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Ann Thorac Surg 2004;77:1150-1151
© 2004 The Society of Thoracic Surgeons

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Ethics in cardiothoracic surgery

Concluding remarks

Should surgeons spend more time with family and personal interests and less time in hospitals? Drs Coselli and Conklin and Drs Dickey and Ungerleider have provided conflicting answers in their respective essays. Their views, taken together, however, do not exhaust all possibilities. Additional insights may be gained by considering fundamental aspects of human behavior as understood by ancient philosophers. To them, Aristotle in particular, the most important of the virtues was phronesis, which has been roughly translated as "prudence" or "practical wisdom," though neither term captures its essence. Phronesis is the wisdom that helps us recognize those particular goals and virtues, both professional and personal, that are of greatest value to us as individuals. By applying this wisdom, we can choose a path that will correctly align our personal goals and virtues so that our individual and unique human potentials can be most fully realized [1].

Drs Coselli and Conklin have spelled out the professional goals and virtues needed for a successful professional life as a surgeon. We have been deeply inculcated with a group of virtues that characterize an excellent surgeon: (1) fidelity: being loyal to our patients before all other loyalties; (2) productiveness: working long hours to do the most we can for our patients; (3) rationality: learning what a surgeon needs to know; (4) integrity: making our actions consistent with our knowledge and beliefs; (5) reliability: being available when needed; (6) compassion: recognizing and sympathizing with the suffering of our patients; and (7) effacement of self interest: placing the best interests of our patients ahead of our own. Drs Coselli and Conklin suggest to us that although many other things are important, professional life should take precedence over all else.

This familiar picture is precisely the target of Drs Dickey and Ungerleider's essay. They point to some needs and values of surgeons that extend well outside the arena of professional life: leisure activities, relaxation, and communicating with those closest to us. Beyond those that they cite, there are many other values as well: painting landscapes or repairing motorcycles (creativity), developing and teaching Sunday school classes (spiritual engagement), reading a novel for escape (relaxation) or enrichment (intellectual growth), or writing a novel (avocation), and so forth down a virtually endless list. Drs Dickey and Ungerleider stress the importance of balance in making choices between pursuing personal goals and responding to professional demands.

These two essays cover a great deal of territory. Yet we wonder whether either viewpoint identifies the right way for a surgeon to achieve a truly fulfilling life. As human beings we all share certain needs, such as nutrition, friendships, and health, yet each of us has a one-of-a-kind blend of specific needs, desires, talents, interests, and tastes. Therefore we each have a unique path to follow if we are to achieve full realization of our individual potentials as human beings, including both our professional and personal lives.

How should we interact with our patients, colleagues, hospitals, spouses, children, friends, and others? How much time should we spend on solitary activities or with others? How much time should we spend on our profession or personal interests? In other words, how should we best utilize our limited time, energy, and resources? Dr Coselli's answer may be right for him, or not. Dr Ungerleider's answer may be right for him, or not. We cannot make that judgment; only they individually have access to personal information and insights that make such judgments possible. For some of us, heavy emphasis will be on the professional, for some, on the personal, and for many, on a roughly even mix of the two. Our essayists have given us ample food for thought, but in the end we must try to know our unique selves, and we must each design our individual paths to personal fulfillment. This is perhaps the most difficult of all human enterprises, and this may be the reason why philosophers from many centuries ago recognized that striving for self-knowledge and the determination to act on that knowledge comprise the most important of the virtues (ie, phronesis).

As for the future of the surgical ethic, crystal balls are notoriously cloudy by nature, and mine is no more revealing than anyone else's. The trend toward shorter work schedules and a bigger share of our time for personal activities is evidenced by medical students' attitudes toward lifestyle [2] and mandatory work limitations for residents [3], as well as advice such as that offered by Drs Dickey and Ungerleider. The evidence for an imminent transition to a personal lifestyle-friendly surgical profession seems compelling. Yet, although the ghastly vision (ghastly for many of us at any rate) of a 40-hour workweek for surgeons may seem just around the corner, it may not come to pass, at least not in our lifetimes. It is not that the nature of surgery necessarily demands workaholic surgeons; surgeons in other countries and other cultures have well-controlled schedules and a work ethic that accommodates a life outside of surgery. It is more that dedication to the well-being of our patients, the intensely personal nature of surgery (eg, how many internists or pediatricians have talked to a patient at dawn, held her heart in his hands in the morning, and talked to her again in the afternoon to tell her that her problem has been fixed), and our deeply embedded work ethic may combine to make the "24/7" surgeon a thing of the future as well as the past. Drs Coselli and Conklin's contribution suggests the possibility of continuing survival of the traditional surgical work ethic, and also provides us with reasons to believe that it may even be a good idea.

What will the practice of surgery look like in the future? This is not clear, but there is one certainty: change is inevitable. We need to prepare for whatever shifts occur as best we can. We may even hope to guide the process of change, perhaps in our profession, but certainly in ourselves. Drs Dickey, Ungerleider, Coselli, and Conklin have helped us to imagine how we may be better surgeons and better human beings, and for that we are grateful.

References

1. Den Uyl D.J. The virtue of prudence. . New York: Peter Lang, 1991:55-83.
2. Lowenstein J. Where have all the giants gone? Reconciling medical education and the traditions of patient care with limitations on resident work hours. Perspect Biol Med 2003;46(2):273-282.[Medline]
3. Bland K.I., Isaacs G. Contemporary trends in student selection of medical specialties: the potential impact on general surgery. Arch Surg 2002;137(3):259-267.[Abstract/Free Full Text]

This Article Full Text (PDF) See related article (Intro) See related article (Pro) See related article (Con) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Robert M. Sade Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Sade, R. M. Search for Related Content PubMed Articles by Sade, R. M.