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The SARS-CoV-2 pandemic has highlighted existing systemic inequities that adversely affect a variety of communities in the United States. These inequities have a direct and adverse impact on the healthcare of our patient population. While civic engagement has not been cultivated in surgical and anesthesia training, we maintain that it is inherent to the core role of the role of a physician. This is supported by moral imperative, professional responsibility, and a legal obligation. We propose that such civic engagement and social justice activism is a neglected, but necessary aspect of physician training. We propose the implementation of a civic advocacy education agenda across department, community and national platforms. Surgical and anesthesiology residency training needs to evolve to the meet these increasing demands., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

The rapid growth of global pediatric surgery beyond direct care delivery into research, education, and advocacy necessitates re-evaluation of the traditional ethical paradigms which have governed our partnerships in low- and middle-income countries (LMIC). Within this paper, we consider current and emerging ethical challenges and discuss principles to consider in order to promote autonomous systems for pediatric surgical care in LMIC.

Purpose of Review: Rapid advancement in the field of pediatric surgery has resulted in unprecedented opportunities to advance the care of children. However, assuring that the highest quality, most appropriate care is available to all pediatric patients remains challenging. Regionalization of care has been proposed as a means of obtaining this critical goal. In this review, we discuss the ethical challenges associated with regionalization of pediatric surgical care., Recent Findings: Regionalization of pediatric surgical care is associated with improved patient outcomes. Over half of pediatric surgeons favor regionalization of care. Despite these findings, regionalization of care may be associated with inequitable distribution of resources, financial and emotional burdens for patients and families, and surgeon dissatisfaction and technical decline., Summary: Regionalization of pediatric surgical care is fraught with complex ethical issues. Development of a system of pediatric surgery networks may offer a solution to these challenges.

As part of establishing a gender surgery center at a pediatric academic hospital, we undertook a process of identifying key ethical, legal, and contextual issues through collaboration among clinical providers, review by hospital leadership, discussions with key staff and hospital support services, consultation with the hospital's ethics committee, outreach to other institutions providing transgender health care, and meetings with hospital legal counsel. This process allowed the center to identify key issues, formulate approaches to resolving those issues, and develop policies and procedures addressing stakeholder concerns. Key issues identified during the process included the appropriateness of providing gender-affirming surgeries to adolescents and adults, given the hospital's mission and emphasis on pediatric services; the need for education on the clinical basis for offered procedures; methods for obtaining adequate informed consent and assent; the lower and upper acceptable age limits for various procedures; the role of psychological assessments in determining surgical eligibility; the need for coordinated, multidisciplinary patient care; and the importance of addressing historical access inequities affecting transgender patients. The process also facilitated the development of policies addressing the identified issues, articulation of a guiding mission statement, institution of ongoing educational opportunities for hospital staff, beginning outreach to the community, and guidance as to future avenues of research and policy development. Given the sensitive nature of the center's services and the significant clinical, ethical, and legal issues involved, we recommend such a process when a establishing a program for gender surgery in a pediatric institution., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

Background: Physician-industry relationships have been complex in modern medicine. Since large proportions of research, education and consulting are industry-backed, this is an important area to consider when examining gender inequality in medicine., Methods: The Open Payments Program (OPP) database from August 2013 to December 2016 was analyzed. In order to identify physicians' genders, the OPP was matched with the National Provider Index dataset. Descriptive statistics of payments to female compared to male surgeons were obtained and stratified by payment type, subspecialty, geographic location and year., Results: 3,925,707 transactions to 136,845 physicians were analyzed. Of them, 31,297 physicians were surgeons with an average payment per provider of $131,252 to male surgeons compared to $62,101 to female surgeons. Significantly fewer women received consultant, royalty/licensure, ownership and speaker payments. However, women received a higher average amount per surgeon compared to their male counterparts within research payments. Overall payments to women trended upwards over time., Conclusion: Gender inequality still exists in medicine, and in industry-physician payments. Industry should increasingly consider engaging women in consultancies, speaking engagements, and research., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Surgical innovation has advanced outcomes in the field, but carries inherent risk for surgeons and patients alike. Oversight mechanisms exist to support surgeon-innovators through difficulties associated with the innovation process., Methods: A literature review of ethical risks and oversight mechanisms was conducted., Results: Oversight mechanisms range from the historical concept of surgical exceptionalism to departmental, hospital, and centralized committees. These fragmentary and non-standardized oversight mechanisms leave surgeon-innovators and patients open to significant risk of breaching the ethical principles at the core of surgical practice. A systematized approach that mitigates these risks while maintaining the independence and dignity of the surgical profession is necessary. We propose an oversight framework that incorporates multiple structures tailored toward the ethical risk introduced by different forms of innovation., Discussion: We summarize ethical risks and current regulatory structures, and we then use these findings to outline an oversight framework that may be applied to surgical practice.

Although certain medical societies have released guidelines on the use of social media, plastic surgery, with its inherent visual nature and potential for sensationalism, could benefit from increasing direction regarding the ethical use of social media. The authors hypothesized that although general platitudes for use exist in the literature, guidelines articulating the boundaries of professional use are nonspecific. Systematic searches of MEDLINE, Embase.com, and Cochrane Central Register of Controlled Trials were completed on January 18, 2017. Searches consisted of a combination of Medical Subject Headings terms and title and abstract keywords for social media and professionalism concepts. In addition, the authors manually searched the three highest impact plastic surgery journals (ending in October of 2017). Two authors screened all titles and abstracts. Studies related to clinical medicine, patient care, and the physician-patient relationship were included for full-text review. Articles related to surgery merited final inclusion. The initial search strategy yielded 954 articles, with 28 selected for inclusion after final review. The authors' manual search yielded nine articles. Of the articles from the search strategy, 10 were published in the urology literature, eight were published in general surgery, six were published in plastic surgery, three were published in orthopedic surgery, and one was published in vascular surgery. Key ethical themes emerged across specialties, although practical recommendations for professional social media behavior were notably absent. In conclusion, social media continue to be a domain with potential professional pitfalls. Appropriate use of social media must extend beyond obtaining consent, and plastic surgeons must adhere to a standard of professionalism far surpassing that of today's media culture.

This case highlights an attending surgeon's conflicts between duty to care for individual patients, train independent surgeons, and serve a patient population in an efficient manner. Although oversight of surgical residents and multiple operating room scenarios can be conducted in an ethical manner, patients might not understand the realities of surgical training and clinical logistics without explicit disclosure. Central to the ethical concerns of the case are the attending surgeon's obfuscation of resident involvement and her insufficient oversight of two concurrent procedures. Full and proper informed consent, increased transparency, better planning, and improved communication could have prevented this difficult situation., (© 2018 American Medical Association. All Rights Reserved.)

Introduction: The tremendous need for increasing the quantity and quality of global pediatric surgical care in underserved areas has been well documented. Concomitantly there has been a significant increase in interest by pediatric surgeons in helping to relieve this problem through surgical volunteerism. The intent of the article is to serve as a practical guide for pediatric surgeons contemplating or planning a short-term global volunteer endeavor., Methods: The article is based on the authors' personal experiences and on the published experiences of other volunteers., Findings: The following aspects of volunteerism are discussed: ethical considerations, where and how to go, what and whom to take with you, what to expect in your volunteer locale, and what to do and what to avoid in order to enhance the volunteer experience., Conclusions: The points discussed in this guide will hopefully make the volunteer activity one that results in greatly improved immediate and long term surgical care for children and improves the chances that the activity will be a meaningful, pleasant, and productive experience for both the volunteer and the host physician., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Innovation is a crucial part of surgical history that has led to enhancements in the quality of surgical care. This comprises both changes which are incremental and those which are frankly disruptive in nature. There are situations where innovation is absolutely required in order to achieve quality improvement or process improvement. Alternatively, there are innovations that do not necessarily arise from some need, but simply are a new idea that might be better. All change must assure a significant commitment to patient safety and beneficence. Innovation would ideally enhance patient care quality and disease outcomes, as well stimulate and facilitate further innovation. The tensions between innovative advancement and patient safety, risk and reward, and demonstrated effectiveness versus speculative added value have created a contemporary "surgical conundrum" that must be resolved by a delicate balance assuring optimal patient/provider outcomes. This article will explore this delicate balance and the rules that govern it. Recommendations are made to facilitate surgical innovation through clinical research. In addition, we propose options that investigators and institutions may use to address competing priorities., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: In 2008, a Position Statement of the Society of University Surgeons (SUS) recommended the creation of institutional surgical innovation committees (SICs) to ensure appropriate oversight of surgical innovations. The purpose of this study was to determine the level of awareness of the position statement, and how innovations are handled in academic departments of surgery., Methods: An electronic survey was designed to determine the level of awareness of the SUS recommendations among members of the Society of Surgical Chairs; the existence and characteristics of SICs; and alternative means of oversight of surgical innovations., Results: The survey was distributed to 150 persons, and 65 (43%) surveys were returned; 84% reported their institution promoted innovative surgery as a strength, but 55% were unaware of the SUS recommendations; 23% reported that their institution has an SIC, and 20% said their institution has discussed or plans an SIC. Existing SICs have a median of 7 members; 57% reviewed 3 or fewer procedures in the prior year; and only 7% reviewed 10 or more. The majority of respondents reported alternative mechanisms of oversight, including morbidity/mortality conferences (88%), peer review (77%), and outcomes registries (51%)., Conclusions: A minority of Surgery Department Chairs is aware of the SUS Position Statement. Although most reported surgical innovation was an institutional strength, only 23% had an SIC and most rely on other mechanisms of oversight. It is unclear whether academic surgical departments are committed to providing education and awareness of the appropriate development and implementation of surgical innovations.

Objective: Asking for help in the operating room occurs within a surgical culture that has traditionally valued independence, decisiveness, and confidence. A tension exists between these deeply ingrained character traits and the new culture of team-based practice that emphasizes maximizing patient safety. The objective of this study is to explore surgeon-to-surgeon help-seeking behaviors during complex and unanticipated operative scenarios., Study Design: Semistructured interviews were conducted with a purposeful sample of 14 consultant surgeons from multiple specialties. We used constructivist grounded theory to explore help-seeking experiences. Analysis occurred alongside and informed data collection. Themes were identified iteratively using constant comparisons., Setting: The setting included 3 separate hospital sites in a Canadian academic health sciences center., Participants: A total of 14 consultant surgeons from 3 separate departments and 7 divisions were included., Results: We developed the "Call-Save-Threat" framework to conceptualize the help-seeking phenomenon. Respondents highlighted both explicit and tacit reasons for calling for help; the former included technical assistance and help with decision making, and the latter included the need for moral support, "saving face," and "political cover." "The Save" included the provision of enhanced technical expertise, a broader intraoperative perspective, emotional support, and a learning experience. "The Threat" included potential downsides to calling, which may result in near-term or delayed negative consequences. These included giving up autonomy as primary surgeon, threats to a surgeon's image as a competent practitioner, and a failure to progress with respect to independent judgment and surgical abilities., Conclusions: Our "Call-Save-Threat" framework suggests that surgeons recurrently negotiate when and how to seek help in the interests of patient safety, while attending to the traditional cultural values of autonomy and decisive action. This has important implications for surgical postgraduate education and also throughout a surgeon's career trajectory., (Copyright © 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

As surgery grew to become a respected medical profession in the eighteenth century, medical ethics emerged as a response to the growing need to protect patients and maintain the public's trust in physicians. The early influences of John Gregory and Thomas Percival were instrumental in the formulation of patient-centered medical ethics. In the late nineteenth century, the modern surgical advances of anesthesia and antisepsis created the need for a discipline of ethics specific to surgery in order to confront new and evolving ethical issues. One of the founding initiatives of the American College of Surgeons in 1913 was to eliminate unethical practices such as fee-splitting and itinerant surgery. As surgery continued to advance in the era of solid organ transplantation and minimally invasive surgery in the latter half of the twentieth century, surgical innovation and conflict of interest have emerged as important ethical issues moving forward into the twenty-first century. Surgical ethics has evolved into a distinct branch of medical ethics, and the core of surgical ethics is the surgeon-patient relationship and the surgeon's responsibility to advance and protect the well-being of the patient.

A younger vascular surgeon has been recruited to start a new program at a suburban hospital outside of a large city hosting a world-class medical center. The new program will provide state-of-the-art equipment, including robotics, free office space, and a generous salary guarantee. Dr Ready obtained a license in the state where he is relocating and is preparing to move. He is an excellent technical surgeon but is uncomfortable with complex aneurysm surgery. This morning he went to sign a contract with the hospital and found that a clause that prevents him from referring patients to physicians outside the hospital in strong legalese is included. How should he proceed?, (Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Innovations are indispensable to the practice and advancement of pediatric surgery. Children represent a special type of vulnerable population and must be protected since they do not have legal capacity to consent, and their parent's judgment may be compromised in circumstances when the child is very ill or no adequate therapy exists. In an effort to protect patients, legislators could pass and enforce laws that prohibit or curtail surgical innovations and thus stifle noble advancement of the practice. The goals of this paper are, 1) To clearly define the characteristics of surgical innovation types so interventions may be classified into 1 of 3 distinct categories along a continuum: Practice Variation, Transition Zone, and Experimental Research, and 2) To propose a practical systematic method to guide surgeon decision-making when approaching interventions that fall into the "Transition Zone" category on the Surgical Intervention Continuum. The ETHICAL model allows those that know the intricacies and nuances of pediatric surgery best, the pediatric surgeons and professional pediatric surgical societies, to participate in self-regulation of innovation in a manner that safeguards patients without stifling creativity or unduly hampering surgical progress., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: The "hidden curriculum" and role models for responding to medical errors might play a central role in influencing residents' attitudes about disclosure. We sought to compare surgical and nonsurgical residents' exposure to role modeling for responding to medical errors and their attitudes about error disclosure., Study Design: We conducted a cross-sectional, electronic survey of surgical and nonsurgical residents at 2 large academic medical centers. The questionnaire asked respondents about personal experience with medical errors; training for responding to errors; frequency of exposure to role modeling related to disclosure; and attitudes about disclosure. Descriptive statistics were used to describe frequencies. Chi-square and Fisher's exact test were used to compare proportions between surgical and nonsurgical trainees., Results: The response rate was 58% (253 of 435). Surgical residents reported more frequently observing a colleague be treated harshly (eg, humiliated or verbally abused) for an error than nonsurgical residents (sometimes or often, 39% [26 of 66] vs 20% [37 of 187]; p = 0.002). Surgical residents were more likely than nonsurgical residents to believe they would be treated harshly by others if they acknowledged making a medical error (35% [23 of 66] vs 12% [23 of 187]; p < 0.001) and believe they have to compromise their own values when dealing with medical errors at their institution (11% [7 of 66] vs 2% [4 of 187]; p = 0.008). Surgical residents were less likely than nonsurgical residents to feel free to express concerns to other members of the team about medical errors in patient care (70% [46 of 66] vs 83% [115 of 187]; p = 0.02)., Conclusions: The punitive response to error by senior members of the health care team might be an impediment to the transparent disclosure of errors among residents that might disproportionally affect surgical training programs., (Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: More than any other allograft, the allotransplantation of the face has a symbolic character, which raises a large number of questions. The objective of this article is to make an analysis through a survey carried out among French surgeons., Methods: A file of 909 e-mail addresses of surgeons was created so as to send out a questionnaire regarding 10 ethical issues., Results: Beyond the technical prowess, the surgeons ethical reflection initially focused on the notion of consent to donation and care. They attached equal importance to all ethical questions. They spontaneously raised the issue of over-mediatization of these first transplants and the place of the transplant surgeons and their patients in the medical information., Conclusion: Over two thirds of the surgeons attached importance to ethical issues regarding the donor and recipient of a facial allograft. Some of the principal questions facing facial transplantation is of an ethical nature as it is an unprecedented procedure that is challenged by the axiom to first do no harm and the need of modern medicine to limit risk to as close to zero as possible. For the non-specialist, accepting psychologically the face of another individual appears to be a real issue. Contrary to that, the main demand expressed by the facial transplant recipients appears to be related to facial functions rather than appearance., (Copyright © 2012 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: Professionalism, an Accreditation Commission for Graduate Medical Education (ACGME) competency, embraces the concept of adherence to ethical principles. Despite this, most surgical residencies do not currently include ethics as part of their core curriculum. Further, expertise in effectively managing ethical dilemmas is frequently obtained via modeling after the attending physician. This study evaluated surgical faculty (SF) and residents (SR) on their understanding of basic ethical principles and their overall confidence in translation of these principles into clinical practice. The objective was to determine if there are any differences in the overall levels of knowledge and confidence in ethics between SR and SF., Design and Setting: Immediately before the first session of a Kamangar Grant supported monthly Ethics Forum, all SF and SR completed a Pre-Curriculum Questionnaire (PCQ) on their knowledge about ethical principles and their confidence in dealing with ethical issues. PQC contained 13 multiple-choice and true/false knowledge questions and 8 questions evaluating confidence rated on a 5-point Likert scale., Participants: Surgical faculty (SF) (n = 16) and SR (n = 36). Knowledge and confidence scores were compared between SR and SF, using Student t-test analysis to evaluate differences between groups., Results: No significant differences were found in ethical knowledge scores between faculty and residents. Faculty confidence is higher than resident (p < 0.05). Further, female faculty confidence is higher than that of their male counterparts (p < 0.05)., Conclusions: While SF are more confident in their ethical decision-making, their fundamental knowledge base in ethics is not different from that of SR. Female SF report greater self-confidence over their male counterparts. In total, SF may not possess the foundation to effectively mentor residents in appropriate ethical principles and their translation to clinical practice. This study supports the need for both SR and SF to engage in an integrated education program in ethics to promote on-going dialogue in this complex topic., (Copyright © 2012 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: To explore surgeons' perceptions of the factors that influence their intraoperative decision making, and implications for professional self-regulation and patient safety., Method: Semistructured interviews were conducted with 39 academic surgeons from various specialties at four hospitals associated with the University of Toronto Faculty of Medicine. Purposive and theoretical sampling was performed until saturation was achieved. Thematic analysis of the transcripts was conducted using a constructivist grounded-theory approach and was iteratively elaborated and refined as data collection progressed. A preexisting theoretical professionalism framework was particularly useful in describing the emergent themes; thus, the analysis was both inductive and deductive., Results: Several factors that surgeons described as influencing their decision making are widely accepted ("avowed," or in patients' best interests). Some are considered reasonable for managing multiple priorities external to the patient but are not discussed openly ("unavowed," e.g., teaching pressures). Others are actively denied and consider the surgeon's best interests rather than the patient's ("disavowed," e.g., reputation). Surgeons acknowledged tension in balancing avowed factors with unavowed and disavowed factors; when directly asked, they found it difficult to acknowledge that unavowed and disavowed factors could lead to patient harm., Conclusions: Some factors that are not directly related to the patient enter into surgeons' intraoperative decision making. Although these are probably reasonable to consider within "real-world" practice, they are not sanctioned in current patient care constructs or taught to trainees. Acknowledging unavowed and disavowed factors as sources of pressure in practice may foster critical self-reflection and transparency when discussing surgical errors.

Dermatologic surgery presents a unique set of ethical dilemmas not frequently discussed within the medical literature. This contribution presents a few cases commonly encountered by dermatologic surgeons. The case-based discussion follows a principles-based framework for analysis and seeks to identify the central moral conflict and exemplify the development of sound reasoning for subsequent decision making through the consideration of multiple viewpoints and the weighing of potential consequences. Additional cases are provided in concise format to encourage further analysis and discourse on the distinct ethical dilemmas encountered within dermatologic surgery., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Understanding what staff surgeons think surgical trainees should learn and the ethical issues that trainees need to manage can strengthen surgical ethics education., Methods: Participants were recruited from the 15 surgical specialty and subspecialty programs at the University of Toronto. Semistructured interviews and focus groups were conducted with 13 ethics coordinators from the surgical staff and 64 resident trainees. Data were analyzed qualitatively using modified thematic analysis., Results: All coordinators and trainees felt that ethics education was an important component of surgical training. Real cases, varying teaching methods, and teachers with applicable clinical experience were valued. Trainees identified intraprofessional and interprofessional conflict, staff behavior perceived to be unethical, and their own lack of experience as challenging issues rarely addressed in the formal ethics curriculum., Conclusions: Ethics education is highly valued by trainees and teachers. Some ethical issues important to trainees are underrepresented in the formal curriculum. Staff surgeons and senior residents are practicing ethicists and role models whose impact on the moral development of residents is profound. Their participation in the formal curriculum helps less experienced junior residents realize its value., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Introduction: Medical research involving human subjects must follow ethical standards as outlined in the Declaration of Helsinki of the World Medical Association. The 3 journals J Ped Surg, Eur J Pediatr Surg and Pediatr Surg Int all require authors' statements regarding ethical approval and the patient or guardian informed consent for studies involving human subjects. It has previously been reported that ethical approval and informed consent is not documented in a considerable proportion of publications in other journals. The aim of this study was to investigate whether ethical approval and informed consent was documented in a consecutive series of publications involving human subjects in the 3 paediatric surgical journals., Material and Methods: All articles involving human subjects or material published in the print and online issues of J Ped Surg, Eur J Pediatr Surg and Pediatr Surg Int in 2010 were systematically reviewed as to whether ethics committee or institutional review board approval and patient or guardian consent to participate in the study was reported. Publications were categorised into prospective studies, retrospective studies, description of new methods and case reports., Results: 579 articles were included in the study (324 J Ped Surg, 103 Eur J Pediatr Surg and 153 Pediatr Surg Int). In case reports (n=142), the lowest level of documentation of ethical approval (1.4%) and informed consent (1%) was observed. The remaining 437 original articles reported ethical approval in 54% of publications (prospective studies 66%, retrospective studies 59%, new methods 27%). Informed consent was documented in 16% of the original articles (prospective studies 50%, retrospective studies 17%, new methods 14%). Detailed investigation of the different journals revealed the highest rate of reporting of ethical approval for J Pediatr Surg (71%), followed by Eur J Pediatr Surg (43%), and Pediatr Surg Int (24%). Patient or guardian informed consent was reported in 15% of the publications in J Pediatr Surg and Pediatr Surg Int, respectively, and in 24% of the papers published in Eur J Pediatr Surg., Conclusion: Adherence to ethical principles in paediatric surgical research should be improved. Information on ethical approval and informed consent should be included in all manuscripts accepted for publication. Editors should consider establishing a specific online template asking authors for the necessary information during the submission process., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: The ethical dilemmas that residents experience throughout their training have not been explored qualitatively from surgical residents' perspectives., Methods: Grounded theory methodology was used. All University of Toronto surgical, otolaryngology, and obstetrics and gynecology residents were invited to participate. Twenty-eight face-to-face interviews were conducted. Interviews were transcribed and analyzed by 3 reviewers., Results: Five encompassing themes emerged: (1) residents prefer operating with another resident while the staff watches; (2) residents felt that patients were rarely well informed about their role; (3) residents develop good relationships with patients; (4) residents felt ethically obliged to disclose intraoperative errors; and (5) residents experience ethical distress in certain teaching circumstances., Conclusions: Residents encounter ethical dilemmas leading to moral angst during their surgical training and need to feel safe to discuss these openly. Staff and residents should work together to establish optimal communication and teaching situations., (Copyright 2010 Elsevier Inc. All rights reserved.)