In this article I propose to reframe debates about ideals of emotion in medicine, abandoning the current binary setup of this debate as one between ‘clinical detachment’ and empathy. Inspired by observations from my own field work and drawing on Sky Gross’ anthropological work on rituals of practice as well as Henri Lefebvre’s notion of rhythm, I propose that the normative drive of clinical practice can be better understood through the notion of attunement. In this framework individual types of emotions (...) are not, as such, appropriate or inappropriate, but are evaluated depending on their synchronicity with the specific rhythms of the practice. To set up this proposal, I show how typical arguments about emotions in medicine—what I call emotion-entity focused frameworks—are insufficient. I then draw on ethnographic observations from two orthopaedic departments and interviews with medical practitioners to show (1) how clinical practice is driven by rhythmicity, shaped in the case of orthopaedic surgery by a clinical aim of efficient, controlled intervention, and (2) how clinicians continuously refer to this drive and the flow of rhythms when evaluating inappropriate or problematic emotion. I argue that the use of a rhythm framework rather than ideals of detachment or empathy allows for a sensitivity to the complexity and situation-dependent elements of emotional ideals in clinical practice; and I end by proposing the term ‘attuned concern’—which stresses the importance of regulation and adjustment to circumstances rather than of maintaining a constant distance/involvement—as a more fitting alternative to ‘clinical detachment’. (shrink)

The COVID-19 pandemic has increased demand for physicians, leading to widespread redeployment of specialty physicians to care for patients with COVID-19. These redeployments highlight an important question: How do physicians balance competing obligations to their own health, their own patients, and society during a public health crisis? How can physicians, specifically subspecialists, navigate this tension? In this article, we analyse a clinical scenario in which an orthopaedic sports surgeon is redeployed to care for patients with COVID-19. This case raises (...) questions about physicians’ obligations to their own patients compared with society at large, the relative value of specialty physicians during a global pandemic, and the ethical permissibility of compulsory redeployment. Using the orthopaedic surgery specialty as a model, we build a redeployment framework for surgical specialists that is both ethical and equitable. We argue that although orthopaedic surgeons have a moral obligation to participate in physician redeployment schemes, the scope of this obligation is limited and contingent on the following conditions: (1) the number of local COVID-19 cases is high; (2) obligations to their own patients or orthopaedic patients requiring urgent or emergency care have been fulfilled; (3) their value as physicians exceeds their value as specialists because of the pandemic climate; (4) voluntary redeployments are exhausted before compulsory redeployments are implemented; and (5) redeployment would not put the physicians at unreasonable risk of harm. (shrink)

Randomised placebo-controlled trials (RPCTs) are the gold standard for evaluating novel treatments. However, this design is rarely used in the context of orthopaedic interventions where participants are assigned to a real or placebo surgery. The present study examines attitudes towards RPCTs for orthopaedic surgery among 687 orthopaedic surgeons across the USA. When presented with a vignette describing an RPCT for orthopaedic surgery, 52.3% of participants viewed it as ‘completely’ or ‘mostly’ unethical. Participants were (...) also asked to rank-order the value of five different types of evidence supporting the efficacy of a surgery, ranging from RPCT to an anecdotal report. Responses regarding RPCTs were polarised with 26.4% viewing it as the least valuable (even less valuable than an anecdote) and 35.7.% viewing it as the most valuable. Where equipoise exists, if we want to subject orthopaedic surgeries to the highest standard of evidence (RPCTs) before they are implemented in clinical practice, it will be necessary to educate physicians on the value and ethics of placebo surgery control conditions. Otherwise, invasive procedures may be performed without any benefits beyond possible placebo effects. (shrink)

Ransomware attacks on healthcare systems are becoming more prevalent globally. In May 2021, Waikato District Health Board in New Zealand was devastated by a major attack that crippled its information technology system. The Department of Orthopaedic Surgery faced a number of challenges to the way they delivered care including, patient assessment and investigations, the deferral of elective surgery, and communication and patient confidentiality. These issues are explored through the lens of the four key principles of medical ethics (...) in the hope that they will provide some guidance to future departments who may experience such attacks. (shrink)

Advances in veterinary orthopaedics are assessed on their ability to improve the function and wellbeing of animal patients. And yet historically veterinarians have struggled to bridge the divide between an animal's physicality and its interior experience of its function in clinical settings. For much of the twentieth century, most practitioners were agnostic to the possibility of animal mentation and its implications for suffering. This attitude has changed as veterinarians adapted to technological innovations and the emergence of a clientele who claimed (...) to understand and relate to the subjective experiences of their animals. While visualising technologies and human analogies have shaped the nuts and bolts of veterinary orthopaedic practices, an emerging awareness of the inability of radiographic images to apprehend or correlate to a patient's experience of their function reliably has required veterinarians to place a greater emphasis on the owner's knowledge of the "selves" inhabiting their animals. Rather than simply basing clinical judgments on the "look" of their patients, the indeterminacy in the connection between form and function has compelled veterinarians to put questions regarding particular human-animal relationships near the centre of their practices, not least in orthopaedic surgery. (shrink)

Developments in biomedical science continue to transform our understanding of concepts such as health and disease. The creation of this expertise has also had a substantive role in changing the veterinary approach to animal diseases. Traditionally, companion animal veterinarians modelled their practices on developments in the diagnosis and treatment of human patients. As science and technology have realigned the boundaries between normalcy, intra-species variation and pathology in particular domains of expertise such as orthopaedic surgery, these patterns of knowledge (...) translation have changed. Not so long ago, treatments for the rupture of the cruciate ligament in human and canine patients were based on pathoanatomical comparison and designed to reestablish the stability of the joint by the functional restoration of ligament anatomy. Recently, a radically different characterization of the canine injury—with a corresponding alternative intervention—has been proposed within the field of veterinary orthopaedics. It views the normal anatomy of the canine knee as being in some way inherently pathogenic and proposes the surgical creation of an idealized structure as a remedy to dysfunction and disease. The veterinary focus on an ideal of patient performance, rather than a specific pathology, is now influencing how orthopaedists choose to approach analogous human injuries. In this article, I chart the history of canine ‘cruciate disease’ therapies as a means to map some of the epistemic assumptions, interplays of idealized and analogical reasoning and patterns of knowledge translation central to the biomedicalization of the science and practice of orthopaedic surgery. (shrink)

Consent plays a vital role in every aspect of medicine and surgery, facilitating the patient in making informed decisions about their treatment. The recently published Reference Guide to Consent, by the Department of Health (DH), notes that, although not a legal requirement, the completion of consent forms is good practice, particularly in interventions such as surgery. In addition, the Parliamentary and Health Service Ombudsman noted that a significant number of complaints about consent involved the complainant feeling that they (...) did not fully understand what was going to happen. It was often found that there was no documentation to clarify what the patient was told, when and by whom. We have performed an audit of 71 randomly selected consent forms, elective and trauma cases within our district general hospital orthopaedics department. Our data demonstrate that a significant number of consent forms were incorrectly or insufficiently completed. This could not only leave the patient confused about their procedure but also leaves the doctor open to litigation, with little in the way of documentation support. Minor changes in consenting methods and more precise documentation could significantly improve patient experience and satisfaction. (shrink)

ObjectiveTo evaluate the knowledge and performance of surgical residents regarding the person from whom informed consent should be taken for surgery and from whom the consent is taken in practice.Materials and methodsThis study was done in 2013. The population of this study was all residents of urology, surgery, orthopaedic surgery and gynaecology of Tehran and Iran University of Medical Sciences. The study tool was a self-administered questionnaire, containing questions on their knowledge and performance regarding informed consent (...) acquisition from patients with different conditions in terms of age, sex, marital status and their capacity to make treatment decisions.ResultsA total of 213 residents participated in the study. The mean score of the participants’ knowledge was 72.95 out of 100. There was no significant correlation between the residents’ knowledge and performance. Regarding a competent married male patient, 98.2% of the residents knew that the person’s consent was enough, but only 63.6% obtained informed consent only from the patient. These percentages were 69% and 19.7% for a competent married female patient, respectively. For a competent single male patient, 90.9% of the residents were aware that the patient’s consent was enough, while only 40% of the residents obtained informed consent only from the patient. These percentages were 65.3% and 16% for a competent single female patient, respectively.ConclusionDespite the residents’ average knowledge of patient autonomy, this right is not observed for female patients, and their treatment is subject to consent acquisition from other family members. (shrink)

In many countries, there are health care initiatives to make smokers give up smoking in the peri-operative setting. There is empirical evidence that this may improve some, but not all, operative outcomes. However, it may be feared that some support for such policies stems from ethically questionable opinions, such as paternalism or anti-smoker sentiments. This study aimed at investigating the support for a policy of smoking cessation prior to surgery among Swedish physicians and members of the general public, as (...) well as the reasons provided for this. A random sample of general practitioners and orthopaedic surgeons as well as members of the general public received a mail questionnaire. It contained a vignette case with a smoking 57-year old male farmer with hip osteoarthritis. The patient had been recommended hip replacement therapy, but told that in order to qualify for surgery he needed to give up smoking four weeks prior to and after surgery. The respondents were asked whether making such qualifying demands is acceptable, and asked to rate their agreement with pre-set arguments for and against this policy. Response rates were 58.2% among physicians and 53.8% among the general public. Of these, 83.9% and 86.6%, respectively, agreed that surgery should be made conditional upon smoking cessation. Reference to the peri-operative risks associated with smoking was the most common argument given. However, there was also strong support for the argument that such a policy is mandated in order to achieve long term health gains. There is strong support for a policy of smoking cessation prior to surgery in Sweden. This support is based on considerations of peri-operative risks as well as the general long term risks of smoking. This study indicates that paternalistic attitudes may inform some of the support for peri-operative smoking cessation policies and that at least some respondents seem to favour a “recommendation strategy” vis-à-vis smoking cessation prior to surgery rather than a “requirement strategy”. The normative reasons speak in favour of the “recommendation strategy”. (shrink)

Ojectives Low energy hip fractures are one of the greatest causes of morbidity and mortality in orthopaedics. This study aims to evaluate written consent forms with respect to basic standards as set out in the Good Practice in Consent Initiative. In particular the stated risks and benefits of each procedure were assessed. Methods 100 consecutive consent forms were reviewed prospectively. The stated procedure, side and complications were recorded. Appropriate signature and legibility was assessed. 13 consultant orthopaedic surgeons were surveyed (...) to identify what risks and benefits they thought should be stated. Results Of 100 consent forms, 31 were for patients who are unable to consent. All 100 consent forms were correctly filled in with patient details and signed. 98% were legible. All stated the side of the operation. The number of complications listed per form ranged from 4 to 11. Infection, bleeding and thromboembolic complications were stated in the majority of consent forms. In total, 30 different complications were recorded; some were only stated once. Discussion and Conclusions This work suggests consent forms are completed well with respect to patient identifiers, legibility and procedure. The variability of complications stated is vast. We suggest standard pre-printed consent forms containing risks and benefits should be used as this may improve standards of informed consent. This has also been recently supported by the British Orthopaedic Association. (shrink)

Health Care Centres are institutions which, because of their specificity and character, are particularly exposed to various kinds of risk. One of the most important and most frequently used methods of risk management is the black spots method. The research material collected for the study comes from one of the hospitals in Wrocław. All hospital stays of the C22 (Face and Jaw Surgery Ward) and H05 (Injury and Orthopaedics Surgery Ward) settlement groups (DRG) were analysed - a total (...) of 178 hospitalisations. The black spots method was used in the study, which consisted of risk identification, the ordering of threats and proposals for remedial actions. Using the black spots method, it was possible to identify adverse events that occurred during the hospitalisation of patients with H05 and C22 DRGs in the Injury and Orthopaedics Surgery Ward and Facial and Jaw Surgery Ward. In both cases, the treatment costs for patients with complications were higher than for the stays without complications. (shrink)

Preoperative informed consent is a legal and ethical requirement that ensures patients understand a procedure, its associated risks and benefits, alternative treatment options, and potential complications to make an informed decision about their care. This cross‐sectional study evaluated the informed consent process for major orthopaedic surgeries at a tertiary hospital in Nigeria. A self‐administered questionnaire was used to collect data from 120 adult participants. Results showed that many patients do not read the consent form before signing it, and surgeons (...) do not adequately explain the alternatives to surgery, potential risks, and available anaesthetic options. Higher‐educated patients are more likely to read the consent form. Surgeons performed well in explaining the nature of the condition and prognosis, the procedure's potential benefits, and answering patients' questions. The study emphasises the need to improve the informed consent process to ensure patients understand and can make rational decisions about their healthcare. (shrink)

Russia did not participate in the bourgeois revolution, the revolution occurred in Russia after the Tsar absolute doctrine, dictatorship, terrorism, superstition and personal police state. Stalinist Marxism beyond recognition, damaged Marx's own image. Impoverishment of the proletariat of Marx and Engels theory, crisis theory has been declared invalid, the Marxist dialectics is still valid is that the theory of contradiction. Contradictions of capitalism can be accurately understood as the general alienation, self-alienation. Inherited estate will determine the natural rights of free (...) face of communism. Straight orthopedic surgery is the most urgent task of socialism, and humane socialism contains the highest human rights as straight. Marxism is not is not a utopia, but a concrete utopia. Russia did not join in the bourgeois revolution, and there appeared absolutely Tsarism, autarchy, terror, individual superstition and police country after its revolution. Stalinism made the Marxism distorted beyond recognition and destroyed the figures of Marx himself. The theory of Proletarian poverty and the theory of crisis of Marx and Engles' were declared invalid, while its dialectic, that is Contradiction, is still valid. The contradiction of Capital can be understood precisely as Total-alienation and Self-alienation. Inheriting natural rights will decide the freedom face of Communism. Orthopaedic surgery of upright way is the most urgent mission of Socialism, and human Socialism contains the upright way as the highest human rights. Marxism is not non-Utopia, but concrete Utopia. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:I Am Not Sure?Paul E. LevinIt was a beautiful Friday morning, a few weeks into the summer. My schedule appeared lighter than usual and I even envisioned leaving work a bit early. Maybe a challenging bike ride before dinner. I was sitting in the chairman’s office having our weekly meeting. One of our junior faculty members called... he needed help. He was on call and a 32–year–old pregnant woman (...) with a displaced femoral neck fracture had just been transferred to our emergency department (ED). Ms. B tripped in her kitchen last evening. She was unable to stand and was brought to the local ED by ambulance.My colleague was concerned that he wouldn’t be able to successfully reduce the fracture. The long–term prognosis of the hip joint depended on a successful reduction of the femoral neck fracture. In addition, there was an ongoing debate in the orthopaedic literature related to the urgency of operative care to prevent osteonecrosis of the femoral head. I reviewed the x–rays, didn’t anticipate a problem and let him know that I would come to the operating room (OR) to assist. “No”, he responded, “I am not comfortable caring for this patient”. I immediately left the office, went to the hospital and assumed care of the patient. Clearly, my plans for a bike ride were gone, but I had the opportunity to help a woman in need of expert orthopaedic care.Ms. B had been admitted to the obstetrical service. She was a 32–year–old woman of Haitian descent who had recently immigrated to the United States. She had very limited English comprehension and her primary spoken languages were French and Creole. She was alone, in a hospital in a foreign country. She was 24 weeks pregnant with her first child and had no other co–morbidities. Her pregnancy had ben progressing uneventfully.When I first met Ms. B she was lying on a stretcher in an observation unit on the obstetrical floor. She appeared frightened. Two orthopaedic residents were present and obtaining consent for surgical repair of the hip. In their minds there was nothing to discuss, the patient had a displaced femoral neck fracture and needed to have surgery immediately. In their minds, no other options were available and obtaining consent would be straightforward. I introduced myself, sat down on a lab stool by the bed and began a conversation. I needed to meet the patient, understand who she was and discuss treatment. I am not sure that obtaining an informed consent is ever “straightforward” when [End Page 14] a doctor is explaining to a patient that they require emergency surgery. This discussion surely would not be easy or straightforward.We utilized a telephone interpretation service. Every question and response required the transfer of the handset between the patient and physician. Ms. B was in pain and frightened. She immediately expressed concern about her pregnancy and her baby. I arranged for her to meet all of the physicians who would possibly be involved in her care and the care of her baby. Each consultant could explain their area of expertise and potential involvement in the care of Ms. B and her child. She met and had an opportunity to talk with the obstetrician on call, a maternal fetal medicine (MFM) fellow and a neonatologist. I supplied the orthopaedic information. I explained the severity of the injury, the risks of osteonecrosis either with or without surgery as well as concerns over non–union and traumatic arthritis of the hip. Undoubtedly, in a healthy 32–year–old woman who wasn’t pregnant, early surgical intervention would be the most appropriate management in hopes of preserving a normal hip joint. We also discussed the possibility of treating her without surgery. She would be administered pain medication, which were known to be safe during pregnancy, and allowed to begin to ambulate with a walker or crutches. I explained potential problems without surgery and what options would be available to treat any problems that developed with her hip after the child was born. Of course, hip fractures in pregnant woman are very rare, and as a result treating a... (shrink)

Surgical clinical trials have seldom used a “sham” or placebo surgical procedure as a control, owing to ethical concerns. Recently, several ethical commentators have argued that sham surgery is either inherently or presumptively unethical. In this article I contend that these arguments are mistaken, and that there are no sound ethical reasons for an absolute prohibition of sham surgery in clinical trials. Reflecting on three cases of sham surgery, especially on the recently reported results of a sham-controlled (...) trial of arthroscopic surgery for arthritis of the knee, I present an ethical analysis that focuses on the methodological rationale for use of sham surgery, risk-benefit assessment, and informed consent. (shrink)

Cosmetic surgery is a fast-growing medical practice. In 1997 surgeons in the United States performed the four most common cosmetic procedures443,728 times, an increase of 150% over the comparable total for 1992. Estimated total expenditures for cosmetic surgery range from $1 to $2 billion. As managed care cuts into physicians' income and autonomy, cosmetic surgery, which is not covered by health insurance, offers a financially attractive medical specialty.

Recently, there has been a shift in attitude among some feminists towards the practice of cosmetic surgery away from that of outright rejection. Kathy Davis, for instance, offers a guarded `defence' of the practice as a strategy that enables women to exercise a degree of control over their lives in circumstances where there are very few other opportunities for self-realization. Others, such as Kathryn Morgan, Anne Balsamo and Orlan, though highly critical of the current practice of cosmetic surgery, (...) go even further than Davis in advocating its redeployment as a tool to subvert the dominant patriarchal ideals of feminine beauty. In this article I critically appraise this `rehabilitation' of cosmetic surgery, arguing, in the case of Davis, that she leaves unchallenged the social structures of inequality responsible for women's dissatisfaction with their bodies. The proposal to use cosmetic surgery as a tool of political critique is equally problematic insofar as it shares with the cosmetic industry its instrumentalization of the body as mere matter, which is almost infinitely transformable, and also effaces the economic inequalities within which such body transformations occur. (shrink)

Surgical clinical trials have seldom used a "sham" or placebo surgical procedure as a control, owing to ethical concerns. Recently, several ethical commentators have argued that sham surgery is either inherently or presumptively unethical. In this article I contend that these arguments are mistaken and that there are no sound ethical reasons for an absolute prohibition of sham surgery in clinical trials. Reflecting on three cases of sham surgery, especially on the recently reported results of a sham-controlled (...) trial of arthroscopic surgery for arthritis of the knee, I present an ethical analysis that focuses on the methodological rationale for use of sham surgery, risk-benefit assessment, and informed consent. (shrink)

Sham surgery is a controversial and rarely used component of randomised clinical trials evaluating surgical interventions. The recent use of sham surgery in trials evaluating efficacy of intracerebral fetal tissue grafts in Parkinson’s disease has highlighted the ethical concerns associated with sham surgery controls. Macklin, and Dekkers and Boer argue vigorously against use of sham surgery controls. Macklin presents a broad argument against sham surgery controls while Dekkers and Boer present a narrower argument that sham (...) surgery is unnecessary in the specific setting of fetal tissue engraftment for Parkinson’s disease. I defend sham surgery controls against both these criticisms. Appropriate clinical trial design, sometimes including sham surgery, is needed to ensure that false positive trial results do not occur and endanger public safety. Results of a completed trial of fetal tissue grafting for Parkinson’s disease are used to illustrate the potential benefits of, and problems associated with, sham surgery controls. Sham surgery controls, however, should be employed only when absolutely necessary. I suggest criteria for appropriate use of sham surgery controls. (shrink)

Leading feminist scholars have been brought together for the first time in this comprehensive volume to reveal the complexity of feminist engagements with the exponentially growing cosmetic surgery phenomenon. Offering a diversity of theoretical, methodological and political approaches Cosmetic Surgery: A Feminist Primer presents not only the latest, cutting-edge research in this field but a challenging and unique approach to the issue that will be of key interest to researchers across the social sciences and humanities.

Innovative surgery raises four kinds of ethical challenges: potential harms to patients; compromised informed consent; unfair allocation of healthcare resources; and conflicts of interest. Lack of adequate data on innovations and lack of regulatory oversight contribute to these ethical challenges. In this paper these issues and the extent to which problems may be resolved by better evidence-gathering and more comprehensive regulation are explored. It is suggested that some ethical issues will be more resistant to resolution than others, owing to (...) special features of both surgery and innovation. (shrink)

Surgical innovation involves practices, such as new devices, technologies, procedures, or applications, which are novel and untested. Although innovative practices are believed to offer an improvement on the standard surgical approach, they may prove to be inefficacious or even dangerous. This article considers how surgeons considering innovation should reason in the conditions of uncertainty that characterize innovative surgery. What attitude to the unknown risks of innovative surgery should they take? The answer to this question involves value judgments about (...) the acceptability of risk taking when satisfactory scientific information is not available. This question has been confronted in legal contexts, where risk aversion in the form of the precautionary principle has become increasingly influential as a regulatory response to innovative technologies that pose uncertain future hazards. This article considers whether it is appropriate to apply a precautionary approach when making decisions about innovative surgery. (shrink)

COVID-19 is reducing the ability to perform surgical procedures worldwide, giving rise to a multitude of ethical, practical and medical dilemmas. Adapting to crisis conditions requires a rethink of traditional best practices in surgical management, delving into an area of unknown risk profiles. Key challenging areas include cancelling elective operations, modifying procedures to adapt local services and updating the consenting process. We aim to provide an ethical rationale to support change in practice and guide future decision-making. Using the four principles (...) approach as a structure, Medline was searched for existing ethical frameworks aimed at resolving conflicting moral duties. Where insufficient data were available, best guidance was sought from educational institutions: National Health Service England and The Royal College of Surgeons. Multiple papers presenting high-quality, reasoned, ethical theory and practice guidance were collected. Using this as a basis to assess current practice, multiple requirements were generated to ensure preservation of ethical integrity when making management decisions. Careful consideration of ethical principles must guide production of local guidance ensuring consistent patient selection thus preserving equality as well as quality of clinical services. A critical issue is balancing the benefit of surgery against the unknown risk of developing COVID-19 and its associated complications. As such, the need for surgery must be sufficiently pressing to proceed with conventional or non-conventional operative management; otherwise, delaying intervention is justified. For delayed operations, it is our duty to quantify the long-term impact on patients’ outcome within the constraints of pandemic management and its long-term outlook. (shrink)

In this paper, I analyse the issue of conscientious objection in relation to cosmetic surgery. I consider cases of doctors who might refuse to perform a cosmetic treatment because: (1) the treatment aims at achieving a goal which is not in the traditional scope of cosmetic surgery; (2) the motivation of the patient to undergo the surgery is considered trivial; (3) the patient wants to use the surgery to promote moral or political values that conflict with (...) the doctor's ones; (4) the patient requires an intervention that would benefit himself/herself, but could damage society at large. (shrink)

In this article, we explore the relation between bodies and selves evident in the narratives surrounding aesthetic surgery. In much feminist work on aesthetic surgery, such narratives have been discussed in terms of the normalising consequences of the objectifying, homogenising, cosmetic gaze. These discussions stress the ways in which we model our bodies, under the gaze of others, in order to conform to social norms. Such an objectified body is contrasted with the subjective body; the body-for-the-self. In this (...) article, however, we wish to make sense of the narratives surrounding such surgery by invoking the expressive body, which fits on neither side of this binary. We wish to explore how the modification of the body’s anatomical features (physiology) is taken to be a modification of its expressive possibilities, and therefore a modification of possibilities for inter-subjective relations with others. It is such expressive possibilities that, we suggest, underlie decisions to undergo surgical procedures. The possibility of modification of the expressive possibilities of the body, by the modification of its anatomical features, rests on the social imaginaries attached to anatomical features. In the context of such imaginaries, individual decisions to undergo or promote surgery can be both intelligible and potentially empowering. However, the social consequences of such acts are an increasing normalisation of the ‘body under the knife’ and an intolerance of bodily difference. This, we suggest, can only be changed by a re-visioning of bodily imaginaries so that expressive possibilities can be experienced across bodies with a range of physiological features. (shrink)

Video recording is widely available in modern operating rooms. Here, I argue that, if patient consent and suitable technology are in place, video recording of surgery is an ethical duty. I develop this as aduty to protect,arguing for professional and institutional duties, as distinguished forduties of rescue.A professional duty to protect is described in mental healthcare. Practitioners have to take reasonable steps to prevent serious, foreseeable harm to their clients and others, even if that entails a non-consensual breach of (...) confidentiality. I argue surgeons have a similar duty to patients which means that, provided the patient consents, surgery should be routinely videoed. This avoids non-consensual breaches of patient confidentiality and is aligned with stated professional obligations.An institutional duty to protect means institutions have to take reasonable steps to prevent serious, foreseeable harm at the hands of their surgeons. Rulli and Millum highlighted how institutions can meet their duty using a more consequentialist approach that balances wider interests.To test the force and scope of such duties, I examine potential impacts of routine videoing on aspects of autonomy, justice, beneficence and non-maleficence. I find routine videoing can benefit areas including safety, candour, consent and fairness in access (to surgical careers and expertise). Countervailing claims, for example, on liability, confidentiality and privacy can be resisted—such that where consent and the technology are in place, routine videoing meets aduty of easy protection. In other words, its use should be standard of care. (shrink)

This article argues for a ban on the performance of medically unnecessary genital normalizing surgeries as part of assigning a binary sex/gender to infants with intersex conditions on the basis of autonomy, regardless of etiology. It does this via a dis/analogy with the classic case in bioethics of Jehovah Witness (JW) parents' inability to refuse life-saving blood transfusions for their minor children. Both cases address ethical medical practice in situations where parents are making irreversible medical decisions on the basis of (...) values strongly held, identity, and relationship-shaping values—such as religious beliefs or beliefs regarding the inherent value of binary sex/gender—amidst ethical pluralism. Furthermore, it takes seriously—as we must in the intersex case—that the restriction of parents' right to choose will likely result in serious harms to potentially large percentage of patients, their families, and their larger communities. I address the objection that parents' capacity to choose is restricted in the JW case on the basis of the harm principle or a duty to nonmaleficence, given that the result of parent choice would be death. I provide evidence that this is mistaken from how we treat epistemic uncertainty in the JW case and from cases in which clinicians are ethically obligated to restrict the autonomy of nonminor patients. I conclude that we restrict the parents' right to choose in the JW case—and should in the case of pediatric intersex surgery—to secure patient's future autonomy. (shrink)

The market for cosmetic surgery tourism is growing with an increase in people travelling abroad for cosmetic surgery. While the reasons for seeking cosmetic surgery abroad may vary the most common reason is financial, but does cheaper surgery abroad carry greater risks? We explore the risks of poorly regulated cosmetic surgery to society generally before discussing how harm might be magnified in the context of cosmetic tourism, where the demand for cheaper surgery drives the (...) market and makes surgery accessible for increasing numbers of people. This contributes to the normalisation of surgical enhancement, creating unhealthy cultural pressure to undergo invasive and risky procedures in the name of beauty. In addressing the harms of poorly regulated surgery, a number of organisations purport to provide a register of safe and ethical plastic surgeons, yet this arguably achieves little and in the absence of improved regulation the risks are likely to grow as the global market expands to meet demand. While the evidence suggests that global regulation is needed, the paper concludes that since a global regulatory response is unlikely, more robust domestic regulation may be the best approach. While domestic regulation may increase the drive towards foreign providers it may also have a symbolic effect which will reduce this drive by making people more aware of the dangers of surgery, both to society and individual physical wellbeing. (shrink)

This article identifies a prevalent strand of feminist writing on beauty and aesthetic surgery and explores some of the contradictions and inconsistencies inscribed within it. In particular, we concentrate on three central feminist claims: that living in a misogynist culture produces aesthetic surgery as an issue predominantly concerning women; that pain - both physical and psychic - is a central conceptual frame through which aesthetic surgery should be viewed; and that aesthetic surgery is inherently a normalizing (...) technology. Engaging with these ‘myths’, we explore the tensions uncovered through a historical analysis of the practices of aesthetic surgery as well as the challenges to feminist claims offered by post-feminism. In particular we seek to destabilize the connection in feminist writing between beauty and passivity. We argue that through aesthetic references to denigrated black and working-class bodies, young women may mobilize aesthetic surgeries to reinscribe active sexuality on the feminine body. (shrink)

For historians of medicine, the professor Theodor Billroth of the University of Vienna was the leading European surgeon of the late nineteenth century and the personification of intervention by organ or body part removal. For social and political historians, he was a German nationalist whose book on medical education heralded the rise of anti-Semitism in the Austrian public sphere. This article brings together and critically reassesses these two hitherto separate accounts to show how, in a period of dramatic social and (...) political change, Viennese surgery split into two camps. One, headed by Billroth, was characterized by an alliance with the German educational model, German nationalism leading to racial anti-Semitism and an experimental approach to the construction of surgical procedure, which heavily relied on the methods of pathological physiology. The other, which followed a long Austrian tradition, stood for a clinically oriented and strictly organized medical education that catered to an ethnically and socially diverse population and, simultaneously, for an anatomically oriented surgery, largely of the locomotor apparatus. This study shows how, in a major centre of medical education and capital of a multiethnic empire, surgical and national identities were forged together. (shrink)

More than one single professional group deals with therapeutic manipulations of the spine and the joints. Osteopaths, Chiropractors, Naprapaths, Physical Therapists (and a contingent Physicians) all share this interest. Each profession is also very clear about where its bulk of knowledge stems from. The disciplines that are reckoned as the oldest are from the USA. A number of “inventors” are to be found, all without a formal university degree in Medicine. Andrew Taylor Still (1828–1917) came up with his system of (...) Osteopathy in 1874. Daniel D. Palmer (1845–1913), the man behind Chiropractic, founded his system in 1894, and Palmer’s colleague and former student, Oakley Smith (1880–1967), developed Naprapathy in 1906/1907. Physical Therapists working with what is called Orthopaedic Manual Physical Therapy are on the other hand not claiming American ancestry, nor do their body of knowledge and clinical skills originate from outside the medical profession. It is an offspring of Orthopaedic Medicine (OM) which was an invention by Physicians. Date and place of birth is said to be 1929 in England. This article turns the above-mentioned chronology on its head. It will show that Orthopaedic Medicine likely is the oldest system. It will also unearth OM’s sturdy roots in a strong but forgotten, and even hidden, discourse of Mechanical Medicine found in 19th century Europe, which was ruled by Physical Therapists. Why “we” do not know about this “history” is analysed and explained from a variety of perspectives. (shrink)

BackgroundBariatric surgery for children and adolescents is becoming widespread. However, the evidence is still scarce and of poor quality, and many of the patients are too young to consent. This poses a series of moral challenges, which have to be addressed both when considering bariatric surgery introduced as a health care service and when deciding for treatment for young individuals. A question based (Socratic) approach is applied to reveal underlying moral issues that can be relevant to an open (...) and transparent decision making process.DiscussionA wide range of moral issues with bariatric surgery for children and adolescents is identified in the literature. There is a moral imperative to help obese minors avoiding serious health problems, but there is little high quality evidence on safety, outcomes, and cost-effectiveness for bariatric surgery in this group. Lack of maturity and family relations poses a series of challenges with autonomy, informed consent, assent, and assessing the best interest of children and adolescents. Social aspects of obesity, such as medicalization, prejudice, and discrimination, raise problems with justice and trust in health professionals. Conceptual issues, such as definition of obesity and treatment end-points, present moral problems. Hidden interests of patients, parents, professionals, industry, and society need to be revealed.SummaryPerforming bariatric surgery for obese children and adolescents in order to discipline their behavior warrants reflection and caution. More evidence on outcomes is needed to be able to balance benefits and risks, to provide information for a valid consent or assent, and to advise minors and parents. (shrink)

Since the late 1980s, intersex adults and activists have critiqued the clinical recommendations defined in the 1950s to treat children born with ‘ambiguous genitalia’ with normalising medicine. While their struggles continue, in particular to halt the practice of genital surgery in early infancy, some European surgeons travel to African countries to transfer standards of care that have become highly controversial in the North, including in the medical community. Simple disapproval of these tours as ‘surgical safaris’ forecloses the possibility of (...) analysing more complex situations in which the so-called transfer of competence involves surgeons who promote ‘less cutting and more talking’. Such is the case – and the interest – of the surgical missions in West Africa in which I conducted recent fieldwork, accompanying a team of paediatric surgeons from a European university hospital collaborating with a renowned international NGO. This article analyses the ways in which a variation of sex development called hypospadias is framed and managed in this context through what I call a surgical script for hypospadias. I examine the conditions of (im-)possibility for Northern surgeons to operationalise, and sometimes revise, this script at the missions (but also closer to home). I discuss what the surgeons do in practice to reflect critically on the normative work of the surgical script for hypospadias as a social script on morphological ideals of sex, gender and reproductive heterosexuality. I consider in what sense genital surgery can be said to (re-)construct ‘normal’-looking genitalia, but also, fundamentally, the very idea of genitalia. (shrink)

I argue that the televisual cosmetic surgical makeover is usefully understood as a contemporary manifestation of normalization, in Foucault’s sense—a process of defining a population in relation to its conformity or deviance from a norm, while simultaneously generating narratives of individual authenticity. Drawing on detailed analysis of “Extreme Makeover,” I suggest that the show erases its complicity with creating homogeneous bodies by representing cosmetic surgery as enabling of personal transformation through its narratives of intrinsic motivation and authentic becoming, and (...) its deployment of fairy tale tropes. (shrink)

In April 1999, Dr. Curt Freed of the University of Colorado in Denver and Dr. Stanley Fahn of Columbia Presbyterian Center in New York presented the results of a four-year, $5.7 million government-financed study using tissue from aborted fetuses to treat Parkinson’s disease at a conference of the American Academy of Neurology. The results of the first government-financed, placebo-controlled clinical study using fetal tissue showed that the symptoms of some Parkinson’s patients had been relieved. This research study involved forty subjects, (...) nineteen women and twenty-one men; all suffered from Parkinson’s disease for an average of 13.5 years. In the study, each subject underwent neurosurgery: “four tiny burr holes, drilled through the wrinkle lines above the eyebrows into the skull, to clear a pathway to the brain. But only half received injections of fetal cells into the putamen, the region of the brain that controls movement; the other half received nothing. One year later, three members of the placebo group said their symptoms had improved.” In two-thirds of the transplant recipients, the fetal tissue took hold and seemed to establish a new network to produce the missing neurochemical dopamine. (shrink)

Biological conservation has a long story, but what distinguishes Conservation Biology from previous conservation fields is its multidisciplinary scope and its character as a mission-oriented crisis discipline. These characteristics suggested the introduction of the metaphor of biological conservation as a sort of surgery. This paper is about the initial stages of such surgery. Firstly, some data about the so-called “Big Sixth”—the disease—will be presented together with some information about Conservation Biology—the surgeon. Then epistemic and epistemological difficulties in extinction (...) assessment and conservation prioritization, and triage in particular, will be pointed out. It will be argued that, while data deficiency arising from empirical and practical constraints can in principle be overcome, a different order of difficulties stems from the competition among several species concepts. In this case, it will be suggested that the extent of complications is of such significance to require a thorough re-assessment of the very nature of the patients, i.e., outside the metaphor, of the concept of species. (shrink)

Debate continues about the ethics of sham surgery controls. The most powerful argument for sham surgery controls is that rigorous experiments are needed to demonstrate safety and efficacy of surgical procedures. Without such experiments, there is danger of adopting worthless procedures in clinical practice. Opponents of sham surgery controls argue that sham surgery constitutes unacceptable violation of the rights of research subjects. Recent philosophical discussion has used two thought experiments—the transplant case and the trolley problem—to explore (...) the circumstances under which individuals may be harmed to benefit a larger group. The transplant case is felt to exemplify circumstances that forbid harming some to benefit a larger group while the trolley problem exemplifies circumstances that permit harming some to benefit others. I argue that sham surgery controls satisfy criteria derived from the trolley problem and are morally permissible. (shrink)

La historia de la Cirugía Pediátrica cubana está pendiente de ser documentada científicamente. Se estableció como objetivo definir las etapas de desarrollo de la especialidad en Cuba, para lo cual se hizo un análisis histórico y se identificó cuatro períodos fundamentales. Este artículo tiene una significación práctica puesto que permite conocer en qué momento se encuentra la especialidad para modelar el futuro de la misma. The history of Cuban pediatric surgery is pending of being scientifically documented. It was established (...) as an objective to define the stages of the development of the specialty in Cuba. For this purpose a historical analysis was carried out and four main periods were identified. This study has a practical importance because it allows knowing the stage in which the specialty is to model its future. (shrink)

In the nineteenth and early twentieth centuries, scientific and technological developments made surgery safer, more reliable, and, with the corresponding increase in experimentation permitted, more exploratory and successful than ever before. The age of the heroic surgeon, however, obscured procedures that relied on the patient’s cooperation for a final, positive outcome. This essay focuses on the debates surrounding cleft palate surgery in Britain, Europe, and North America between about 1800 and 1930, where the constancy of failure dogged the (...) surgeon, even with improved operative surroundings. Although an anatomical correction could eventually be secured by surgery, without the patient’s participation in learning “normal” speech, the ultimate result was unsuccessful. Patient responsibility and self-control became, therefore, the key to success. By exploring what this meant for patients, their families, and surgeons, a new way of thinking about surgical outcomes, even during a period of increasing confidence in surgery, can be posited. -/- . (shrink)

In the recent past, several papers have pointed to the possibility that tumour removal generates a permissive environment in which tumour growth is potentiated. This phenomenon has been coined “perioperative tumour growth” and whilst it represents a departure in terms of our attitude to the surgical process, this concept was first hinted at by Paget1Sir James Paget (1814–1899) was a surgeon and physiologist who is widely held (along with Rudolph Virchow) to be the father of the science of pathology. Paget (...) described Paget's disease of the nipple as well as Paget's disease of bone. himself. Despite this, the time interval immediately before and after cancer surgery (i.e. the perioperative period) remains an underutilised interval during which chemotherapeutic regimens are rarely implemented. Herein, we present a summarised review of the literature that supports the concept that tumour removal may potentiate the growth of residual neoplastic disease. We also outline current knowledge regarding underlying mechanisms and in this manner highlight potential therapeutic entry points. Finally, we emphasise the urgent need for trials of agents that could protect patients against the harmful host–tumour interactions that may occur during the perioperative period. BioEssays 28: 433–437, 2006. © 2006 Wiley Periodicals, Inc. (shrink)