One of the inherent problems with the field of Surgery is that aside from emergency surgery, surgical indications can be somewhat nebulous.

If you are a victim of trauma and in a life and death situation, a surgeon can do surgery on you in order to save your life if you are not able to make medical decisions. Physicians in general walk a fine line between “doing what is necessary” and “doing what is necessary and defensible in a court of law.”

Aside from the emergency situation or the defensive medicine situation, surgeons are somewhat in an ethical bind when it comes to their elective practice. A surgeon makes his living by doing procedures. No surgeries means no income. Therefore, a surgeon has a financial incentive to recommend surgery to a patient. All physicians must abide by the Oath of Hippocrates. However, some bend the rules and in every community there are surgeons who lean toward surgery sooner than others.

There is DEFINITELY a grey area between what needs surgery and what clearly does not. The grey area means that a patient may do OK without surgical intervention or may not. Sometimes there are factors that push a surgeon one way or the other. For example, a patient who does not want surgery clearly will not get it. One that has other issues that might make post-surgical care difficult may also not get surgery.

I’m of the school of thought that ultimately the patient should decide. It is imperative that surgeons offer patients all of the options including non-operative treatment, aggressive surgery, surgery only after failure of conservative treatment. Physicians must document these conversations copiously to prevent lawsuits. Patients must also know what they are getting into.

I’m not sure the ethical bind will ever change for surgeons. Often patients come wanting surgery that may not be necessary, but the patient will simply find another surgeon to do the procedure if this one declines. Thus, in this day and age of the empowered patient, the surgeon is not always the one that decides if surgery is necessary.

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