Ethical issues of the introduction of new surgical technologies and techniques.
Lessons from the past.

Second International Workshop on Natural Orifice Surgery

Milano, 7 febbraio 2009, Ospedale Niguarda Ca’ Granda

I believe this meeting will be for us a great opportunity to see what are the actual outcomes obtained so far in this emerging field in terms of technology and techniques, and I hope we are going to find answers to some of the questions that we have today regarding whether or not NOTES will really represent the next step in the field of minimally invasive surgery.
Choosing between the possibility of reducing the length of the incision from 1 to half a cm or of reducing the number of trocars in order to add any clinical advantage to the patient is, for sure, of great importance.
This problem arises any time we face with the introduction of new technology. But it’s my opinion, and we go straight to the topic of my presentation that before this we must always wonder which are in general the first and last aims when introducing new technologies in the medical field.
It’s a fact that we have never seen so many technologies invading the medical field in the history of humanity.
Fiber optics that allow us to explore the deepest parts the of human body , all sorts of imaging technology that allow visualization in vivo down to the cellular level, pace makers , artificial valves if not entire artificial organs and more relevant technology that is able to interfere with the most secret aspect of human beings : genetic engineering.

We strongly perceive that all this technology has transformed the human being into the closest planet and the most remote frontier to explore.
What is the issue with technology then?
Technology is intrinsic to human beings and represents one of its highest forms of expression and responsibility.
When asking whether a particular technology should be used, we should first wonder whether and how it benefits the patient.
Those who are involved in research and experiments to determine all that could be done in the fight against illness must be the ones who lead also the debate over what should be done in that struggle – two tasks that today tend most often to be separated.
Scientific research has demonstrated several times that its results can be used (within certain limits) to produce positive effects like energy from nuclear power or disasters, like the nuclear bomb or molecular cancer screening and treatment, starting from the understanding of DNA.
But also the clonation of mammals up to human beings that in my opinion may lead under the human point of view to a disaster.
So what is the question?
Technology and research achievements are basically the same, but the use of those results has completely different implications and effects for human beings.

The major risk of technological deviation could be that in false expectation to demonstrate the aim by improving the tool this will become the only goal of the efforts of the researchers.
In this way technology in itself will become the first and final aim that produces its own system of values and goals completely detached from the very first and last question about how all this technology can be useful and helpful to human beings.
Quoting Alexis Carrel a French Surgeon and biologist who said:
“Man cannot be split up into parts. We must absolutely consider a man in all his aspects. The results of the specific efforts of specialists require first a synthesis before being applied to man.”
Unfortunately, these sorts of questions are made more difficult by the current separation in medicine between technical skills and education about more humanistic issues.
Doctors today are, by training, more technicians than accustomed to ethical issues – and that’s not inherently a bad thing, considering how much technical skill is required for modern medicine.
However, at the same time, all those skills must be tempered by wisdom and a strong understanding of both the general and specific ethical issues involved in the various aspects of their work.
In agreement with Hans Jonas I would like to state: “We fear a nihilistic perspective that applies the maximum power to a minimum knowledge of the objectives”
So here comes in my opinion the most important question about our position with respect to that of the patient.
The question is What is the man you care for? Who is the other being that I’m caring for?
This topical question clarifies that it is the doctor’s responsibility towards the patient which comes first, the technical skills will follow.
It also suggests that answering questions about whether and how certain treatments should be used must depend mainly on the answers to questions about our general responsibilities to other human beings.
If we try to separate the two, our answers to technological questions will not be adequate to the problems before us.
Unfortunately today there is a common behaviour to divide personal, professional and social dimensions so that the ideal of good is identified with a general model of respect for the rules that ends up in not taking into account the real and deepest instances of the individual From this idea the need to re-focus our medical activity in order to consider the patient as a total being arises more and more, and for this reason we talk more and more of the need to humanize medicine.
In our efforts to try to cure the patients from their disease we must never forget the important aspect of considering them in all their human expectations.
In this perspective the most important aspect becomes the trust that will grow between the patient and the physician.
An alliance between two subjects is necessary; so that, starting from mutual respect and confidence, they will establish realistic aims to follow and, on that basis, they will define a therapeutic plan that would take into account the choices of the patients and the competence and responsibility of the doctor, who must recognize his limits and those of the environment in which he works.

This critical concept of this alliance and trust is the key that changes the horizon also of the professional.
For the best of the patient the physician should be urged at any time to recognize his limits and to look for the support of other colleagues in his decisions in a multidisciplinary approach.
This attitude will remind us to control the temptation of considering the patient as a testing ground where we are going to discover our limits.
These limits must be analysed beforehand and lead us to look for collaboration
so to respect in any case and situation the hierarchy of values that implies the alliance between all the subjects involved.
This will avoid us the risk of considering that everything has been discovered and that it would be useless to look for any new technological improvement; it will also prevent us from running the risk that many pioneers have suffered in the history of medicine to be attacked by their colleagues, such as Eric Muhe, the German surgeon that first performed a laparoscopic cholecystectomy in 1986.
Concluding, we need to maintain an open minded position that will allow us to welcome the technological developments in the research for the best solution for patients.
By the way, well bearing in mind that no matter what the Achievements of medical research are, they will never completely cancel suffering from the life of a man. There are other dimensions that play a role. And Reality beyond this limit has a different reference point.