Legal & ethical dilemmas in incidental findings during surgery: Review article

Background: Discovering IF (incidental findings) during surgery results in ethical and legal dilemmas for the surgeon, especially those in training or recently qualified. The situation is further compounded as these can occur in an emergency. The immediacy of making the correct decision can be paramount for both the surgeon and the patient. Methods: Firstly, this article will review the ethical and legal frameworks of IF during surgery for those unfamiliar on the literature. Secondly, it will evaluate the use of a proposed IF tool to illustrate the decision-making processes in published case reports for those unfamiliar to the process. After the above two have been completed, a decision-making IF guidance tool will be constructed, which could help educate trainee surgeons. Results: The ethical and legal frameworks include the Hippocratic oath, domestic and European legislation, case law, civil and criminal laws. In the evaluated case reports there were IF which were either life-threatening or affecting the immediate life of the patients. 90% of the cases were emergency and 10% were elective operations. Using the proposed IF tool and combining it with peer-reviewed published best practice, 60% of the cases were correct in their intra-operative decision-making. This demonstrates the need of some type of guidance on the subject. As a consequence of these results, the article describes the construction of an IF decision-making guidance tool. The essential components of the guidance tool involve decision-making, the inference from other medical fields, ethical and legal elements, the available experience, skills and specialist knowledge at the time, best clinical practice and post-operative management and counselling. Conclusions: On finding an IF during surgery, the surgeon must balance the ethical dilemmas of autonomy, beneficence, justice, and non-maleficence for the patient. This is further complicated by applying these principals to current civil and criminal laws. By constructing an IF guidance tool may assist in improving patient safety and help the trainee and newly qualified surgeon and his team to come to the correct decisions in the best interests of the patient.