7 Ethical Considerations Abstract This chapter will review common ethical principles and their applications in plastic surgery. The reader will be able to assess the ethical considerations in ethical dilemmas likely to appear on the plastic surgery oral board examination and in practice, and resolve those using ethical principles. Keywords: biomedical ethics, ethics, principlism Six Key Points • Modern bioethics relies on principlism. • Any given issue can have different resolution depending on application of principles. • Decision-making capacity is dynamic and can be assessed by a clinician. • Using reviews to influence surgical decision-making is unethical. • Financial contracts should be arranged prior to surgery. • Different societies have different guidelines. Ethical considerations in plastic surgery tend to manifest in three ways: billing/coding, decisions to operate, and informed consent. Ethics in billing and coding requires an attention to detail and continual education in coding practices. The American Society of Plastic Surgeons provides resources for coding. General principles include avoiding unbundling and avoiding upcoding. It is important to remember that while systematic upcoding is potentially fraudulent, so too is downcoding. The principles of bioethics underpin decisions to operate and informed consent. There are seven basic rights of patients—three negative rights and four positive rights. Negative rights include the following: not to be killed intentionally or negligently by the surgeon, not to be harmed by intent or negligence of the surgeon, and not to be deceived by the surgeon. Positive rights include the following: to be adequately informed of the risks and benefits of surgery; to be treated by a knowledgeable, competent practitioner; to have his health more highly valued than the surgeon’s economic interest; and to decide whether to accept treatment under the conditions described.1 The principlism approach to biomedical ethics has four principles as its under-pinning respect for autonomy, nonmaleficence, beneficence, and justice (Fig. 7.1). A casuistic approach is a heuristic approach of ethical analysis, originally performed by Jesuits—this case-based approach is still used today. In this approach, underlying principles include the indications for medical intervention, patient preference, quality-of-life concerns, and contextual features. Autonomy requires that the surgeon identifies the patient’s values and beliefs, respects their role in the patient’s life, and elicits the patient’s preferences from among the medical and surgical alternatives supported in beneficence-based clinical judgment. Beneficence requires that the surgeon act in ways that are reliably expected to result in a greater balance of clinical goods over harms for the patient. A classic example of the intersection of autonomy and beneficence is blood transfusions in the Jehovah’s Witness population.
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