Royal Australasian College of Surgeons Annual Scientific Meeting

The first object of this College is to cultivate and maintain the highest principles of surgical practice and ethics.

Obviously there is a close link between maintaining principles and ethics. There has long been an obligation that a doctor seek and accept advice from professional colleagues. This is the peer review. Criticism can be awkward so here is a quote from an article 'Institutional Ethics' which appeared in The Lancet of October 1987:

"Those academic institutions who claim leadership in medicine should now be hard at work devising a system whereby practitioners can maintain the skills and excellence that are fostered in medical schools.

"Secondly, practitioners should be encouraged to look critically at what they themselves are doing, in terms of the need of people for care and cure. The self scrutiny that began with the clinical pathological conferences and infant and maternal mortality conferences, needs to be extended to the daily practice of medicine."

Your peer review carried out by Richard Stewart and Kenneth Menzies and entitled Surgical Standards and Peripheral Surgical Units says that "arguably the most difficult thing for us to cope with has been the explosion of medical technology" and "the College strives to maintain competence in its fellows by fostering continuing education activities "

That is what this scientific meeting is all about and I wish you well as you deal with the complexities and the skills needed to be a surgeon today.

I want to talk more about ethics, that other element named in your first object. Ethics comes from the Greek word which literally means a dwelling or a stall for animals needing protection and shelter. Ethics then becomes the stability and security needed if a person is going to act at all. From there it is only a short step to say ethics is concerned with what holds human society together and what provides the security vital for mature human living.

But there are two destabilising factors which make medical ethics very difficult. One is that we are struggling with the limitations of a well intentioned but contradictory medical legal system trying hard to form logical, humane guidelines for a bewildering and expensive medical technology. The other is that professions, once seen as the trusted repositories of special skills, are now going through the painful process of learning how to be accountable to those who pay for their services. At the moment we seem to have a spate of incompetent doctors and crooked lawyers appearing before disciplinary bodies.

The difficulties have been highlighted by the findings of the 1988 Report of the Cervical Cancer Inquiry. The first finding in part said " there has been a failure adequately to treat a number of patients with cervical CIS at the National Women's Hospital. The outcome of treatment for the majority has been adequate although a significant number were not managed by generally accepted standards over a period of years. For a minority of women their management resulted in persisting disease, the development of invasive cancer and, in some cases, death."

The finding pinpoints the management of the treatment of carcinoma in situ as an issue. Once you use the word management you are talking about allocation of resources, consultation, decision making and where power resides in that process. It raises issues of partnership and whether you are talking about the Treaty of Waitangi, the relationship between husband and wife or the manner in which a doctor relates to a patient you discover that partnership is difficult and may require you to share things you would rather keep to yourself.

Ethics involves making decisions. Traditionally the doctor was regarded as the one who decided what was in the best interests of the patient. There was a tendency to confuse ethics with etiquette and doctors were reluctant to interfere with the work of their colleagues. That traditional view, as you know, has been challenged by the recognition that the patients are usually the best judges of what is in their own best interests provided they are properly informed of the available options.

Patient consent must be informed consent and it must be freely given. A witness at the Cervical Cancer Inquiry who was asked during labour to be part of a research programme said:

"There was no way I felt I could say 'no' I know that other women feel the same way, you are in something completely different, your state of mind is separate from the kind of world of medical research "

Question: You didn't feel at that stage that you could refuse to participate?

Answer: No, no way, because I think it was also in there at that time, a real eagerness and willingness to please, in the hope that the whole thing would go smoothly."

That's an example of coercion, not consent freely given.

I close with Judge Cartwright's final words on ethics and patients' rights:

" I prefer to advocate a system which will encourage better communication between patient and doctor, allow for structured negotiation and mediation, and raise awareness of patients' medical, cultural and family needs. The focus of attention must shift from the doctor to the patient."

To me, that seems to be the basis of a good partnership, and a context in which good ethical decisions can be made.

I wish you well in your very important meeting.