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Imperfect by design: the problematic ethics of surgical training
  1. Connor Brenna1,
  2. Sunit Das1,2
  1. 1 Department of Surgery, University of Toronto, Toronto, Ontario, Canada
  2. 2 Centre for Ethics, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Dr Sunit Das, Surgery, University of Toronto, Toronto, ON M4P 1A6, Canada; sunit.das{at}


There exists in academic medicine a core ethical issue that is seldom pursued: trainees are frequently not the best person in the operating room at a given intervention being performed, and yet as a profession we understand a fundamental need to afford them opportunities to perform. Academic centres are traditionally associated with a higher quality of care than non-academic centres, suggesting that practical measures exist within teaching hospitals that effectively mask the clinical discrepancies between trainees and their preceptors. Nonetheless, we are bound by our ethical commitments as physicians to balance the obligations of care with the duty to teach. In order to ethically validate the model of ‘surgeon as teacher’, we propose that there must be a reconciliation of the tensions between traditional professional values in medicine (which tend towards individualist deontology and the provision of optimal care tailored for each patient) with the constraints inherent in a time-bound utilitarian medical system (in which resources are limited and surgeons are transient). Ultimately, we must consciously accept that ensuring the longitudinal availability of skilled surgeons in society aligns more closely with our core ethical obligations as outlined in the social contract that medical professionals maintain with the general public than does the ethical demand to provide unreservedly individual-focused patient care. It is the duty of individual practitioners, as a necessity of lineage to maintain and fulfil our greater duties to society, to foster deontological relationships where possible within this utilitarian system while accepting short-term imperfection in our practice.

  • applied and professional ethics
  • clinical ethics
  • education
  • surgery

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  • Contributors CB wrote the initial and revised manuscripts. SD conceived of the study and revised the initial and revised manuscripts.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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