Escobar Mauricio A, Hartin Charles W, McCullough Laurence B
Department of Surgery, University of Washington, Seattle, Washington; Pediatric Surgical Services, Mary Bridge Children's Hospital & Health Center, Tacoma, Washington.
Texas Children's Hospital, Baylor College of Medicine, Houston, Texas.
J Surg Educ. 2014 Jan-Feb;71(1):102-9. doi: 10.1016/j.jsurg.2013.06.022. Epub 2013 Sep 14.
The authors examine the ethical implications of teaching general surgery residents laparoscopic pyloromyotomy.
DESIGN/PARTICIPANTS: Using the authors' previously presented ethical framework, and examining survey data of pediatric surgeons in the United States and Canada, a rigorous ethical argument is constructed to examine the question: should general surgery residents be taught laparoscopic pyloromyotomies?
A survey was constructed that contained 24 multiple-choice questions. The survey included questions pertaining to surgeon demographics, if pyloromyotomy was taught to general surgery and pediatric surgery residents, and management of complications encountered during pyloromyotomy. A total of 889 members of the American Pediatric Surgical Association and Canadian Association of Paediatric Surgeons were asked to participate. The response rate was 45% (401/889). The data were analyzed within the ethical model to address the question of whether general surgery residents should be taught laparoscopic pyloromyotomies.
From an ethical perspective, appealing to the ethical model of a physician as a fiduciary, the answer is no.
We previously proposed an ethical model based on 2 fundamental ethical principles: the ethical concept of the physician as a fiduciary and the contractarian model of ethics. The fiduciary physician practices medicine competently with the patient’s best interests in mind. The role of a fiduciary professional imposes ethical standards on all physicians, at the core of which is the virtue of integrity, which requires the physician to practice medicine to standards of intellectual and moral excellence. The American College of Surgeons recognizes the need for current and future surgeons to understand professionalism, which is one of the 6 core competencies specified by the Accreditation Council for Graduate Medical Education. Contracts are models of negotiation and ethically permissible compromise. Negotiated assent or consent is the core concept of contractarian bioethics. Nonnegotiable goods are goals for residency training that should never be sacrificed or negotiated away. Fiduciary responsibility to the patient, regardless of level of training, should never be compromised, because doing so violates the professional virtue of integrity. The education of the resident is paramount to afford him or her the opportunity to provide competent care without supervision to future patients. Such professional competence is the intellectual and clinical foundation of fiduciary responsibility, making achievement of educational goals during residency training another nonnegotiable good.
作者探讨了向普通外科住院医师传授腹腔镜幽门肌切开术的伦理意义。
设计/参与者：运用作者之前提出的伦理框架，并研究美国和加拿大儿科外科医生的调查数据，构建了一个严谨的伦理论证来审视这个问题：是否应该向普通外科住院医师传授腹腔镜幽门肌切开术？
构建了一项包含24个多项选择题的调查。该调查包括与外科医生人口统计学、是否向普通外科和儿科外科住院医师传授幽门肌切开术以及幽门肌切开术期间遇到的并发症管理等相关的问题。总共邀请了889名美国儿科外科协会和加拿大儿科外科医生协会成员参与。回复率为45%（401/889）。在伦理模型内对数据进行分析，以解决是否应向普通外科住院医师传授腹腔镜幽门肌切开术的问题。
从伦理角度来看，依据将医生视为受托人的伦理模型，答案是否定的。
我们之前基于两条基本伦理原则提出了一个伦理模型：将医生视为受托人的伦理概念和契约主义伦理模型。作为受托人的医生在行医时会切实考虑患者的最大利益。受托专业人员的角色为所有医生设定了伦理标准，其核心是正直的美德，这要求医生按照智力和道德卓越的标准行医。美国外科医师学会认识到当前和未来的外科医生都需要理解专业精神，这是毕业后医学教育认证委员会指定的六项核心能力之一。契约是谈判和道德上允许的妥协的模型。协商同意是契约主义生物伦理学的核心概念。不可协商的事项是住院医师培训的目标，绝不应该被牺牲或协商放弃。无论培训水平如何，对患者的受托责任都不应受到损害，因为这样做违反了正直的职业道德。住院医师的教育至关重要，能为其提供在未来无需监督就能提供胜任医疗服务的机会。这种专业能力是受托责任的智力和临床基础，使得在住院医师培训期间实现教育目标成为另一个不可协商的事项。
