Patient consent in spectator surgery not the only consideration

The debate occurring over Dr Charlie Teo’s ‘‘spectator surgery’’ was precipitated by a report of an article I wrote for the British Medical Journal. In the article I never used his name, being concerned to discuss the principles involved rather than the individual. Its title, ‘‘Should the spectacle of surgery be sold to the highest bidder?’’, invited debate that is now occurring both inside and outside medicine.

There are important reasons why other surgeons don’t offer the same opportunity to the paying public. Many, I am certain, are equally concerned to donate to good causes, support cancer research, demystify surgery and urge people to get treatment. Remarks by the Royal Australian College of Surgeons, the Australian Medical Association and a leading bioethicist suggest that I am not Robinson Crusoe.

So is Teo the only surgeon marching in step here? The ethical argument he advances is that the patients involved consent to being observed by paying strangers. They are approached by his staff, not him. Some refuse, so he believes there could be no coercion. But judgements about the adequacy of the cardinal ethical principle of informed consent in medicine and research are never left to individual practitioners or researchers. They are referred to human research ethics and professional standards committees who set rules designed to preserve patient interests. As Teo’s own hospital has reported that it does not endorse paying spectators, is it therefore sensible to defer to his judgement here?

There are many examples where societies deem there to be wider considerations involved than simply consent, and that a person’s agreement is not all that matters. Here, Teo’s patients are under the care of a man whose skills they may sometimes believe represent their last hope. This is likely to produce a highly loaded decision-making context. Patients would instantly understand that this was something that Teo wanted. Few would want to incur the slightest risk of displeasing him. A large body of research on the process of consent makes it clear that patients have feelings of obligation towards doctors: ‘‘He’s asking for my co-operation. If I refuse, he may be disappointed. I’d better agree.’’

Teo says no one criticises medical reality TV programs like RPA, in which millions of viewers follow the treatment of real patients. In fact there are many parallel problems and some differences. It would be unimaginable if RPA patients being filmed were unable to withdraw their consent at any time before broadcast. Patients or families may decide they no longer wished to share developments: to have millions witness their grief and anxiety, for example. But the ‘‘live’’ viewing of an operation by strangers cannot be erased. There is no cooling-off period between the operation and the ‘‘viewing’’: it has already happened.

Equally, it would be unimaginable if the RPA film crew were not bound by journalistic ethics to respect the privacy of patients and families. All hospital staff encounter public figures, neighbours, colleagues, friends and acquaintances as patients. The same possibility arises for film crews and paying spectators. If hospital staff or medical students were to gossip about patients to others outside the hospital, major consequences would follow. No such sanctions are available for members of the public.

My good friend Andrew Penman, from the Cancer Council, defended his charity’s acceptance of surgery-viewing auction money on the grounds that patient participation was not ‘‘materially different’’ from things like inviting patients to join a research trial. I disagree. Research trials involve health professionals being bound by enforceable ethical protocols. Researchers are frequently removed from the provision of healthcare to the patient to minimise confounding of effects caused by patients wanting to please their doctors. I know of people who have lost their jobs by breaching the ethical requirements.

Important questions remain about Teo’s spectator surgery. Does he impose restrictions on who can bid to watch him? Does he run security or character checks on those who win? Most importantly, if his hospital does not endorse the practice, how has it been allowed to happen?

In the early days of surgery, operating ‘‘theatres’’ were packed with spectators. A historian of medicine records that ‘‘Patients put up with the audience to their distress because they received medical treatment from some of the best surgeons in the land.’’ When I grew up in Bathurst in the 1950s, freak-show tents appeared at the local show each year, and people with malformations were displayed for paying customers. Those displayed presumably ‘‘consented’’ to appearing. Thankfully, society has moved on by recognising that consent alone is sometimes not in a person’s or society’s best interests.