The qualities listed below are necessary for surgeons: i.e. a good surgical technique is also necessary for them to master the art of surgery, in addition to honesty, fairness, kindness, punctuality, and perseverance [7]. These surgical techniques are learned over the course of extensive training and are then repeatedly practiced by the surgeon as they work in the field. This practical virtue, which is based on practical wisdom, judgmental ability and phronesis. Phronesis is a disposition that is accompanied by a cause that is put into motion and is either good or bad for mankind [6,7]. Technical proficiency during surgery cannot be the only goal. The proportion of care and the patient's best interests must be taken into account when putting this into perspective. Contrary to the Hippocratic principle of "primum non nocere," surgical incisions, sutures, and diathermy cauterizations appear to disregard the integrity of the patient. But in order to heal patients, surgeons must disentangle the patient's body from their soul, which calls for a penetration of the patient's body. To avoid damage the spiritual part may be sheltered whilst the object being the body may be disrupted to allow healing [8,9].

The support of any unnecessary surgery that only serves to artificially prolong life should not be given by caregivers [8]. It is ethically and legally acceptable not to perform the procedure on the patient when it is ineffective. The clinical choice must be made with the patient's best interests in mind, while also honoring any prior wishes the patient may have expressed. A clinical decision regarding whether to operate or not to operate must be made in the patient's best interests if there are no advance directives and in accordance with the presumed patient wishes. Surgery can now extend life in dire situations thanks to advances in surgical technology and critical care management. Due to this, futility issues are now more frequently raised in the surgical field. In the treatment of surgical patients, problems with medical futility are more obvious [9,10]. Grant and associates. Grant, stated that futility discussions are most important when surgery is considered for critically ill patients.

Given that surgical intervention has the potential to harm the patient, it is important to strike a balance between the ethical principles of beneficence and nonmaleficence. In particular, the patient, the anesthesiologist, and the surgeon must all give their consent before any surgery can be performed. In discussions about surgical futility, the autonomy of the patient and the surgeon’s duty to provide care must be taken into account when determining whether to proceed with the procedure.

Informed Consent

When treating patients, doctors' primary duty is to the patients, prioritizing their needs over all other considerations, both personal and professional [10]. Respect for a person's autonomy, often known as patient autonomy, is one of the cornerstones of medical ethics. It recognizes a person's right to decide what will happen to their own body and to act accordingly. The manifestation of this principle in medical practice is informed consent, which consists of three crucial components: the prerequisites for decision-making (capacity to make decisions and voluntariness), the disclosure of information (relevant facts and recommendations), and the consent (which includes both the patient's actual decision and permission for others to carry out that decision) [11].

The patient and the doctor are the two main actors in the decision-making process. Physicians have made choices based on their experience and specialized knowledge unilaterally and paternalistically since ancient times. Today, the procedure has developed into "shared decision making," in which patients contribute their own preferences and values, doctors offer their expert knowledge and guidance, and patients are ultimately accountable for deciding what should be done. The patient and the doctor are the two main actors in the decision-making process. Physicians have made choices based on their experience and specialized knowledge unilaterally and paternalistically since ancient times. Today, the procedure has developed into "shared decision making," in which patients contribute their own preferences and values, doctors offer their expert knowledge and guidance, and patients are ultimately accountable for deciding what should be done.

There are many various ways that one's ability to make decisions can be impaired or lacking. A patient may become handicapped as a result of a physical condition (such as a stroke, dementia, or traumatic brain damage), being young (such as a Newborn or preadolescent), or having a severe mental disability. When a patient lacks the mental capacity to make decisions, they are typically made on his behalf by a surrogate decision-maker (someone who is legally permitted to make decisions) or proxy decision-maker (someone who has previously been given the patient's consent to make decisions). The decision of the patient (or other designated individual) may accept or reject the doctor's advice. Refusal has the same significance and weight as consent.

In recent years, there has been a growing body of research on family participation in resuscitation (FPDR). Many hospitals have a policy known as FPDR that permits or even encourages family members to attend CPR and other procedures, with the exception of those that take place in operating rooms. Many people continue to question the wisdom of FPDR despite surveys suggesting that it is not only acceptable but also helpful to families and healthcare professionals [12]. The difficulty of successfully resolving futility disputes falls on surgeons when there is a significant difference of opinion between the patient and the medical staff. The following list highlights the variations between qualitative and quantitative futility [11].

Quantitative futility, also known as physiological futility, is dependent on the likelihood of success in science. Some people may not consider an intervention to be futile when it has a low chance of success, while others may view it as such [12]. The patient's context must be used to determine the threshold for the probability of success. When high-quality clinical evidence is lacking, judgment and experience are the only resources left to draw a conclusion about futility. After treatment, there is an unacceptable functional status or quality of life, which is referred to as "qualitative futility."

Without conscious autonomy, biological life is thought to be qualitatively futile [12].

Surgery decision-making is a two-step process that considers whether or not a patient can be treated as well as "how to treat" them. As a matter of surgical ethics, the "why treat" issues should also be addressed [13]. Surgeons are faced with a variety of moral conundrums, and studies have shown that the majority of these conundrums center on choosing the best course of action in various situations [14]. Withholding or beginning treatment, fulfilling patient expectations, treating patients with respect, and over treating are some of the situations. In a study by Ferreres et al., decisions involving terminal patients were the most frequent ethical issues, followed by uncertainty about the best treatment, the risk of futility, refusal of surgical intervention, and communication [15,16].

Innovation in patient surgical management could also lead to ethical issues [17]. Innovation is largely responsible for surgical advancements. Innovative surgical techniques had reduced mortality and morbidity for many surgical procedures, which improved patient outcomes [18]. However, not all innovations will necessarily lead to better patient care [18]. With regard to potential harm and safety, there are advantages and disadvantages for patients with surgical innovation. The patient's actual risks are frequently unknown at the time a surgical innovation is put into practice. An innovative surgical technique might need to be tested on thousands of patients to determine safety and compare it to conventional surgical approaches.

Challenges are therefore created for patients, surgeons, and the health system, due to the uncertainty of a particular innovation. In a study by Zarzavadjan Le Brian, it was found that many ethical conflicts were due to doubts about the methodology of innovation and its risk assessment [19]. Upon implementation of new surgical techniques, the following ethical considerations are relevant: safety of the new technology, the process, and timing of the new surgical technique implemented in the hospital informed consent from patients undergoing a new surgical technology, whether the surgeons were trained in the new technique and issues on how the outcomes of the new technique are evaluated.

An ethical conundrum might arise for surgeons when they must decide between two alternative courses of action [20]. Because neither choice has a favorable result, it might be necessary to choose the least undesirable course of action. When there is tension or conflict between two or more principles, ethical quandaries may also develop. The surgeon is in this situation and is unsure of what moral standard or principle should be upheld. Four ethical principles developed by Beauchamp and Childress assist the surgeon in determining "why to treat" [20]. These four moral tenets are beneficence, justice, non-malfeasance, and respect for patient autonomy. These four guidelines should be followed by everyone as they make up a framework of "common morality."

Respect for Autonomy

Patients are independent agents with the capacity to give informed consent, which is crucial to the surgeon-patient relationship. As the last step in the surgeon's information process, informed consent should be given by the patient voluntarily and independently [21].

The Principle of Beneficence

The surgeon is required by this principle to act in the patient's best interest. The surgeons who are in charge of minimizing harm to the patients must maximize the potential benefits for them.

The Principle of Non-Maleficence

It is the surgeon's responsibility to treat patients with care. Patient harm should be kept to a minimum. Surgery should only be performed if the potential advantages outweigh the risks.

The Principle of Justice

All patients should have equal access to healthcare. When resources are scarce, they should be allocated equally, as should the time that surgeons spend with patients. When necessary, expensive surgeries should be performed; under treatment should not occur because of rising healthcare costs. Patients have a right to have their health valued significantly higher than the surgeon's own financial interest.

Jonsen AR, uses a four-box model to describe a clinical ethics approach (). Patient preferences, medical indications, contextual features, and quality of life are the four categories in the box. Numerous details about the patient's goals, way of life, and health are necessary for the surgeon to understand. Therefore, the surgeon should consider the patient's overall life and not just the medical issues. A thorough explanation using this model is given in the Wightman and Angelos paper [22].

The English surgeon Miles little classified surgical ethics into five categories within the moral context of the surgical relationship. Proximity, rescue, aftermath, ordeal, and presence round out the top five [23]. Surgeons must acknowledge the patient’s need for rescue. Surgeons may require assistance from other surgeons to be rescued in situations of difficulty with operations or management and difficulty with diagnosis.

As a result, rescue is the primary tenet of surgical ethics, according to little. Surgeons must be close to their patients in order to comprehend their unique needs and suffering [24]. Integrating this presence enables the surgeon to comprehend what may be demanded in an ethical sense and what is ethically normal [25]. A skilled surgeon is one who is capable of performing both the science and the art of surgery and is regarded as morally and ethically trustworthy.

According to Pellegrini, a capable modern surgeon must possess the following qualities: 1) Knowledge and application of ethics, strong moral principles, and humanism; 2) Good technical skills, including expertise and knowledge in performing operations; and 3) Good clinical skills, including clinical judgment [26].

Ethics is a crucial aspect of surgical practice. Even the most complex and technically demanding surgery must be performed with an ethical mind-set if it is to be successful. A good surgeon must be able to balance technical issues with surgical ethics considerations. It is crucial to recognize the significance of surgical ethics and how it affects society, medical professionals, and patients. Patients must acknowledge the socially endorsed power of surgeons. This authority comes from the surgeon's knowledge (episteme), technical skill (techne), and decision-making ability (phronesis). Power is viewed as annihilation or dominance, and it is a relationship that assumes rescue [27]. Patients should be aware of the power of a society-approved surgeon. This power derives from their knowledge (episteme), technical ability (techne), and surgeon's judgment (phronesis). Power is seen as destruction or domination and is a relationship that presupposes rescue [27].

Establishing the ideal environment for practicing humanism should involve institutions and society. They ought to be made aware of the difficulties that surgeons face on a daily basis. The profession of surgery should not be associated with never-ending, callous, or unbeatable workers. To define futility and create evaluation criteria for it, institutional and community standards should be created. To address these various ethical spaces, committees at the institution and discussion groups should be formed.

In addition to being knowledgeable in the science and art of surgery, surgeons should be morally and ethically reliable. Surgeons must be ready for and aware of this possibility because the nature of surgical work may serve as a fertile ground for the emergence and growth of ethical issues and problems [28].

Surgeons must use their judgment when making moral choices, and ethical committees should be consulted if those choices are particularly challenging. When a surgeon receives an education based on ethics, they are more likely to become culturally competent. Through this training, surgeons will become more capable in their day-to-day work, making moral judgments, and implementing new technology in institutions facing financial strain. The general curriculum should include ethics in all surgical specialties [29]. Surgery should not be seen as merely a useful use of technology but as a humanistic art of healing.

Abbreviations

FPDR - Family presence during resuscitation

The support of the administration of Masaka Regional Referral Hospital in encouraging high standards in the ethical practice by surgeons working in the Department of Surgery. The support of Ethics courses to PhD scholars conducted by the Makerere University International Bioethics Research and Training Programme is also acknowledged.

Declaration of Conflict Of Interest

The author declared no potential conflicts of interest with regards to the research, authorship, and/or publication of this article.

Ethical Approval

Not applicable

Consent for Publication

Not applicable

Competing Interests

The author of this article declares no competing interests and no conflict of interest in the publication of this research article.

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