Ethics Ortho 060823

Ethics in Modern Knee
Osteoarthritis Treatment
dr. Tangkas Sibarani, Sp.OT(K)
Our Privileges
Physicians have been granted the privilege to interact with
individuals in ways that no other citizens can.
On any given day, doctors routinely invade people’s private lives, ask
them decidedly personal questions, touch them, manipulate their
extremities, expose them to radiation, inject them with potential
toxins, prescribe them harmful chemicals, and even cut into their
bodies.
Ironically, when we are done, most people thank us for the incursion.
Capozzi, James & Rhodes, Rosamond. (2015). Ethical challenges in orthopedic surgery. Current reviews in musculoskeletal medicine. 8. 10.1007/s12178-015-9274-y.
Because of our privileges….
We are obligated, as physicians, to use our knowledge of science and

medicine to act for the good of our patients.
We have a fiduciary responsibility, from the Latin fiducia,
meaning trust, to place our patients’ interests above all others,
including our own. It is our obligation as physicians to hold our
patients’ interests and well-being as paramount.
What do we mean by “Ethics”?
Code of professional conduct

◦ Nonmaleficience, “Primum non nocere”
◦ Beneficience
◦ Autonomy
◦ Justice
Holt G, Wheelan K, Gregori A. The ethical implications of recent innovations in knee arthroplasty. J Bone Joint Surg Am. 2006 Jan;88(1):226-9. doi: 10.2106/JBJS.E.8801.eth. PMID: 16391269.
Nonmaleficence
• “Primum non nocere,” first do no harm, is one of the most
fundamental aspects of biomedical ethics.
• Harm in bioethics : physical harm, pain, disability, and death.
Unfortunately, all surgical interventions inevitably cause some harm
and carry some form of risk, and so this principle is impossible to
guarantee in any surgical procedure.
Beneficence
•Beneficence refers to the principle of intervening to benefit the
well-being of an individual what we try to achieve in every
procedure
•The duty of nonmaleficence is more universal than the duty of
beneficence because “it is possible to act nonmaleficently toward all
persons, but it would be impossible to act beneficently toward all
persons.”
Autonomy
•“Personal rule of the self, free from both controlling interferences
by others and from personal limitations that prevent meaningful
choice.”
•Autonomy requires that an individual is independent from a
controlling influence and has the capacity for intentional action.
•The most common way in which a surgeon demonstrates respect for
a patient’s autonomy is by obtaining the patient’s valid consent for a
surgical intervention.
Justice
•Beauchamp and Childress define personal autonomy as “personal rule of the self, free from both
controlling interferences by others and from personal limitations that prevent meaningful
choice.”
•Autonomy requires that an individual is independent from a controlling influence and has the
capacity for intentional action.
•The most common way in which a surgeon demonstrates respect for a patient’s autonomy is by
obtaining the patient’s valid consent for a surgical intervention.
•The consent process demonstrates respect for a patient’s decision-making capacity
• Our conduct must justify our patients’ trust both in us and in
ou profession; it is essential that we are honest about our
own experience and qualifications.
•Every surgeon should recognise the limitations of his
Surgeon experience, skill and surgical expertise and be prepared to
refer to a more experienced colleague when necessary.
Ground rule
•We must not promise excellent clinical results when the
outcome is often unpredictable.
Benson, M. (2022). Efort Ethical Orthopaedics. Efort.

Resident Training
CASE ILLUSTRATION
Hip Arthroplasty
•A senior resident was assisting attending physician to

perform hip arthroplasty, as the resident has assisted
the attending physician on many occasion, the
attending allows the resident to prepare the femur.
•Upon broaching the canal, the proximal femur is
fractured necessitating fixation of the fracture and
conversion to a long stem prosthesis
•In the above scenario, the patient required a more
extensive surgical procedure, likely requiring additional
anesthesia, incurring a greater blood loss, and
necessitating a more complex prosthesis.
•The patient was subjected to greater risk, discomfort,
and potential complications violating the medical
dictum of “do no harm”
•Respect for a patient’s autonomy requires that patients be
informed of their role in the teaching process
•It is essential that patients be made aware of the presence
of residents in the operating room, the extent of resident
involvement in their case, and the level of experience of
the resident.
•Patients must be allowed to make informed decisions
regarding their participation in the medical education
process.
•Reasonable people understand that continuing medical education
is essential for having trained physicians available to their
community.
•Everyone would like only the most experienced surgeon to
perform their surgery, only the most knowledgeable clinician to
care for them.
•At the same time, people realize that additional physicians must
continually be trained and that patient involvement is an integral
part of that training.
New Technology
ANOTHER CASE
New Technology
•New devices or innovative surgical techniques may fill a void in our armamentarium of patient
care options.
•New technology may address a problem that was previously unsolvable or may improve upon an
existing treatment modality that had previously been ineffective or incomplete.
•Before embracing new technology, orthopedic surgeons must carefully examine our reasons for
utilizing unproven modes of treatment with the potential for substantial risks to the patient.
•Many patients, as well as their physicians, want what
is new.
•People often equate new with better, new with
improved, and new with the latest technological
advances.
•Minimally invasive surgery platelet-rich plasma,
anterior approach to the hip has been touted as being
safer, better, and more effective than more traditional
modalities, even though much of the literature has
demonstrated uncertain or conflicting results
Total Knee Arthroplasty
•It is a well validated procedure due to well
established experiments and literature
•It fullfill patient autonomy because we can
provide sufficient evidence regarding predicted
benefits and risks to allow patient to do informed
consent.
•During last decade, improved access to the
medical literature has caused a shift in modern
patient’s expectations and knowledge
• This situation posed ethical issue, mainly by recent
innovation in knee arthropalsty
Minimally Invasive surgery
• It provide early postoperative recovery, reduced length of
stay and rehabilitation, early return to work, improved
cosmetic appearance, and high patient satisfaction
• Despite potential advantage, there are several disadvantage
such as restricted visual field, issue related to learning a
new exposure and technique. These issues may lead to
implant malposition, intraoperative fracture or
neurovascular injury
One vital question
that must always
be foremost in our
thoughts is: When does a new technique
represent unacceptable
experimentation rather than
innovation?
Minimally Invasive vs Conventional Technique
Patients often assume that the outcome of a new procedure such as minimally invasive total
knee replacement will be better than the outcome of a standard technique
Actually, there are several risks of the new procedure
Patients may not grasp the concept that, although a “minimally invasive” procedure has a
smaller skin incision, the complications associated with that procedure may be equal to or even
greater than those associated with a standard surgical approach.
Current situation of Minimally Invasive Surgery
for Knee Replacement
•At present, minimally invasive techniques for total knee

arthroplasty do not meet the ethical standards that are
already met by existing conventional techniques
•The widespread use of a new technique should be
delayed until the indications, pitfalls, and potential
complications have been identified
Take home message
•Our desire to improve the outcome after surgery is what drives us to develop innovative surgical
techniques.
•A new technique may not be better than the standard procedure. Therefore, true informed
consent is absolutely essential
•Therefore, true informed consent is absolutely essential. It is important for the surgeon to have
a frank discussion with the patient about the potential benefits and risks of a new procedure as
well as the surgeon’s experience with that procedure.

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Ethics Ortho 060823

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Ethics in Modern Knee

We are obligated, as physicians, to use our knowledge of science and

Code of professional conduct

Benson, M. (2022). Efort Ethical Orthopaedics. Efort.

•A senior resident was assisting attending physician to

Actually, there are several risks of the new procedure

•At present, minimally invasive techniques for total knee

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