The ethics of a surgeon leaving his mark on a patient

By Daniel Sokol
Medical ethicist


A surgeon in Birmingham has been suspended after a colleague found the surgeon's initials branded on a patient's liver.

If true, it is difficult to imagine a plausible defence.

It is usual for surgeons, or the scrub nurse, to test the diathermy - a pen-like device which produces heat to stop bleeding or cut tissue - on wet gauze before using it on the patient, but not on a patient's organs.

Similarly, an argon laser can be tested outside the patient, such as on a wooden spatula, to ensure correct focal length and power, but rarely on the patient's organs.

I have heard of only one other case of this sort, when a surgeon carved his initials with a drill on the inside of a bone flap in a brain operation.

Although minor, there are medical risks to this surgical graffiti.

There is a risk of infection and scarring, with loss of functioning cells.

Using a laser may reduce blood flow by coagulating vessels and cause burns on other parts of the body.

Drilling the bone flap could damage the structural integrity of the bone, and may lead to infection of the flap.

In some cases, branding the patient will prolong the operation, quite unnecessarily, with added risks of complications.

Yet, even if no risks existed, it seems the surgeons' actions did not benefit the patient, nor were they intended to do so.

The motivation was selfish, not altruistic.

In branding their initials on the patient, the surgeons broke the Hippocratic commitment to act in the best interests of the patient.

They also damaged the trust between doctor and patient.

To ensure that patients feel comfortable disclosing their most intimate secrets, patients should trust their doctors to the end of the earth.

Doctors who breach the trust of their patients weaken the edifice of trust which their predecessors have worked so hard to build and maintain.

A cornerstone of modern medical ethics is the principle of respect for autonomy.

This requires doctors to ask mentally competent patients for permission to perform tests or procedures on them.

In the cases described above, the patients did not consent to the bodily inscription.

Their autonomy was violated, even if no physical harm arose from the breach.

Judgement issues

Another source of moral discomfort is the vanity that the inscription - of the surgeon's own initials - reflects on the scribe's moral character and attitude.

Arrogance, in any line of work, is an unattractive trait. In medicine, it sits uneasily with the obligation to treat patients with dignity.

The surgeons' actions bring the medical profession, and surgeons in particular, into disrepute.

They do little to dispel the traditional - and in my view unfair - reputation of surgeons as egotistic.

The branding of initials on a patient may say nothing about a surgeon's technical ability, or their bedside manner, but it does display a worrying lack of judgement and professionalism.

It represents multiple breaches of the General Medical Council's Duties of a Doctor, including the following injunctions:

'Never abuse your patients' trust in you or the public's trust in the profession.'

'Treat patients as individuals and respect their dignity.'

'Make the care of your patient your first concern.'

'Be honest and open and act with integrity.'

More difficult than evaluating the moral rightness or wrongness of the act is the question of punishment.

What should be the appropriate penalty for surgeons found guilty of such misconduct, knowing that the surgeon in question may be technically proficient and that no physical harm has befallen the patient?

As when sentencing offenders in court, the severity of the sentence will depend on the individual features of the case, but my own view is that the nuclear option of permanent removal from the medical register (also known as being 'struck off') would, in many cases, be too harsh.

Once reprimanded, a surgeon is unlikely to repeat the mistake.

Daniel Sokol is a medical ethicist and barrister at 12 King's Bench Walk, London.