Plastic Surgery Poses Unique Ethical Considerations
In the plastic surgery field, “one of the current pushes is to call attention to the many ethical issues that might arise,” according to Chad M. Teven, MD, clinical assistant professor of surgery at Northwestern University Feinberg School of Medicine.
Some older papers included discussions of ethics in plastic surgery.1 However, there was not much in the way of formal research. Teven and colleagues set out to change this with a series of studies. Their first article highlighted the importance of thinking about ethical issues in plastic surgery and the need to study those ethical issues in a formal sense.2
“Plastic surgery is a unique specialty in that there are so many things a plastic surgeon might be asked to do,” Teven says.
This ranges from reconstructive surgery after cancer to cosmetic surgery to congenital abnormalities and also burn reconstruction. “We are one of the last bastions of general surgeons in that our specialty is not limited to one area of the body,” Teven notes. “Plastic surgeons will often operate from head to toe.”
With that comes a whole host of ethical issues. For example, burn reconstruction surgery often involves decisional capacity, surrogate decision-making, and questions on whether services rendered are considered medically futile.
“As technology gets better able to save patients to a much greater degree, thinking about these issues before they happen would be very beneficial,” Teven offers.
Teven would like to see plastic surgeons rely on the underlying fundamental issues that are common in ethically challenging cases of all specialties, and apply those to plastic surgery cases.
“The goal of this paper was to simply call attention to the fact that like all other specialties, there are a whole host of ethical issues with plastic surgery,” Teven shares.
If plastic surgeons believe an ethical issue is present, they should respond to it as any other specialty would, such as with palliative care or treatment of a terminal disease. “Clinicians should know that there are answers available,” says Teven, noting those might come from colleagues who have trained on ethics or straight from the ethics consult service.
Teven suggests ethicists offer targeted training at regional and national plastic surgery conferences. Also, education could be provided to residents during their training. “There is little in the way of formal ethics training on a national level,” Teven notes. “This is an opportunity for dedicated ethics education, such as rotation on an ethics service for residents with a particular interest in ethics.”
For researchers in plastic surgery, there are unique ethical considerations, too. The goal of most plastic surgeons conducting human subject research is to “obtain a relatively quick, expedited IRB review or exemption,” says Caroline A. Glicksman, MD, MSJ, president-elect of the Aesthetic Surgery Education and Research Foundation (ASERF). “A rapid turnaround with a decision letter would be extremely beneficial, especially when residents and fellows are trying to complete a small study during their training.”
Research grants in plastic surgery often are awarded by one of two plastic surgery education and research foundations — ASERF or the Plastic Surgery Foundation (PSF), both of which require IRB approval for any human subject research. In addition, most medical journals associated with the International Committee of Medical Journal Editors require documentation of IRB approval before they will accept a manuscript for publication.
“Whether a plastic surgeon is affiliated with a large academic institution or in a private practice in a community setting, the requirements for IRB approval of studies involving human subjects are the same,” Glicksman says.
When conducting research, Glicksman suggests plastic surgeons provide a carefully crafted informed consent that allows IRBs to determine whether the study is exempt, requires an expedited review, or will require a full review conducting research. Also, they should sign up and complete Collaborative Institutional Training Initiative certification.3 “This certificate program is time-consuming, but is required of those conducting any form of human subject research,” Glicksman explains.
Glicksman says plastic surgeons and their study personnel should recognize the subject identifiers they must remove from all study documents if their protocol states they are collecting de-identified data. “Many studies by fellows or students include prospective or retrospective chart review,” Glicksman says. “They must describe in their protocol how they will de-identify the data and what type of informed consent was obtained.”
Issues might occur with multisite studies, especially those run by giant medical device sponsors using a large, centralized IRB for all investigator sites. “Legal and compliance issues may vary between states and even centers within the same state,” Glicksman says.
For smaller multisite studies funded by ASERF or the PSF, a local IRB may approve studies where biospecimens or patient data are going to be collected at several sites. “These details must be included in the study protocol,” Glicksman adds.
REFERENCES
- Chung KC, Pushman AG, Bellfi LT. A systematic review of ethical principles in the plastic surgery literature. Plast Reconstr Surg 2009;124:1711-1718.
- Teven CM, Bluebond-Langner R, Rohrich RJ. The ever-important role of ethics in plastic surgery today. Plast Reconstr Surg 2022;149:520-522.
- Glicksman C. Human subject research in plastic surgery: Insights into informed consent requirements and obtaining IRB approval. Aesthet Surg J 2021; Dec 29:sjab430. doi: 10.1093/asj/sjab430. [Online ahead of print].
Plastic surgery is a unique specialty in that there are so many procedures a surgeon might be asked to perform. This ranges from reconstructive surgery after cancer to cosmetic surgery to congenital abnormalities and also burn reconstruction. With that comes a whole host of ethical issues.
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