Difficult Decisions in Surgical Ethics: An Evidence-Based Approach

Foreword
Contents
Contributors
Part I: In the Beginning
	Chapter 1: Introduction
		1.1 Special Features of Surgical Ethics
		1.2 Ethical Issues on the Horizon
			1.2.1 Artificial Intelligence in Surgery
			1.2.2 The Surgeon and Ethical Issues in Society
			1.2.3 The Importance of Trust
		References
	Chapter 2: The Importance of Formal Education and Training in Clinical Medical Ethics for the 21st Century
		2.1 Introduction
		2.2 Discussion
		2.3 Concluding Remarks
		2.4 Selected References
		Appendix 1: The 33rd Annual MacLean Fellows Conference on Clinical Medical Ethics. November 12–13, 2021
		Appendix 2: The 2021–2022 MacLean Center Summer Intensive Program for the Fellowship in Clinical Medical Ethics. July 6–30, 2021
		Appendix 3: The MacLean Center’s 40th Annual Lecture Series. The History of Medicine and Ethics. Wednesdays 12:00–1:30 PM CT
		References
	Chapter 3: What Makes Surgical Ethics Unique?
		3.1 Introduction
		3.2 Discussion
			3.2.1 Overview of Ethical Principles and its Application to Health Care
		3.3 Why Do Surgical Ethics Matter?
		3.4 What Makes Surgical Ethics Different?
		3.5 How to Teach Surgical Ethics
		3.6 Future Directions
		3.7 Concluding Remarks
		3.8 Selected References
		References
	Chapter 4: Notable Ethical Surgeons
		4.1 The Healthcare Worker in the Time of COVID
		4.2 John J. Conley MD (1912–1999)
		4.3 Sylvan S. Stool MD (1925–2004)
		4.4 Growth of Surgical Ethics
		4.5 Sir William Stokes, M.Ch. Univ. Dubl., F.R.C.S.I. (1838–1900)
		4.6 C. Rollins Hanlon, MD, FACS (1915–2011)
		4.7 Ostap Selianski, MD (1898–1945)
		References
Part II: Communication
	Chapter 5: Transparency in Surgery
		5.1 Introduction
		5.2 Search Strategy
		5.3 Discussion
			5.3.1 A Spectrum of Understanding
			5.3.2 Challenges to Transparency
			5.3.3 Improving Transparency
		5.4 Concluding Remarks
		5.5 Selected References
		References
	Chapter 6: Is Informed Consent Ever Truly Informed?
		6.1 Introduction
		6.2 Search Strategy
		6.3 Discussion
			6.3.1 History
			6.3.2 Standards
			6.3.3 Legal
			6.3.4 Communication
		6.4 COVID Considerations—SIC has been Challenged by So Many Uncertainties
		6.5 Conclusion
		6.6 Selected References
		References
	Chapter 7: Goals of Care Discussions in High-Risk Surgery
		7.1 Introduction
		7.2 Search Strategy
		7.3 Discussion
			7.3.1 Preoperative Period and Informed Consent
			7.3.2 Discussing Risk
			7.3.3 Managing Expectations, Uncertainty, and Prognostication
			7.3.4 Shared Decision-Making
			7.3.5 Perioperative Judgment and Outcomes
		7.4 Case Conclusion
			7.4.1 Goals of Care in End-of-Life Discussions
		7.5 Conclusion
		7.6 Selected References
		References
	Chapter 8: The Ethics of Telehealth in Surgery
		8.1 Introduction
		8.2 Search Strategy
		8.3 Justice
		8.4 Autonomy
		8.5 Non-maleficence
		8.6 Professionalism
		8.7 Continuous Education
		8.8 Case Conclusion
		8.9 Conclusion
		8.10 Selected References
		References
	Chapter 9: How to Deliver Bad News: A Family Postmortem
		9.1 Introduction
		9.2 Search Strategy
		9.3 Discussion
		9.4 Conclusions
		9.5 Selected References
		References
	Chapter 10: Surgical Empathy
		10.1 Introduction
		10.2 Search Strategy
		10.3 What Is Empathy and How Can It Be Measured?
		10.4 Why Is Empathy Important for the Surgeon?
		10.5 What Are the Costs of Surgical Empathy?
		10.6 How Can We Train Surgeons to Develop and Maintain Clinical Empathy?
		10.7 Conclusion
		10.8 Selected References
		References
Part III: Surgical Education
	Chapter 11: Teaching Surgical Ethics
		11.1 Introduction
		11.2 Search Strategy
		11.3 Informal Ethics Education
		11.4 Formal Ethics Education
		11.5 Lectures
		11.6 Case-Based Learning
		11.7 Small-Group Learning
		11.8 Role-Play/Standardized Patients
		11.9 Ethics Morbidity and Mortality Rounds
		11.10 Challenges to Surgical Ethics Education
		11.11 Assessment of Learning
		11.12 Case Resolution
		11.13 Conclusion
		11.14 Selected References
		References
	Chapter 12: Communication During Awake Surgery: Training Residents and Disclosure to Patients
		12.1 Clinical Scenario
		12.2 Ethical Problem
		12.3 Introduction
		12.4 Search Strategy
		12.5 Awake Procedures
		12.6 Awake Procedure Communication
		12.7 Ethical Challenges of Awake Surgical Communication
		12.8 Trainees in Awake Surgical Procedures
		12.9 Surgical Training
		12.10 Disclosure of Resident Involvement
		12.11 Modifying Communication with the Awake Patient
		12.12 Communication with the Trainee during Awake Procedures
		12.13 Clinical Scenario Revisited
		12.14 Clinical Scenario Review
		12.15 Conclusion
		12.16 Selected References
		References
	Chapter 13: Trainee Involvement in Surgical Care
		13.1 Introduction
		13.2 Search Strategy
		13.3 Discussion
			13.3.1 Ethical Principles for Consideration
				13.3.1.1 Patient Perceptions of Trainee Involvement in Care
			13.3.2 Interventions Directed at Information Communication
		13.4 Case Resolution
		13.5 Conclusion
		13.6 Selected References
		References
	Chapter 14: Can Professionalism Be Taught During Residency?
		14.1 Introduction
		14.2 Search Strategy
		14.3 Discussion
			14.3.1 The Hidden Curriculum
			14.3.2 Informal Curricula and Active Role-Modeling
			14.3.3 Formal Curricula and Simulation
		14.4 Conclusion
		14.5 Selected References
		References
	Chapter 15: Surgical Training During a Pandemic
		15.1 Introduction
			15.1.1 Impact of the Pandemic on the Surgical Residency Construct
		15.2 Search Strategy
		15.3 Discussion
			15.3.1 Impact of the Pandemic on the Residency “Life Cycle”
			15.3.2 Impact of the Pandemic on the Individual Resident
				15.3.2.1 Moral Distress, Moral Residue, and Moral Resilience
				15.3.2.2 Strategies for Addressing and Mitigating Moral Distress
				15.3.2.3 The Role of “Moral Distress Rounds”
				15.3.2.4 The Value of “Moral Distress Rounds” on Resident Well-Being—A Resident’s Perspective
		15.4 Case Concluded
		15.5 Conclusion
		15.6 Selected References
		References
Part IV: Medical Discrepancy/Medical Error
	Chapter 16: Surgical Disclosure of Errors
		16.1 Introduction
		16.2 Search Strategy
		16.3 Discussion
			16.3.1 History of Disclosure
			16.3.2 The Patient Perspective
			16.3.3 The Surgeon Perspective
			16.3.4 Guidelines for Communication
			16.3.5 Facilitating the Disclosure Process
		16.4 Case Conclusion
		16.5 Conclusion
		16.6 Selected References
		References
	Chapter 17: Disclosing Errors of Others
		17.1 Introduction
		17.2 Search Strategy
		17.3 Discussion
			17.3.1 Medical Errors
			17.3.2 Error Disclosure: Personal Errors
			17.3.3 Error Disclosure: Errors of Others
			17.3.4 Systems-Level Process Improvement
		17.4 Conclusion
		17.5 Selected References
		References
	Chapter 18: Expert Witness Testifying Against Colleagues
		18.1 Introduction
		18.2 Search Strategy
		18.3 Discussion
		18.4 Justice
		18.5 Autonomy
		18.6 Beneficence and Nonmaleficence
		18.7 Case Conclusion
		18.8 Concluding Remarks
		18.9 Selected References
		References
Part V: Cultural/Religious Diversity
	Chapter 19: Acceptance or Refusal of Surgery Due to Religious or Cultural Reasons
		19.1 Cases
		19.2 Introduction
		19.3 Search Strategy
		19.4 Discussion
			19.4.1 Culture, Religion, and Medicine: Intersection and Embeddedness
			19.4.2 The Culture of Medicine and the Limits of a Principle-Based Approach to Surgical Ethics
			19.4.3 Strategies for Negotiating Surgical Acceptance or Refusal Based on Culture or Religion
		19.5 Concluding Remarks
		19.6 Selected References
		References
	Chapter 20: Subtle Approach to the Mores of the Navajo Nation
		20.1 Introduction
		20.2 Search Strategy
		20.3 Discussion
			20.3.1 Background
				20.3.1.1 Population Demographics
				20.3.1.2 Social Determinants of Health
				20.3.1.3 Health Inequities
				20.3.1.4 Dikos Ntsaaigii-Na ha ́st’e ́ı ́ts’a ́adah (COVID-19)
				20.3.1.5 Cultural Difference
					Individuality
					Positive Thinking
					Family Structure
					Traditional Medicine
					Allopathic Treatments
			20.3.2 Principles of Medical Ethics in Surgical Care and Cultural Difference
				20.3.2.1 General Concepts
				20.3.2.2 Trust
				20.3.2.3 Patient Autonomy
				20.3.2.4 Advance Directives
				20.3.2.5 Informed Consent
				20.3.2.6 Treatment
					Pain Assessment
					Withdrawal of Treatment
			20.3.3 Cultural Competence and Cultural Humility Improvement Strategies
				20.3.3.1 Individual Provider Strategies
					Unconscious Bias Awareness and Training
					Communication Strategies and Ethical Principles
						Four-Step Approach
						Hypothetical Case Approach
						Ask, Tell, Ask Approach
						Modified Informed Consent
				20.3.3.2 Medical Education Improvements
				20.3.3.3 Health Systems Strategies for Cultural Competence (see Table 20.4)
					Diversify the Workforce
					Interpreters and Patient Advocates
					Traditional Healing
					Hospital Policy Considerations
				20.3.3.4 Societal Advocacy
			20.3.4 Return to the Case
		20.4 Conclusion
		20.5 Selected References
		References
			Electronic Links
	Chapter 21: Surgery on the Incarcerated Patient
		21.1 Introduction
		21.2 Search Strategy
		21.3 Discussion
			21.3.1 Paucity of Data in a Large Population
			21.3.2 Altered Preoperative Care
			21.3.3 Disease Severity
			21.3.4 Implicit Bias
			21.3.5 Mistrust of the Hospital System
			21.3.6 Modified Policies and Procedures
		21.4 Case Conclusion
		21.5 Concluding Remarks
		21.6 Selected References
		References
Part VI: Surgical Dilemmas in the Adult Patient
	Chapter 22: Surgical Buy-In for Major Operations
		22.1 Introduction
		22.2 Search Strategy
		22.3 Discussion
			22.3.1 The Beginning of Buy-In
			22.3.2 Why Surgeons Seek Buy-In
			22.3.3 The Surgeon’s Covenant
			22.3.4 How Patients Perceive Buy-In
			22.3.5 The Ethics of Buy-In
			22.3.6 A Postoperative Caveat
			22.3.7 The Conflict around Buy-In
			22.3.8 A Surgeon’s Time
			22.3.9 Cashing Out
			22.3.10 The Solution
		22.4 Case Conclusion
		22.5 Conclusion
		22.6 Selected References
		References
	Chapter 23: The Changing Ethical Landscape of Cesarean Delivery on Maternal Request
		23.1 Introduction
		23.2 Search Strategy
		23.3 Discussion
		23.4 The History of CDMR
		23.5 Reconsiderations of CDMR
			23.5.1 Focus on the Mother
			23.5.2 Focus on the Newborn
		23.6 Case Resolution
		23.7 Conclusions
		23.8 Selected References
		References
	Chapter 24: Ethics of Fertility Sparing Oncologic Surgery in Women
		24.1 Introduction
		24.2 Search Strategy
		24.3 Discussion
			24.3.1 Fertility Sparing Surgery
		24.4 Options for Reproduction After Cancer Treatment
		24.5 Ethical Issues
			24.5.1 Nonmaleficence
			24.5.2 Beneficence
			24.5.3 Consent/Autonomy
			24.5.4 Justice
		24.6 Case Concluded
		24.7 Conclusion
		24.8 Selected References
		References
	Chapter 25: Anal Sparing Surgery: Pushing the Limits of Patient Autonomy
		25.1 Introduction
		25.2 Search Strategy
		25.3 Discussion
			25.3.1 Medical Indications: The Principle of Beneficence
				25.3.1.1 Why Does This Ethical Problem Occur?
				25.3.1.2 What is the Evidence for a Watch & Wait (W&W) Strategy?
			25.3.2 Patient Preferences: Autonomy
			25.3.3 Quality of Life
			25.3.4 “External” Considerations
		25.4 Case Conclusion
		25.5 More Scenarios
		25.6 Conclusion
		25.7 Selected References
		References
	Chapter 26: Invited Commentary for Anal Sparing Surgery: Pushing the Limits of Patient Autonomy
		References
	Chapter 27: Ethical Decision-Making of Treatment of Aortic Aneurysm, Elective or Emergent (Ruptured)
		27.1 Cases
		27.2 Introduction
		27.3 Search Strategy
		27.4 Discussion
		27.5 Conclusion
		27.6 Selected References
		References
	Chapter 28: Denial of Life Support in Disabled Patients
		28.1 Introduction
		28.2 Search Strategy
		28.3 Discussion
		28.4 Case Continued
		28.5 Conclusion
		28.6 Selected References
		References
Part VII: Surgical Dilemmas in the Pediatric Patient/Family
	Chapter 29: Changing Landscape of What Is Ethical and Appropriate
		29.1 Introduction
		29.2 Search Strategy
		29.3 Discussion
			29.3.1 Section 1. The Effect of Geography on Medical Ethics
			29.3.2 Section 2. The Effect of Socioeconomic Status on Medical Ethics
				29.3.2.1 Case Scenario
				29.3.2.2 For Whom Is ECMO Indicated?
			29.3.3 Section 3. Childhood Vaccines
				29.3.3.1 Case Scenario
			29.3.4 Section 4. How the Coronavirus Pandemic Has Affected Medical Ethics
				29.3.4.1 Case Scenario
		29.4 Conclusion
		29.5 Selected References
		References
	Chapter 30: A Careful Balance of the Benefits and Burdens of Pediatric ECMO
		30.1 Introduction
		30.2 Search Strategies
		30.3 Discussion
			30.3.1 Benefits of ECMO in Pediatrics
			30.3.2 ECMO as a Bridge to Recovery
			30.3.3 Bridge to Corrective Surgery
			30.3.4 Bridge to Transplant
			30.3.5 Bridge to Decision Making
			30.3.6 Burdens of ECMO in Pediatrics
			30.3.7 Challenges with Withdrawing and Withholding Treatment
			30.3.8 Equitable Distribution of Costly, Resource Intensive Care
			30.3.9 Risk of Morbidity Associated with ECMO Support
			30.3.10 Challenges with Informed Consent
		30.4 Case Resolution
		30.5 Conclusion
		30.6 Selected References
		References
	Chapter 31: Ethics of Pediatric Bariatric Surgery
		31.1 Introduction
		31.2 Search Strategy
		31.3 Discussion
			31.3.1 Medical Indications
			31.3.2 Treating Childhood and Adolescent Obesity
			31.3.3 Risks and Long-Term Complications of Metabolic Bariatric Surgery
			31.3.4 MBS Candidate Requirements
			31.3.5 Patient Preferences
			31.3.6 Consent and Assent
			31.3.7 Cognitive Disabilities
			31.3.8 Quality of Life and Psychosocial Barriers
			31.3.9 Cultural Norms
			31.3.10 Social Support Structure
			31.3.11 Contextual Features: Justice of Allocation of Resources
		31.4 Conclusion
		31.5 Selected References
		References
	Chapter 32: Death by Neurologic Criteria in Neonatal and Pediatric Intensive Care Units
		32.1 Introduction
		32.2 Search Strategy
		32.3 History of the Determination of Death by Neurologic Criteria
		32.4 Determination of Death by Neurologic Criteria in Pediatrics
			32.4.1 Epidemiology
			32.4.2 Prerequisites for Death by Neurologic Criteria Declaration
			32.4.3 Clinical Exam
			32.4.4 Apnea Test
			32.4.5 Ancillary Testing
			32.4.6 Determination of Death by Neurologic Criteria in the Neonatal ICU
			32.4.7 Parental Role in Decision Making
			32.4.8 Societal Differences in Determination of Death by Neurologic Criteria
			32.4.9 Donation After Cardiac Death in Pediatrics
			32.4.10 “Accepting” Death by Neurologic Criteria
		32.5 Case Conclusion
		32.6 Conclusion
		32.7 Selected References
		References
	Chapter 33: Ethical Issues Raised by Fetal Interventions for Lethal Anomalies
		33.1 Introduction
		33.2 Search Strategy
		33.3 Discussion
		33.4 Additional Ethical Considerations for Fetal Intervention in Cases of Bilateral Renal Agenesis
			33.4.1 Uncertainty of Risks and Benefits of Intervention
			33.4.2 Surgical Innovation Versus Medical Research
			33.4.3 Informed Consent
		33.5 Access to Care and Medical Justice: What Is Fair?
		33.6 Is There a Role for a Parent Advocate?
		33.7 Beyond Fetal Intervention: Recognizing and Addressing Conflict and Moral Distress of Providers and Parents
		33.8 Case Resolution
		33.9 Conclusion
		33.10 Selected References
		References
Part VIII: Critical Care
	Chapter 34: Dealing with Families of Patients with Severe Brain Injury: How Long to Treat, When to Turn Off Support, Organ Donation
		34.1 Introduction
		34.2 Search Strategy
		34.3 Discussion
			34.3.1 Ethics of Head Trauma
			34.3.2 Family Communication
			34.3.3 Informed Consent
			34.3.4 Prognostication
			34.3.5 Support
			34.3.6 Organ Donation
			34.3.7 Framework for Communication with Families (see Table 34.3)
		34.4 Case Conclusion
		34.5 Conclusion
		34.6 Selected References
		References
	Chapter 35: Burned Beyond Recognition: Ethics of Care
		35.1 Introduction
		35.2 Search Strategy
		35.3 Discussion
		35.4 Respect for Autonomy
		35.5 Shared Decision Making
		35.6 Patient Capacity and Consent for Treatment
		35.7 Surrogate Decision Making
		35.8 Futility of Medical Treatment
		35.9 Withholding and Withdrawing Treatment
		35.10 Special Consideration: Self-Immolation
		35.11 Special Consideration: Pediatric Burn Injuries
		35.12 Case Analysis
		35.13 Concluding Remarks
		35.14 Selected References
		References
	Chapter 36: Rationing Ventilators
		36.1 Introduction
		36.2 Search Strategy
		36.3 Discussion
			36.3.1 The Goals of Resource Allocation
			36.3.2 Saving Lives
			36.3.3 Saving Life-years
			36.3.4 Saving Quality-adjusted Life-years
			36.3.5 Realizing or Upholding Shared Values
			36.3.6 To What Extent Should Allocation Policy Adhere to Government Guidelines?
			36.3.7 Who Should Make Allocation Decisions?
		36.4 Evaluation of Possible Allocation Criteria
			36.4.1 First-come, First-serve
			36.4.2 Lottery
			36.4.3 Age
			36.4.4 Mortality Risk
			36.4.5 Long-term Mortality Risk
			36.4.6 Short-term Mortality Risk
			36.4.7 Health Care Worker Status
			36.4.8 Other Patients Requiring Ventilation
			36.4.9 Operationalizing Allocation Guidelines
			36.4.10 How/Where/When do Triage Teams Meet?
			36.4.11 Calculating the Objective Mortality Risk Score
			36.4.12 Comorbid and Frailty Indexes
		36.5 Conclusion
		36.6 Selected References
		References
Part IX: Do Not Resuscitate/Palliative Care/End of Life
	Chapter 37: Peri-Operative DNR: An Ethical Dilemma
		37.1 Introduction
		37.2 Search Strategy
		37.3 Discussion
			37.3.1 History of Cardiopulmonary Resuscitation (CPR)
			37.3.2 Contemporary Experience with Cardiopulmonary Resuscitation
			37.3.3 An Unintended Consequence of Cardiopulmonary Resuscitation
			37.3.4 Popular Perception and the Medical Reality of CPR Outcomes
			37.3.5 DNR Orders Should Be Discussed in the Context of Goals of Care
			37.3.6 Self Determination and the Right to Refuse Life-Prolonging Treatment
			37.3.7 When Is Maintaining a Perioperative DNR Appropriate?
		37.4 Perioperative DNR Orders Still Elicit Tension Despite Clear Professional Guidelines
			37.4.1 Society Guidelines and Position Statements
			37.4.2 Integrating Required Reconsideration into Ethical Surgical Practice
		37.5 Case Conclusion
		37.6 Concluding Remarks
		37.7 Selected References
		References
	Chapter 38: Goals of Care with Palliative Surgery
		38.1 Introduction
		38.2 What Palliative Surgery Is and Is Not
		38.3 Ethical Framework
		38.4 Discussion: Ethical Analysis
		38.5 Conclusion
		38.6 Selected References
		References
	Chapter 39: Ethical Conflicts in Surrogate Decision Making
		39.1 Introduction
		39.2 Search Strategy
		39.3 Discussion
			39.3.1 Decisional Capacity
			39.3.2 Surrogate Decision Making
			39.3.3 Complicating Factors in Surrogate Decision Making
			39.3.4 Conflict in Surrogate Decision Making
			39.3.5 Ethical Principles in Surrogate Decision Making
			39.3.6 The Physician’s Role in Surrogate Decision Making
			39.3.7 Managing Conflict in Surrogate Decision Making
		39.4 Case Revisited
		39.5 Conclusion
		39.6 Selected References
		References
Part X: Global Surgery
	Chapter 40: Medical Missions to Developing Countries (Pro)
		40.1 Introduction
		40.2 Search Strategy
		40.3 Discussion
			40.3.1 Beneficence
			40.3.2 Justice
			40.3.3 Nonmaleficence
			40.3.4 Autonomy
			40.3.5 Surgery as a Special Case
			40.3.6 STEGHs for surgical trainees
			40.3.7 STEGH Frameworks
		40.4 Concluding Remarks
		40.5 Selected References
		References
	Chapter 41: The Ethics of Medical Missions (Con)
		41.1 Introduction
		41.2 Search Strategy
		41.3 Discussion
		41.4 Justice
		41.5 Beneficence and Non-Maleficence
		41.6 Respect for Autonomy
		41.7 Case Conclusion
		41.8 Concluding Remarks
		41.9 Selected References
		References
	Chapter 42: Invited Commentary: Medical Missions to Developing Countries
		References
	Chapter 43: Ethics and National Health Policy Change: A Case Study of the Transplant System in China
		43.1 Introduction
			43.1.1 Evolution of Transplantation in China
		43.2 Search Strategy
		43.3 Discussion
			43.3.1 The Cyclosporine Age
			43.3.2 Source and Rights of the Organ Donor
			43.3.3 Regulation of Quality and Reform
			43.3.4 New Ethical System
		43.4 Concluding Remarks
		43.5 Selected References
		References
Part XI: Covid-19 Pandemic of 2020
	Chapter 44: COVID-19 Caught the World Unprepared
		44.1 Introduction
			44.1.1 Public Health
			44.1.2 Pandemics
		44.2 Discussion
			44.2.1 Coronaviruses and COVID-19
			44.2.2 The Issues
		44.3 Conclusion
		44.4 Selected References
		References
	Chapter 45: The Panic of the Pandemic: Who Lives, Who Dies
		45.1 Introduction
		45.2 Search Strategy
		45.3 Discussion
		45.4 Competing Ethical Norms
		45.5 Tragic Choices and Frameworks for Allocation of Resources
		45.6 Common Trends in Ethical Guidelines
		45.7 Differences in Ethical Guidelines
		45.8 Special Considerations: The Elderly
		45.9 Special Considerations: Children
		45.10 Special Considerations: Healthcare Workers
		45.11 Special Considerations: Residents and Fellows in Training
		45.12 Public Perception and Trust
		45.13 The Socioeconomic Divide
		45.14 The Pandemic’s Effect on Surgery
		45.15 After the Pandemic
		45.16 Case Conclusion
		45.17 Selected References
		References
	Chapter 46: A System Overwhelmed by a Pandemic: The New York Response
		46.1 Introduction
		46.2 Search Strategy
		46.3 Discussion
			46.3.1 Retired Physicians
		46.4 Age and Risk
		46.5 Credentialing
		46.6 Medical Students on the Frontlines
		46.7 Outpatient Sub-Specialists
			46.7.1 Qualifications
		46.8 Feelings of Unpreparedness
		46.9 The Silver Lining
		46.10 Resolution
		46.11 Case Conclusion
		46.12 Concluding Remarks
		46.13 Selected References
		References
	Chapter 47: Cardiovascular Services in the COVID-19 Hot Zone: Italy
		47.1 Introduction
		47.2 Search Strategy
		47.3 Discussion
			47.3.1 Lockdown of the Country
		47.4 Healthcare System Reorganized
		47.5 Effect on Cardiac Services
		47.6 Guidelines at the Time of COVID-19
		47.7 A New Sunrise: 2021 and the Vaccination Era
		47.8 Case Concluded
		47.9 Conclusion
		47.10 Selected References
		References
Part XII: Surgical Innovation/Research
	Chapter 48: Ethical Questions of Surgical Trials
		48.1 Introduction
		48.2 Search Strategy
		48.3 Discussion
			48.3.1 Ethical Standards in Clinical Trials: A Historical Perspective
			48.3.2 Clinical Trials in Medicine and Surgery
			48.3.3 The Concept of Clinical Equipoise
			48.3.4 Ethics of Study Design
			48.3.5 Informed Consent: Patient Autonomy
			48.3.6 Evidence Based Medicine and Need for Surgical Trials
		48.4 Case Discussion
		48.5 Concluding Remarks
		48.6 Selected References
		References
	Chapter 49: Introducing New Techniques, Technology, and Medical Devices
		49.1 Introduction
		49.2 Search Strategy
		49.3 Discussion
			49.3.1 Medical Advancements in History
			49.3.2 Modern Medical Oversight
			49.3.3 The Role of the Food and Drug Administration in Regulating Medical Devices
			49.3.4 Transparency in Surgical Innovation
			49.3.5 Research Vs Innovation
			49.3.6 The Learning Curve and Surgical Training
			49.3.7 Disclosing Potential Conflicts of Interest
			49.3.8 Informed Consent
			49.3.9 The Principles of Bioethics: A Case Review
		49.4 Conclusion
		49.5 Selected References
		References
	Chapter 50: Uterus Transplantation
		50.1 Introduction
		50.2 Search Strategy
		50.3 Historical Perspectives on Uterus Transplantation
		50.4 Technical Aspects of Uterus Transplantation
		50.5 The Process of Uterus Transplantation
		50.6 The Unique Characteristics of Uterus Transplantation
		50.7 An Overview of Ethical Issues Raised in Uterus Transplantation
		50.8 Case Discussion: Addressing Conflicts Over Graft Hysterectomy
		50.9 Case Conclusion
		50.10 Concluding Remarks
		50.11 Selected References
		References
	Chapter 51: Cancer Patients Paying Hefty Prices for Newest Treatments: Case of High Intensity Focused Ultrasound (HIFU) Ablation of Prostate Cancer
		51.1 Introduction
		51.2 Search Strategy
		51.3 Discussion
		51.4 Medical Indications
		51.5 Patient Preferences
		51.6 Quality of Life
		51.7 Contextual Features
		51.8 The Responsibility of Funding Innovative Treatment Options
		51.9 Concluding Remarks
		51.10 Selected References
		References
Index