American College of Surgeons
Statements on principles
(These statements were collated, approved by the Board of Regents, and initially published in 1974. They were last revised in October 1997.)
Founded to provide opportunities for the continuing education of surgeons, the American College of Surgeons has had a deep and effective concern for the improvement of patient care and for the ethical practice of medicine. The ethical practice of medicine establishes and ensures an environment in which all individuals are treated with respect and tolerance; discrimination or harassment on the basis of personal attributes, such as gender, race, or religion, are proscribed as being inconsistent with the ideals and principles of the American College of Surgeons. Applicants for Fellowship have always been evaluated from the standpoint of their professional competence and established reputation, and then judged as to their ethics. At the College's organizational meeting in 1913, the assemblage strongly endorsed a resolution that Fellows of the College must practice in strict honesty and must avoid any and all forms of fee splitting. Ever since, applicants have been refused Fellowship because of unacceptable financial practices or other unethical behavior. Further, Fellows have been disciplined or expelled for violation of the Fellowship Pledge and the Bylaws of the College.
Recognizing that the American College of Surgeons seeks to exemplify and develop the highest traditions of our ancient profession, I hereby pledge myself, as a condition of Fellowship in the College, to live in strict accordance with its principles and regulations.
I pledge myself to pursue the practice of surgery with honesty and to place the welfare and the rights of my patient above all else. I promise to deal with each patient as I would wish to be dealt with if I were in the patient's position, and I will set my fees commensurate with the services rendered. I will take no part in any arrangement, such as fee splitting or itinerant surgery, which induces referral or treatment for reason other than the patient's best welfare.
Upon my honor, I declare that I will advance my knowledge and skills, will respect my colleagues, and will seek their counsel when in doubt about my own abilities. In turn, I will willingly help my colleagues when requested.
Finally, I solemnly pledge myself to cooperate in advancing and extending the art and science of surgery by my Fellowship in the American College of Surgeons.
I. Principles of patient care
Certain aspects of the ethical practice of medicine are of particular interest to surgeons. Related statements are presented in this section.
A. The responsibility of a surgeon includes preoperative diagnosis and care, the selection and performance of the operation, and postoperative surgical care.
A surgeon may delegate part of the care of patients to associates or residents under his or her personal direction, because modern surgery is often a team effort. However, the surgeon's personal responsibility must not be delegated or evaded. It is proper for the responsible surgeon to delegate the performance of part of a given operation to assistants, provided the surgeon is an active participant throughout the essential part of the operation. If a resident is to operate upon and take care of the patient, under the general supervision of an attending surgeon who will not participate actively in the operation, the patient should be so informed and consent thereto.
It is unethical to mislead a patient as to the identity of the doctor who performs the operation.
It is unethical to turn over the postoperative care of a patient completely to the referring physician.
Visits made by a referring physician during the postoperative period, for which charges are submitted but a needed service is not rendered, constitute a breach of ethics that comes under the category of unnecessary treatment.
When a patient is ready for discharge from the surgeon's care, it may be appropriate to transfer the day-to-day care to another physician.
B. Qualification of a surgeon as a specialist carries the implication that practice will be conducted within specialty limits.
It is desirable that surgeons be highly educated, trained, and qualified to do the type of surgery they are to perform. A fine mark of such qualification, though not a rigid requirement, is certification either by a surgical board approved by the American Board of Medical Specialties or by the Royal College of Physicians and Surgeons of Canada.
Obviously, proper care of a patient on occasion may demand that a surgeon engage in practice outside usual specialty limits when no appropriately trained physician is available. This should not be a frequent or continuing occurrence.
C. Itinerant surgery is proscribed.
The elements of time and distance are not pertinent in determining whether an individual has performed "itinerant surgery." An ethical surgeon will not perform elective surgery at a distance from the usual location where he or she operates without personal determination of the diagnosis and of the adequacy of preoperative preparation. Postoperative care will be rendered by the operating surgeon unless it is delegated to another physician who is as well qualified to continue this essential aspect of total surgical care.
It is recognized that for many operations performed in an ambulatory setting, the pattern of the patient's postoperative visits to the surgeon may vary considerably; it is, however, the responsibility of the operating surgeon to establish communication to ensure that the patient receives proper continuity of care. Similar circumstances may pertain when patients travel great distances for elective surgery.
Emergency surgery that is performed in locations that are unusual for the surgeon may be necessary on occasion, but habitual or even frequent performance of operations under these circumstances cannot be condoned. If the condition of the patient permits and additional skills are required, the patient should be transported to a medical center where they are available. Not only does itinerant surgery violate ethical relations between surgeon and patient, it may also raise serious questions with regard to "ghost surgery."
D. Completion of an accredited residency program is the only valid way in which a physician can become a surgeon.
Some hospitals permit arrangements through which a staff member can achieve surgical privileges under the tutelage of a qualified surgeon in the operating room without serving in a formal, organized, accredited residency training program. This is an undesirable situation, because it frequently results in an inadequately trained physician who may aspire to be a surgeon. Opportunities for the type of surgical training that meets the approval of the College are numerous. Performance of surgical procedures under guidance is only one part of the training of a qualified surgeon.
E. Training of assistants.
Surgeons may participate in the training of allied health personnel to act as technical assistants. Such individuals must perform their duties under the direct supervision of the surgeon, who has the responsibility for all of their actions.
II. Principles of qualifications for sugical privileges
A. Qualifications of the responsible surgeon.
Eligibility to perform surgical procedures as the responsible surgeon must be based on an individual's adequate education and training, continued experience, and demonstrated proficiency.
Acceptable education will consist of graduation from a medical school approved by the Liaison Council on Medical Education or from a school that is acceptable to the medical licensing board of the state in which the surgeon is practicing,* plus education leading to qualification as a surgical specialist.
(*Certain state and federal laws may require recognition of other types of health education.)
A physician is considered to be a surgical specialist if the physician:
- Is certified by an American surgical specialty board approved by the American Board of Medical Specialties; or
- Has been judged eligible by such a board for its examination by reason of education, training, and experience; or
- Is a Fellow of the American College of Surgeons; or
- Has obtained, in a country outside the United States, graduate surgical education that satisfies the educational requirements for Fellowship in the American College of Surgeons.
It is recognized that surgical procedures may be performed by physicians who do not meet this definition, under the following conditions:
- A physician who has just completed formal training in an accredited surgical residency program as defined by the appropriate specialty, for whom the appropriate surgical board has not yet determined eligibility.+
- (2) A physician who renders surgical care in (a) an emergency, or (b) an area of limited population where a surgical specialist is not available.
(+Ordinarily, this situation would be within a time frame that would not exceed one year plus the board's practice requirement, if any.)
A resident in training in an approved surgical program may provide surgical care under supervision as determined by the surgical staff.
The granting and continuation of surgical privileges should be based upon the surgeon's record of demonstrated performance as evaluated by an established peer review mechanism and medical audit. Requests for privileges that are not generally associated with the field in which the applicant has been trained must be specifically requested and documented with evidence of appropriate training and experience.
In some geographically isolated and sparsely settled areas, fully trained surgeons in various fields may not be available. The performance of certain surgical procedures, especially of an emergency nature, by a physician without special surgical training may be in the best interest of the public in that area. The medical staff and the governing body of hospitals in such areas should periodically review the quality, the number, and the variety of surgical procedures being performed, as well as the surgical referral policies of the staff. Attention should be directed to any referral pattern in surgical care that may discourage the application of properly trained and qualified surgeons for staff membership.
B. Qualifications of the first assistant in the operating room.
The first assistant to the surgeon during a surgical operation should be a trained individual who is capable of participating in the operation and actively assisting the surgeon as part of a good working team. The first assistant provides aid in exposure, hemostasis, and other technical functions, thereby helping the surgeon carry out a safe operation with optimal results for the patient. This role will vary considerably with the surgical operation, specialty area, and type of hospital.
The American College of Surgeons supports the concept that, ideally, the first assistant to the surgeon at the operating table should be a qualified surgeon or resident in a surgical education program that is approved by the appropriate residency review committee and accredited by the Accreditation Council for Graduate Medical Education. It is a principle of surgical education and care that residents at appropriate levels of training should be provided with opportunities to assist at and participate in operations. Other physicians who are experienced in assisting the responsible surgeon may participate when a trained surgeon or a resident in an accredited program is not available.
Attainment of this ideal in all hospitals is recognized as being impracticable. In some circumstances it is necessary to utilize appropriately trained nonphysicians to serve as first assistants to qualified surgeons. Surgeon's assistants (SAs), or physician's assistants (PAs) with additional surgical training, may be employed if they meet national standards. These individuals are not authorized to operate independently.
Certified surgeon's or physician's assistants must make a formal application for appointment to the hospital, which should include:
- An outline of their qualifications and credentials.
- Stipulation of their requests to assist in a surgeon's practice including assisting at the operating table.
- Indication of the surgeon who will be responsible for the SA's or PA's performance.
The appropriate committee or board of the hospital should review such individuals' qualifications for hospital privileges.
Registered nurses with additional specialized training may also function as first assistants to the surgeon at the operating table in those situations or hospitals where more completely trained assistants are not available. If a nurse functions in this role, however, the size of the operating room team should not be reduced; the assigned nurse should function solely as the first assistant and not also as the scrub or instrument nurse. Similarly, surgical technologists may function as first assistants in the absence of more qualified individuals.
In some hospitals in this country, there may be no specifically trained and readily available surgical assistants in the operating room. Traditionally, the first assistant's role in such institutions has been filled by a variety of individuals from diverse backgrounds. It is the surgeon's responsibility to designate an individual who is most appropriate for this purpose in keeping with the bylaws of the medical staff of the hospital.
Practice privileges of individuals acting as first assistants should be based upon verified credentials, should be reviewed and approved by the hospital credentialing committee, and should be within the defined limits of state law.
C. Surgery in hospitals by persons not holding medical degrees.
The policy of the American College of Surgeons has been well discussed and outlined in the Bulletin of the American College of Surgeons (May 1970, page 14). Important features of this policy are:
- The Division of Oral Surgery should be under the overall supervision of the surgeon-in-chief of the hospital or the chairman of the appropriate surgical department. In nondepartmentalized hospitals, the Division of Oral Surgery will be under the Chief of Staff or designated committee.
- The surgeon-in-chief, the departmental chairman, or the designated committee has the authority and responsibility for recommending to the hospital's governing board who shall, or shall not, perform surgical procedures.
- In the total care of patients with injuries in multiple regions or with complicated medical-surgical problems, the oral surgeon may be an essential member of the team and may act independently in an area of special competence. In instances requiring a team approach for the management of injuries in multiple regions or extensive and complicated medical-surgical problems, the surgeon who is captain of the team and who has final responsibility for the care of the patient must be a physician.
- Licensed podiatrists may be hospital staff members and admit patients to the hospital in collaboration with a physician who shall be responsible for the overall aspects of the patient's care throughout the hospital stay.
- Surgical procedures that are performed by podiatrists must be under the overall supervision of the chief of the appropriate surgical service.
- The type and extent of operative procedures to be performed by podiatrists will be determined by the chief of surgery upon the advice of members of the surgical staff.
Except as provided by law, there are no ethical or collective impediments to full professional association and cooperation between doctors of chiropractic and medical physicians.
III. Principles of qualifications for fellowship
In this section are broad statements of the criteria that are used to determine the eligibility of applicants for Fellowship. These criteria are also used to evaluate the continuing eligibility of a Fellow. Precise, current requirements for applicants are published separately.
A. Licensure is a basic necessity.
The license must be valid in the state, province, or country in which the practice is conducted (unless the surgeon is a career officer in a federal medical service).
Some states issue a restricted license, or some form of certificate, to a resident or hospital employee for a limited time. An applicant for Fellowship must possess a full and unrestricted license.
B. Each Fellow must demonstrate professional and ethical fitness. Surgery is to be practiced with scientific honesty, placing the welfare of patients above all else.
For applicants, this fitness is determined based on reports from Fellows of the College who are used as references, and on reports from appropriate Credentials Committees, which are made to the Director and the Board of Regents.
Eligibility for Fellowship is gauged by the demonstrated surgical judgment and professional conscience of the applicant. The applicant's performance of surgery and its evaluation by peers are important considerations.
Each applicant must be approved by a three-fourths vote by the Regents. Any question as to the ethical practices of an applicant results in postponement to permit clarification. Reasonable documentation that an applicant fails to meet the standards results in his or her being "not approved."
Upon accepting Fellowship, the member must abide by the principles that are enunciated in the Fellowship Pledge, which appears on page 3 of these statements.
The same professional and ethical qualifications that are demanded of an applicant are requirements for Fellows. Deviations from these high principles during the Fellow's career can be cause for disciplinary action.
C. A surgeon must refuse to split fees.
Fee splitting as an inducement to refer a patient to another physician is unethical. The premise for referral must be quality of care. Violation of this tenet disqualifies an applicant. If a surgeon who is already a Fellow violates this principle, it is a cause for expulsion from Fellowship.
Many states have laws that forbid any form of fee splitting, and there is no state that sanctions it. Additionally, federal law makes illegal any form of rebate, kickback, or splitting of fees that includes any federal money. Thus, such illegal inducement cannot be considered an item of deductible business expense.
D. Physicians are to present their own statements for services.
A patient should have full knowledge of the services for which payment is made, the amount of the bill, and the recipient of the payment.
The patient's surgical experience may be divided into a period of diagnosis and preoperative care, the operation itself, postoperative care, and care during convalescence. When all of these services are performed by the surgeon, the patient should be billed accordingly. When the diagnosis and preoperative care have been accomplished by a referring physician, who may also render convalescent care, it is proper for the referring physician to charge for those services, and the surgeon should then charge for performance of the operation and for the postoperative care.
Since each attending physician has a contractual relationship with the patient, it is proper to bill the patient for the services that are performed. The surgeon should bill for personal services, and should not include charges for services performed by the referring physician.
When the surgeon employs an assistant who has no other professional relationship to the patient, the surgeon may pay this assistant and should disclose this expense in the patient's bill. If preferred, such an assistant may charge the patient directly.
A referring physician should send his or her own bill for services rendered, including assisting at an operation, but should not seek reimbursement for unnecessary duplication of postoperative hospital visits.
E. Partnerships, groups, clinics, or managed care organizations may bill as individuals.
Legally established associations of physicians in practice (partnerships, groups, clinics, or managed care organizations) are regarded as entities. When professional income is pooled and professional expenses are paid out of a common fund, the association may use a single bill to charge for the services of its members.
If a surgeon with an established practice at one location is also a consultant for an association at a different office, it is not ethical for the association to charge a patient for the surgeon's services. The surgeon should present a separate bill. If the association is paid for the use of space, services, and supplies, the payment should be justified by amounts for rent, salaries, and so on, that are common in the community; such payments should be totally unrelated to income that is generated from patients of the association.
F. Unnecessary surgery is condemned.
Whether due to repeated ineptness, lack of knowledge, or willful failure to apply acceptable indications for operations or other procedures, the performance of unnecessary surgery is an extremely serious violation of ethical principles for which disciplinary action is indicated. Committees in hospitals are organized to guard against such violations or repeated mistakes.
G. Fellows of the College are expected to make continuing efforts to improve their knowledge of surgery.
Every physician has the obligation to keep abreast of new knowledge and advances in the art and science of medicine. For the surgeon, attendance at meetings of the College and of other scientific societies is invaluable, as is continuing study of current journals and texts.
The Regents encourage periodic voluntary self-assessment by examination and professional improvement through continuing education programs.
H. Maintenance of Fellowship is jeopardized by infractions of College principles.
Upon receiving information indicating that a Fellow may be violating any principle of the College, the Director will follow the Bylaws of the College with regard to investigation and referral to the Central Judiciary Committee. If disciplinary action is imposed, it may take one of the following forms:
- Admonition—A written notification, warning, or serious rebuke.
- Censure—A written judgment, condemning the Fellow's action as wrong. This is a firm reprimand.
- Probation—A punitive action for a stated period of time, during which the Fellow
- loses the rights to hold office and to participate as a leader in College programs
- retains other privileges and obligations of Fellowship
- will be reconsidered by the Central Judiciary Committee periodically, and at the end of the stated term.
- Suspension—A severe punitive action for a stated or indefinite time, during which the Fellow
- loses the rights to attend and vote at College meetings, to hold office, and to participate as a leader, speaker, or panelist in College programs
- is subject to the removal of the Fellow's name from the Yearbook and from the mailing list of the College
- surrenders his or her Fellowship certificate to the College, and no longer explicitly or implicitly claims to be a Fellow of the American College of Surgeons
- pays the visitor's registration fee when attending College programs
- is not subject to the payment of annual dues.
- When suspension is lifted, the Fellow is returned to full privileges and obligations of Fellowship.
- Expulsion—The certificate of Fellowship and all other indicia of Fellowship previously issued by the College must be forthwith returned to the College. The surgeon thereafter shall not explicitly or implicitly claim to be a Fellow of the American College of Surgeons, and may not participate as a leader, speaker, or panelist in College programs.
I. Fellows are expected to report knowledge of violations of principles or bylaws.
When a Fellow is convinced that another Fellow is violating the Fellowship Pledge, the Bylaws of the College, or its principles, a written confidential communication should be sent to the Director of the College. The information so submitted will then be further investigated and processed according to the provisions of the Bylaws.
IV. PRINCIPLES OF PUBLIC RELATIONS
Educational, sociological, and political developments make it essential that every doctor be concerned about public relations. Principles are unchanging, but they require interpretation and application in the light of current conditions. This section presents statements relevant to such principles.
A. Explanation of the nature and risk of an operation to the patient or to the patient's representative is essential.
Patients should understand the indications for the operation, the risk involved, and the result that it is hoped to attain. In the instance of a minor or a desperately ill or comatose patient, the responsible relative or guardian should be informed. Written consent should be obtained whenever the condition of the patient permits, before an operation is performed. A consent form should be signed by the patient. If the seriousness of the illness or other conditions do not make it feasible for the patient to do so, or if the patient is a minor, the form should be given to and signed by one or more persons who are authorized to do so by law.
B. Discussion of fees with patients prior to the submitting of a statement is recommended.
When a physician agrees to care for a patient, a contract is established (even if it is not written). This relationship implies agreement that the doctor will be compensated for services rendered to the patient. Whenever requested by the patient, a surgeon should fully discuss the fee with the patient. It is often desirable to discuss the fee prior to the operation.
C. Fees are to be commensurate with services rendered and with the patient's rights.
Surgeons have individual bases for their charges, and fees vary in different communities. The College has not attempted to establish fee schedules for its Fellows. Instead, applicants and Fellows are expected to make charges commensurate with what is considered to be reasonable by local mediation or peer review committees. Such charges may be related to the economic status of the patient.
D. Every patient's right to privacy must be respected.
The surgeon should maintain the confidentiality of information from and about the patient, except as such information must be communicated for the patient's proper care or as is required by law.
E. Surgeons should report new methods of or innovations in treatment to professional audiences to permit evaluation and authentication before release to public news media.
Both the patient's right to privacy and the medical profession's related rights must be observed, and any public release of scientific information should have the approval of the appropriate institutional committee, as well as the approval of the physician in charge of the patient. The best interests of patients and doctors are served when physicians observe the traditional practice of reporting innovations and discoveries to the profession before release to the news media.
In issuing releases to audiovisual media or nonprofessional publications, the surgeon should be guided by patients' best interests. In addition, the release of such information should be designed for education and public information.
Communications to the public must not convey false, untrue, deceptive, or misleading information through statements, testimonials, photographs, graphics, or other means. Such communications must not create unjustified expectations of results and must include realistic assessments of safety, efficacy, and material risks, as well as the availability of alternatives. Communications must not misrepresent a surgeon's credentials, training, experience, or ability, and must not contain material claims of superiority that cannot be substantiated. If a surgeon pays for a communication, that fact must be disclosed unless the nature, format, or medium makes it apparent. The issuance of inaccurate communications to the public may result in disciplinary action by the Board of Regents.
F. Biomedical research must be conducted within ethical and legal guidelines.
Progress in medical care that is achieved through research depends on informed partnership between patients and physicians in the development of new drugs and treatment methods. Certain advances in the treatment of disease can be learned only through properly conducted clinical trials during which the results of varying treatments recommended by individual doctors are compared carefully.
When applicable, animal studies should precede the use of new and experimental techniques in humans. Research programs involving human beings should follow certain guidelines, including prior approval by an impartial committee on human experimentation, full description to the patient of procedures to be undertaken, and explanation of the risk involved. There should be a justifiable expectation that the potential benefit of clinical trials outweighs the risks. The patient's personal rights must be respected, including an appropriate informed consent process and the right to withdraw consent at any time. There should be continuous observation and approval by the local committee that gave initial approval to the protocol.
G. Disclosure of commercial interest.
A Fellow's failure to disclose a financial interest in a commercial enterprise makes it unlikely that other professionals or the public can accurately evaluate statements made by the Fellow about the products or services. The statements may be misleading or deceptive. Failure to disclose remuneration or financial interest may constitute grounds for disciplinary action under Article VII, Section 1 (i) of the College's Bylaws.