About Informed consent.

In my practice, all operations are the choice of the patient and you can only make the right decisions for yourself if you are properly informed. One of my most important roles as a plastic surgeon is to provide you with all the relevant information necessary for you to make properly informed decisions when considering plastic surgery.

Please enjoy learning about the procedure or procedures that interest you and explore the resources I present here. You should also do your own research so that you can address any concerns you may have.

The areas of knowledge you will need:

• Choosing the right surgeon for you. Of course, hopefully that will be me or one of my associates, but the choice is entirely yours and you should do the right thing by yourself in making your decision.
• The procedure itself – you should be well informed and be professionally assessed by your surgeon as together we plan the procedure that is best for you.
• The normal consequences of the procedure – things that always happen because of the procedure. For example, if an incision is needed, you will have a scar.
• The likely and expected results of the procedure for you, as an individual. Everybody gets their own result of surgery.
• Understanding the possible risks and complications of the procedure – things that we don’t expect to occur, but which are known to happen from time to time.

What else do I need to know?

I would like you to understand the ethics of surgical complications, so that you are aware of the moral framework and ethical standards that you have a right to expect from me, as your surgeon.

Ethics of Surgical Complications

World Journal of Surgery 33(4):732-7
March 2009

Four principles of medical ethics: a dominant moral framework

During the 1970s, the American philosophers Tom Beauchamp and James Childress introduced the influential ‘‘Four Principles’’ approach to medical ethics. Their conceptual framework relies on the application of four basic moral principles that, alone or in combination, help identify and resolve many ethical issues in medicine.

A brief description of the principles follows:

1. Respect for autonomy
   Autonomy usually refers to people’s ability to make choices based on their own beliefs and values. In health care, respect for autonomy requires doctors to respect a competent patient’s deliberated wishes and provide adequate information to support patients in their decision-making.
2. Beneficence
   This refers to the Hippocratic commitment to benefit patients by acting in their best interests. Because the conception of what constitutes benefit (and harm) varies from person to person, this principle usually requires respecting patient autonomy.
3. Nonmaleficence
   This principle refers to the moral obligation not to cause harm to patients. Surgery, with its necessary incision, could be seen to defy this principle. Indeed, all attempts to benefit patients, whether through words, drugs, or procedures, carry risks of harm. Hence nonmaleficence is best described as the obligation to avoid causing net harm to patients and should be considered in conjunction with the principle of beneficence.
4. Justice
   In health care ethics, the principle of justice primarily refers to the obligation to distribute scarce health care resources fairly. It also includes the obligation to respect people’s human rights and to respect morally acceptable laws.

These four broad principles generate more specific rules. Under respect for autonomy, for example, are rules such as ‘‘obtain consent,’’ ‘‘respect confidentiality,’’ and ‘‘avoid deception.’’ For our purposes, the four principles serve as a framework to consider systematically the ethics of surgical complications.

Some of the ethical issues, such as the duty to possess adequate technical skill, are captured by more than one principle. We then elaborate on those issues pertaining more specifically to surgical complications. As will become apparent, there is a significant overlap between the ethics of surgery and the ethics of surgical complications.

This is not surprising given that surgical complications fall within the realm of surgical practice and that the most efficient way of reducing complications is to strive for high standards of surgical care.

Application of the four principles approach to plastic surgery and its surgical complications

Respect for autonomy

The main autonomy-related issue in surgical ethics is duty to obtain adequately informed consent.

Beneficence

• Surgical competence
• Ability to exercise sound judgment
• Continuous professional development
• Research and innovation in surgery
• Responsible conduct Functioning equipment and optimal operating conditions
• Minimizing harm (including pain control)
• Good communication skills

Nonmaleficence

• Surgical competence
• Continuous professional development
• Ability to exercise sound judgment
• Recognizing the limits of one’s professional competence
• Research and auditing
• Disclosure and discussion of surgical complications including medical errors
• Good communication skills

Justice

• Allocation of scarce resources
• Legal issues
• Respecting human rights
• Whistle blowing

Informed consent is more important in surgery given the invasiveness of the act, the short-term harm, and the temporarily unconscious state of the patient during the procedure.

One difficulty relates to the degree of disclosure necessary to satisfy the consent conditions. How much information is adequate? It is neither practical nor desirable to list all possible complications to a patient. Not only would such a disclosure be time-consuming, but providing too much information can reduce rather than enhance a patient’s autonomy by confusing the patient.

Clear disclosure that is neither deficient nor excessive in detail and that is tailored to the patient’s own situation requires a combination of good judgment and communicative ability.

About risks and complications in plastic surgery

We all use these terms, but what do they really mean?

Risk is easy – the Cambridge Dictionary defines it as ‘the possibility of something bad happening. Complication is harder to define. Even surgeons themselves disagree on what “a surgical complication” is.

I define a surgical complication as any deviation from the normal range of the post-operative course of events that is not inherent in the procedure.

Fortunately, in plastic surgery, complications are very rarely life threatening. But they can influence the result of the procedure, and occasionally affect your health or comfort.

Before you decide to go ahead with surgery, I will clearly explain the main surgical complications that could occur during or after the operation, so that you can make an informed decision as to whether to undergo the operation. It’s important to bear in mind that the risk of a complication occurring varies for different individuals and we will discuss this as well.

It’s my aim to ensure that you can give truly informed consent before any surgery in my practice. By personally consulting with me, and by using the information and resources on this website, I am confident you will be able to do this. Please let me know if you have any feedback on how this information could be improved so that it can be more useful.

Welcome to my surgical practice.

Howard Webster
Plastic Surgeon