Antibiotics (Properties, Application, Interaction) - M.P. Cherenko 1999

Deontology in Surgery

Since time immemorial, the snake has been considered the medical emblem—a bearer of health and wisdom. This emblem characterizes the objective side of our profession. Alongside it exists another, lesser-known symbol, a precept reflecting the inner essence of medical practice. It was left to us by the prominent Dutch surgeon and burgomaster of Amsterdam, Nicolaas Tulp (1599–1674). It is a burning candle, accompanied by the motto: «Aliis serviendo ipse consumor» — «By serving others, I consume myself».

A multitude of physicians have remained faithful to this precept until the last hour of their lives. One cannot count all these modest, unknown medical workers who, in the name of serving suffering humanity, labored at the epicenters of epidemics, died of typhus, demonstrated supreme self-sacrifice at the fronts of war, in partisan detachments behind enemy lines, in Hitler's death camps, Stalin's torture chambers, and ultimately—in the modest conditions of ordinary, everyday labor in peacetime.

The history of medicine knows many instances of self-sacrifice by men of science who, for the good of people, gave away their property, health, and even their lives.

One cannot fail to mention here the example of profound self-sacrifice, truly Spartan endurance, and fidelity to the high ideals of medicine demonstrated in The final stage of his life by the famous Russian surgeon and innovator Professor V. Oppel.

In 1931, at the peak of his creative powers, V. Oppel was diagnosed with a malignant tumor of the maxillary sinus. As the tumor began to invade the eye, the question of surgical intervention—resection of the Maxilla with enucleation of the eye—arose acutely. Having bravely listened to the doctors' decision regarding the operation, V. Oppel engaged in self-training. Bandaging the eye designated for removal, he trained himself to operate under these new conditions. Indeed, having undergone the operation and remaining with one eye, V. Oppel resumed intensive work, lecturing, and writing until death cut short his vibrant life.

However, unfortunately, even today one encounters individuals who do not burden themselves with «futile reflections», for whom the entire essence of existence lies in serving the interests of their own small «ego». Naturally, they are devoid of broad interests, indifferent to the lofty goals of their chosen profession, and, worst of all, indifferent to other people. It is a great fortune that they are relatively rarely attracted to our profession: it seems to them too painstaking and unprofitable. These people seem to follow the precept of Jeremy Bentham, an English jurist of the late 18th and early 19th centuries, who, by an ironic twist of fate, was the first to introduce the term «deontology». Bentham taught that the foundation of morality is «each person caring for themselves, with no one caring for others». Into METABOLISM/2.html">THE CONCEPT OF «deontology», Bentham incorporated the means of achieving individual happiness.

By the way, the term «deontology» comes from two Greek words: deon — that which is proper, necessary, and logos — word, teaching. Translated, it means «the science of duty», «the science of the proper».

Although the term «deontology» was introduced only at the end of the 18th century, its fundamental principles were formulated long ago. Hippocrates already paid great attention to this issue, which was reflected in his Oath.

The Hippocratic Oath

I swear by Apollo the Physician, by Asclepius, by Hygieia, by Panacea, and by all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and covenant: To hold my teacher in this art equal to my own parents; to make him partner in my livelihood; when he is in need of money to share mine with him; to consider his family as my own brothers, and to teach them this art, if they want to learn it, without fee or indenture; to impart precept, oral instruction, and all other instruction to my own sons, the sons of my teacher, and to indentured pupils who have taken the oath according to medical law, and to no other. I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice. I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art. I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work. Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.

Whatever in my professional practice—or even outside of my practice—I see or hear in the lives of men which should not be divulged abroad, I will hold as secret, considering that such things should not be spoken of. Now if I carry out this oath and break it not, may I gain for ever reputation among all men for my life and for my art; but if I transgress it and forswear myself, may the opposite befall me.

The teachings of Hippocrates played a major positive role in the subsequent development of medicine. His core principles—in other words, the heritage of classical ancient Greek medicine—warned physicians against errors and one-sided fixations, of which there were not a few throughout the centuries-long development of medicine.

Great attention must be paid to the issue of deontology in The process of student training. In the long and complex process of their medical education, a crucial and responsible moment arrives when they first enter the clinic—the complex and dramatic world of a sick person. It opens a new page of human understanding before them. Crossing the threshold of the clinic for the first time, students encounter the patient, and this is a serious event in their learning process. And much of their future medical destiny will depend on how their relationships with colleagues, patients, and patients' relatives take shape from the very beginning.

To become a good specialist, more than just sound professional training is required. The patient entrusts the physician with the dearest thing they have—their health, and sometimes their life. The authority of a physician is secured primarily by knowledge of their discipline and high professional skill. But this is only one side of the matter. It is not enough to be merely a good specialist. The patient must be confident that the physician not only can help them, but will try to do everything possible in this regard, drawing upon modern medical advances and personal experience. Hope for recovery dominates the thoughts and feelings of a patient during illness. The patient strives to feel that the physician shares this hope and cares for them. Naturally, this applies not only to physicians, but to all medical personnel. The atmosphere surrounding the patient in a healthcare institution depends on them. Each of us has been ill, and we have all thought about the same thing—how to recover quickly. The physician must understand the patient's psychological state. They are obliged to act in such a way as not to harm the patient through their actions and words, and not to cause anxiety, uncertainty about the future, or a depressed emotional state.

At the same time, one must remember that patients' trust does not come of itself; it must be earned and won through a humane attitude. True physicians are greeted by patients with hope and love. It is said that during the siege of Sevastopol, soldiers carried the headless body of their comrade from a bastion to the medical station where the famous surgeon N. Pirogov worked. When the paramedic asked where the soldier's HEAD was and why they were bringing him there, the comrades replied: «It's all right, Your Honor, the head is being carried behind us, perhaps Dr. Pirogov will stitch it on somehow. He is a very good man indeed». True or not, this example vividly illustrates the soldiers' faith in N. Pirogov. Patients trustingly lie on the operating table of such a surgeon.

Some representatives of medicine do not recognize the division of deontology into «therapeutic», «surgical», «oncological», and so on. In their view, There is a single general deontology that defines the physician's behavior during contact with the patient. However, as G. Karavanov points out, surgery has its own specific features that may be little known or entirely incomprehensible to physicians of other specialties.

The distinction of surgical deontology is based primarily on the purely Specific features of medical profiling.

Many patients have a special attitude toward the surgical method of Treatment—they believe in it, understand the necessity and inevitability of surgery in certain cases, hope for recovery, and at the same time fear pain, complications, etc. In the minds of patients, the surgeon, the scalpel, and pain are inseparable. And this has great psychological significance. Medical personnel must always maintain in patients the belief in a successful outcome of the operation and recovery. In their activities, the physician must be guided by the patient's interests—in other words, their health.

There is no doubt that surgery has its own specific deontological features. They are diverse. The most important task of surgical deontology is to convince the patient of the necessity of Surgical treatment and to obtain their consent. Understandably, from a psychological standpoint, the most unsettling aspects for the patient are realizing The Need for surgery and giving consent to it. Sometimes, conversely, it can be quite difficult for the surgeon to convince the patient that a surgical intervention is unnecessary (e.g., phantom Cancer, etc.). At times, even the surgeon themselves finds it difficult to resolve the problem regarding the need for surgical intervention. In many situations, the question of its expediency or potential consequences is discussed with relatives. In all these cases, the surgeon's personality, tact, authority, and the reputation of the surgical institution they head are of great, even decisive, significance. The surgeon must be confident in their own abilities, in the availability of conditions for performing the operation, and must take into account everything upon which its successful completion depends. All this provides grounds for singling out surgical deontology with its specific features, problems, and Methods of resolving them.

The peculiarity of the surgeon's profession lies primarily in the fact that all flaws in their work impact human health directly: visibly and tangibly. Shoddiness is unacceptable in a surgeon's work; mistakes are impossible.

And yet, these mistakes do happen. As in any line of work. And for these mistakes, for their failures, the surgeon pays a high price: severe emotional distress, condemnation by the patient's relatives, and damage to their own reputation. They are responsible for The Fate of their patients.

It is said that surgeons' feelings become dulled over time. But is this really the case? In answering this question, it is appropriate to cite the thoughts on the emotional qualities of a surgeon expressed in his time by V. Oppel in his memoirs «Surgical Novellas».

«People say that surgeons operate on patients without any emotion. They operate calmly and remain calm regarding the outcomes of their operations. But if someone were ever to peer into the soul of a surgeon who is beginning to operate independently and takes responsibility for the entire future, they would discover something unexpected. Recall the sleepless nights when you lie in bed, tossing and turning, thinking and thinking: how not to do harm. Which of the surgeons has not experienced intense strain during an operation to suppress feelings of despair and fear for the patient's life? Which surgeon does not know how The Heart aches when he is informed that a patient's Temperature has risen? Who does not visit critically ill patients in the evening and at night, feeling a sense of dread before entering the ward—is the patient alive or dead? Which of the surgeons, having overcome a severe illness, performed a risky operation and, seeing that the patient is saved, is not ready to weep with happiness? Only self-control allows one to replace tears of happiness with a relaxed, cheerful smile. No, let no one speak of indifference. Surgeons possess a composure of which they can be proud, because composure, and only composure, makes it possible to save the patient. But what this composure costs, how dearly it is bought by surgeons, is better not asked—they will not tell anyway».

The surgeon's profession imposes certain demands upon them. Much has been written in medical literature about what a surgeon should be like.

N. Bidloo, in his book «A Guide for Those Studying Surgery in the Anatomical Theatre», characterizes the surgeon as follows:

"A surgeon should be neither too young nor too old, thoroughly versed in The Theory of science, and skilled in his art. He must possess a sound judgment, a sharp Vision, and be healthy and strong. During an operation, he should remain outwardly merciless, yet free from anger, and sober. A surgeon should not be capricious, so as not to rush through the Procedure or recklessly abandon it halfway, nor should he grow angry at a patient's remarks. Furthermore, he must be agile and deft to confidently begin the operation. He must not harbor anger toward the patient, but rather strive to make the latter rely on him. If the hope of saving the patient outweighs the danger, the procedure must be performed. However, if the danger exceeds the hope of recovery, one ought to refrain from operating. Never undertake an operation for personal gain, but treat the patient out of calling. Moreover, a surgeon must not begin an operation without consulting a colleague or a person well-versed in this art."

So what actually lies at the core of shaping a surgeon's traits? First and foremost, self-devotion is one such trait. According to H. Karavanov, this character trait manifests in many different forms that directly and immediately relate to a surgeon's practice. Some of these—such as self-perception, introspection, self-analysis, self-assessment, and self-criticism—are more closely tied to the cognitive aspect of an individual's activity, while others—such as self-esteem, complacency, modesty, a sense of responsibility, and duty—constitute the emotional component.

Meanwhile, such manifestations as composure, self-control, self-discipline, initiative, confidence, and resolve are associated with human volitional activity. It is hard to overstate The Role of all these forms of self-awareness in a surgeon's work.

The next trait characterizing a surgeon is breadth of intellect, The ability to think creatively, to anticipate a patient's future condition, to maintain independent thinking, and to be an optimist.

A physician who has chosen the surgical profession must be surgically gifted, capable of using precisely the right movements to cut and suture Tissues, stop bleeding, remove tumors, or open abscesses. Much here depends on the surgeon's hands and finger dexterity.

One of the hallmarks of a modern surgeon is intellectual refinement in the broadest sense of the word. Regarding this, A. Ochkin wrote that, given the aggregate of demands placed upon him, a physician must be superhuman, and his position "the most arduous of all existing professions."

Humanism is the most essential character trait of a surgeon. A surgeon cannot be imagined without qualities such as kindness, empathy, and gentleness. Callousness and indifference to a sick person's fate undoubtedly impair therapeutic outcomes, no matter how profound the physician's professional knowledge may be. Habituation to patients' suffering and professional cold-bloodedness must not degenerate into heartlessness. A true physician is precisely the one who knows where to draw this line.

Ultimately, a surgeon's individual psychological characteristics are of paramount importance. The physician's emotional and volitional state, temperament, character traits, and abilities manifest in every specific interaction with a patient. Every time a surgeon leans over a patient's bed, a whole spectrum of emotions arises.

Establishing contact with the patient and winning their trust is crucially important. This can be achieved through the physician's individual approach, demeanor, and ultimately, personal appearance. Untidy clothing, disheveled Hair, dirt under the fingernails, an unwashed shirt—all these evoke negative emotions in the patient toward the doctor.

The patient's psychological state, their belief in successful treatment, trust in the surgeon, and will to live play an important, and sometimes decisive, role. Instilling hope for recovery and sustaining the will to live—that power which, in the words of English writer W. S. Maugham, "works from within and with its bright flame illuminates every minute of our existence so that even the unbearable becomes bearable"—is so vital for a patient's recovery, or, if recovery is impossible, for prolonging their life. It is well known how acute the perception of life is among people looking death in the eye: every single day of life becomes priceless to them. One can believe in the sincerity of England's Queen Elizabeth, who, on her deathbed, assured her physician that she would gladly surrender her entire kingdom for just one day of life. It is hard to read without emotion the deathbed pleas of H. de Balzac to extend his life by merely six days: "Just six days—not much," he urged his physician.

"I shall manage to quickly review all fifty of my volumes. In six days, I can bestow immortal life upon this world I created." Yet even those six days were not granted to him.

American writer O. Henry justly noted that when a patient begins to count the carriages in their funeral procession, the healing power of medicine is cut precisely in half. But if the patient shows even a passing interest in what sleeve styles will be worn in winter, one can rest assured that the doctor has a great chance of curing their charge.

A surgeon's work is multifaceted, and their position is restless. A person who has dedicated themselves to surgery wages a continuous battle in which the joy of victory is punctuated by the bitterness of occasional failures. A physician must tirelessly study and improve within their field, mastering the scientific and cultural heritage as deeply as possible. They must treat patients with exceptional conscientiousness, caring for their health and working capacity, and act as an organizer of the struggle for public health.

Under modern working conditions for physicians, a new question has emerged: is every person who wants to become a doctor capable of it? What is The Essence of a medical vocation? Who can become a doctor? Are there criteria of aptitude for the medical profession? When entering theatrical, art, or physical education institutes, or conservatories, applicants are invariably tested for talent. No such criteria are applied during admission to medical schools. True, there have been attempts in medicine to establish certain restrictions, even physical ones, for individuals entering medical universities. The specialized press has debated the formulation of qualification rules for surgeons. After all, restrictions exist for drivers, train engineers, pilots, and astronauts. Why, then, do they not exist for a profession that involves the right to actively intervene in The Human Body? Unfortunately, no such restrictions exist today. Consequently, one occasionally encounters individuals who lack the calling of a physician, and particularly of a surgeon.

Over two millennia have passed since the time of Hippocrates. Much of his oath has lost its relevance. Yet, many of its principles have survived to this day and are reflected in the Oath of a Physician of Ukraine, taken by medical graduates upon completing their higher education.

On June 15, 1992, the President of Ukraine issued a Decree on the Oath of a Physician of Ukraine.

THE PHYSICIAN'S OATH

Having attained the profession and recognized Structure/19.html">The Importance of the duties entrusted to me, in the presence of my teachers and colleagues, I solemnly swear: to dedicate all my knowledge, strength, and skills to the cause of protecting and improving human health, treating and preventing diseases, providing medical care to all who need it, remaining unfailingly guided in my actions and thoughts by the principles of universal morality, being selfless and responsive to patients, acknowledging my mistakes, and worthily continuing the noble traditions of world medicine;

to maintain medical confidentiality, not to use it to the detriment of human well-being, to adhere to the rules of professional ethics, and not to conceal the truth unless doing so harms the patient;

to continuously deepen and improve my knowledge and skills, to seek help from colleagues when necessary, and never to refuse them such help myself, remaining truthful toward my colleagues;

by my own example, to promote the upbringing of a physically and morally healthy generation, and to uphold the ideals of mercy, love, harmony, and mutual respect among people.

I swear to carry fidelity to this oath throughout my entire life.