‘Spend a day with Charlie Teo’

Over the last few days the Australian media has been covering Sydney based Charlie Teo’s auction of ring side seats in his operating theatre. The auction is reported as raising about $1500 for a children’s cancer charity and while this might raise some eyebrows Teo has been clear about his commitment to ensuring that patient care is not compromised in any way.

He is a highly regarded neurosurgeon who has pioneered minimally invasive techniques and has a reputation for taking on very difficult cases. He’s also a prominent and respected public figure: he was a State finalist for Australian of the year in 2010, is the founder of the Cure for Life Foundation and was awarded Member of the Order of Australia. (The Australian Jan 26th 2011) Despite his high profile and assurances, he has attracted criticism from his peers.

John Quinn of the Royal Australasian College of Surgeons is reported in the Sydney Morning Herald as worrying that there is a risk that observers might spread infections or be a distraction. (Jan 28th, 2011) He is reported as saying ”The College does have a code of conduct. There are rules and sanctions,” and that the College would consider this matter. Given the interest the ‘auction’ has caused and the responsibility that this body has for professional standards, it seems reasonable that the College is reviewing this.

Nonetheless, it would be surprising if they found that there was an increased risk of infection or that the effectiveness of the surgical team was compromised. Infection rates are critical, not only for patients but also for surgeons and it would be strange if a surgeon of this calibre had taken a risk with this for the sake of a charity auction. Likewise for the possibility of his team being distracted: you would expect that his theatres are carefully managed and that he is well of what is likely to impair his team’s performance. These are things that the College will examine and at the present point in time can only be speculated about.

Consent and autonomy based objections have been expressed by Professor Simon Chapman in a short opinion piece published in the BMJ late last year. One objection is that patients who are about to have brain surgery are likely to be ‘desperate and vulnerable, fearful that the operation may fail.’ This seems overwhelmingly likely and is a good reason gaining the consent of patient’s to having a member of the public there needs to be handled carefully. Of course one might question whether consent is required for having a non-treating person present during an operation: this routinely happens with medical students. Still, Chapman is right to be concerned about patients agreeing to this out of a desperate need to whatever their surgeon wishes. Teo is aware of this worry and made sure that he had nothing to do with gaining the agreement of his patients for this. He says that he was reassured about this by the fact that a number of his patients did not agree to have someone present.

Despite the fact that those about to have brain surgery are extraordinarily dependent upon their surgeons there’s no reason to rule out the possibility of a second party talking it through with them and them giving a voluntary consent. After all, Teo didn’t have a huge interest in recruiting patients: it was just for charity.

Chapman goes on to consider the possibility that confidential biographical information about the patient may leak to an observer. This objection seems much less cogent than the consent worry: the probability of this seems no greater than the chances of information leaking to members of the public passing through a teaching hospital.

Whatever you make of the consent and autonomy based worries, I suspect that another factor in play is the perjorative term ‘Unprofessional’ that has become popular of late. Medical schools teach and monitor ‘professionalism’ and medical boards, along with the medical colleges have codes of professional conduct. These are often taken to be obligations that are over and above legal and ethical obligations.

Chapman was at the auction and describes how two medics that were with him ‘pulled perplexed faces as the item appeared’. It might be that they were simply worried about the autonomy and safety of patients. However, I suspect that it was at least in part a judgement about the appropriateness of a surgeon doing this and the propensity of Charlie Teo to do things that create controversy.

If this is right then care needs to be taken about the basis on which he is criticised. ‘Professionalism’ is a term of art, many seem to know ‘unprofessional’ conduct when they see it but there is no wholly satisfactory account of what this means. The risk is that those who like to push the traditional boundaries of their profession are being criticised merely for ‘not doing the kind of stuff that we think good doctors should’. While professionalism seems to be a buzzword at the moment, something that perhaps supplants some shortcomings of ethics and the law, it has a long history of entanglement with medical ethics. A quick look though the American Medical Association’s first code of ethics in 1847 makes their concern to use ethics so as to distinguish medicine from quackery apparent. While it doesn’t seem unreasonable for boards and colleges to be concerned for the well-being of the profession, assessing whether or not behaviour genuinely does damage the profession is a tricky task. In the case of Charlie Teo, I can see no reason to think that it would.

Simon Chapman BMJ Should the Spectacle of Surgery be for Sale? 2011: 342: 237

American Medical Association Code of Medical Ethics of the American Medical Association 1847 http://www.ama-assn.org/ama1/pub/upload/mm/369/1847code.pdf

The Australian Jan 26th 2011 “Brain surgeon is quite an operator”
http://www.theaustralian.com.au/news/nation/brain-surgeon-is-quite-an-operator/story-e6frg6nf-1225994511595

The Sydney Morning Herald Jan 28th 2011 “Knives out over sale of ringside seats”
http://www.smh.com.au/nsw/knives-out-over-sale-of-ringside-surgery-seats-20110127-1a6xa.html

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14 Responses to ‘Spend a day with Charlie Teo’

  • Julian Savulescu says:

    Sometimes, I am a Kantian. Let's see what the Categorical Imperative says about surgical spectacles. Could we universalise a principle of running surgical spectacles for charity? In particular, could I endorse such a spectacle if I were the patient with the brain tumour. Well, if I was lucky enough to have one of the best neurosurgeons operating on my brain, and the presence of spectators did not increase infection or reduce performance (even in an emergency), and the spectacle provided money to address children's cancer, what possible reason could I cite not to be a part of the spectacle? It would be irrational not to be a part of such a spectacle. If the facts are as they are purported, not only is spectacular surgery morally permissible, it is morally required by a principle of beneficence. Teo is a professional leader, not an unprofessional maverick.

    Remember those wonderful pictures of anatomy dissections in Padua with students peering down above the dissection. Perhaps our future hospitals will have similar spectator seating, perhaps behind glass or plastic walls to ensure minimal risk of infection and auditory disruption. Students and young doctors could use these grand stands for learning. And when they are done, the eager public could be invited to pay for seats, as a part of community outreach. Bring on the Colosseum of surgery. It could be good, in so many ways. Teo may be the father of a new way of doing surgery. Not keyhole surgery, but open surgery.

  • Irene says:

    I would definitely have the public in my surgery if I were a patient. Not for any reasons of beneficence, but out of self preservation! As per Alex's post (http://blog.practicalethics.ox.ac.uk/2010/12/people-will-behave-badly-if-its-not-too-much-work-and-if-no-one-is-watching) people act better/ more professionally when they know others are watching…

  • Julian Savulescu says:

    And there would be less loud rock music …

  • Peter Wicks says:

    I agree that care needs to be taken when criticising people on the grounds of "unprofessionalism". Likewise, we also need to be careful to define what we mean when we ask whether a particular activity will "damage" a profession. What do we mean by "damage" here?

    In this case, an obvious kind of "damage" one might be concerned about is undermined confidence, so we might wish to ask questions such as, "Are people less likely to be willing to have brain surgery if they know people are watching?" Seems unlikely.

    On the other hand, I still have difficulties with Julian's use of the term "irrational". I still don't really know what this means. To my mind, to be truly rational you pretty much have to be a moral subjectivist, and yet many philosophers who make or comment on posts here seem to be moral realists, despite there being (as far as I can see) no convincing combination of empirical evidence and logical argument that would justify such a position.

    Obviously this is a view that is not likely to be shared by the (moral) realists themselves, but then how many people *are* willing to accept that they are being "irrational", particularly if they have made their career in philosophy? And if we can't be sure that we aren't being irrational, how can we be sure that other people *are* being irrational?

    The fact is that some people have an idea of how the medical profession should operate that does not involve auctioning seats at the operating table, even for charity. That is not irrational; it is a preference. As for whether there is any "possible reason" that one could cite for not wanting to be a part of the spectacle, well obvious one can imagine all sorts of them. Some of them could be very simple, such as, "The idea makes me sick."

    I guess the general point I want to make is that it's really not that important, at least from the perspective of my own values, whether ethical positions are "rational" or "irrational". I happen to like rational argument, which is one reason why I like commenting on this blog, but that doesn't necessarily make it good. What makes it good–what makes anything good–is that it helps to steer us towards futures characterised by love, peace, harmony and well-being. Sorry if that sounds a bit new-agey, but that's the kind of future I want to steer myself towards. And it seems highly likely to me that rationalist philosophers–whether moral realists or moral subjectivists–have a tendency to over-estimate the importance of being "rational" in this context.

    • Matt Sharp says:

      "To my mind, to be truly rational you pretty much have to be a moral subjectivist, and yet many philosophers who make or comment on posts here seem to be moral realists, despite there being (as far as I can see) no convincing combination of empirical evidence and logical argument that would justify such a position"

      For moral realism, start with:
      If all other things are equal, suffering is bad, and pleasure is good.

      Then:
      If all other things are equal, actions which increase suffering are bad, and actions which increase pleasure are good.

  • Anthony Drinkwater says:

    Peter doth protest too much : I am sure he doesn't really mean that choosing rationality is merely a personal preference.
    Glenn Beck could (possibly) be also motivated by a desire for "futures characterised by love, peace, harmony and well-being", but his sheer irrationality discredits what he says (I hope) :
    see, for example :
    http://www.usnews.com/opinion/blogs/scott-galupo/2011/02/02/glenn-becks-egypt-protest-theories-show-hes-finally-lost-his-marbles

    Kant still hasn't lost his marbles…. thank you, Julian, for keeping him alive.

  • Peter Wicks says:

    Thanks for the reactions.

    No I don't see being rational as "merely a personal preference": I think it's good to the extent that it leads to futures characterized by love, peace, harmony and well-being. As for Glenn Beck, does his "sheer irrationality" discredit what he says? Apparently not in the eyes (and ears) of those who listen to them.

    Am I protesting too much? Perhaps. I certainly expressed my views quite "vividly". But did I actually say anything false? I think I may have exaggerated by stating that whether ethical positions are rational or not is "not that important" (important compared to what?), but I stand by my claims that rational argument is not always good, and that philosophers are likely to overestimate the importance of being rational.

    What about my comments regarding moral realism? Am I convinced by Matt's counter-argument? Not really. The formula is not sufficiently precise. How do we know when other things are equal? Equal in what respect? It still makes more sense to me to regard the claim that "suffering is bad, and pleasure is good" as an expression of one's values, and consequently a matter of choice, rather than as a truth-apt statement about the world.

    Coming back to Glenn Beck: let's go with Matt's suggested basis for morality, forgiving it's imprecision and agreeing to disagree on whether it's truth-apt or an expression of our values, and let's assume that on this basis that Glenn Beck is acting badly. It's not solely because of his of his "sheer irrationality". It's also because he is intervening in a contact, and with a degree of influence (because of his irrationality) is causing harm. I'm sure it's possible to channel his immense talent, without necessarily making it more "rational", so that it would be a force for good. Any suggestions are welcome!

    • Matt Sharp says:

      "What about my comments regarding moral realism? Am I convinced by Matt’s counter-argument? Not really. The formula is not sufficiently precise. How do we know when other things are equal? Equal in what respect? It still makes more sense to me to regard the claim that "suffering is bad, and pleasure is good" as an expression of one’s values, and consequently a matter of choice, rather than as a truth-apt statement about the world."

      Equal as in nothing else changes except the amount of suffering or pleasure; suppose nothing else of any value changes as a result of experiencing this suffering or pleasure. People will often claim that suffering can be beneficial in the sense that it leads to future good, and that may well be true (and vice versa for pleasure), but it doesn't tell us about the intrinsic value of suffering or pleasure. If someone gains something beneficial as a consequence of suffering, that only shows us that suffering can be instrumentally good.

      Obviously, in practice we may not know whether all other things are equal. But that is an epistemic problem; in practice we can simply argue "to the best of our knowledge".

    • Anthony Drinkwater says:

      Peter,
      "Rational argument is not always good" : if that means that an outcome of a rational argument could be bad, I agree. Two conflicting points of view on a moral position can each be rationally conducted.
      Rationality is not a sufficient condition for a moral truth, any more than a correct syllogism is a sufficient condition for a true conclusion.
      But whilst not sufficient, it is, I believe, a necessary condition for moral philosophy. The reference to Glenn Beck was to suggest that even if his intentions were good, and even if his conclusions were right (I acknowledge that there might be a question of verifiability here!), the "sheer irrationality" condemns the point of view.

      To go further, isn't rationality in fact what philosophy is, in essence ?

  • Peter Wicks says:

    PS Sorry for the typos (edit button please!). Most are obvious, but "contact" should read "context" in the last para.

  • John Mcmillan says:

    @Julian

    How you formulate that maxim is going to make a difference to whether you could will that means as a universal means of attaining that end. The maxim is something like "agree to your surgery being observed by members of the public so as to raise money for charity". Whether you would univeralise that means depends both upon the nature of the means and the value of the end.

    The auction only raised about 1500$ which is something, but not a huge amount of money. Brain surgery is shown on television from time to time so perhaps it isn't that big a deal to have an observer there. There are other operations that might be more sensitive. I'm not sure what I would think if I developed testicular cancer and needed an orchidectomy, but I might be less willing to universalize this as a means for that end.

  • Peter Wicks says:

    Thanks to Matt for clarifying the "other things being equal" caveat. That's much clearer. What's left, in relation to my original comments, are two questions: (i) is this a matter of truth or a matter of choice, and (ii) what bearing, if any, does this have on my various comments about "rationality".

    In relation to the first question, it seems to me that your "suffering is bad, happiness is good" formula is closely related to utilitarianism, in the sense that it is consequentialist by nature (you wrote that "actions which increase suffering are bad"), and maximising happiness and/or minimising pain seems to feature strongly in utilitarian thinking. I'm less sure to what extent this is the case for other logical constructions such as Kant's categorical imperative, or Rawl's reflective equibrium.

    Of course what you believe is always to some extent a matter of choice: you can believe the earth is flat if you want. But that does not make it true, whereas there are some beliefs whose truth actually does depend on act of believing. I guess the purest example of this is, "This stratement is true," but there are also in-between cases, like, "I am happy", or "I'm going to nail this job interview." So perhaps the real question is where on this spectrum the statement, "Happiness is good, and suffering is bad" lies on this spectrum.

    With regard to my second question, I'm actually delighted that I've succeeded in "smoking out" such a robust-yet-succinct defence of moral realism, and I'm grateful to you for having come up with it. It's helped to refine my own thinking on these issue. I wasn't really trying to insult moral realists (at least not consciously)! I think what I was really objecting to was the stridency of Julian's dismissal (as "irrational") of opposition to technological progress. My day job is in environment policy (including its interface with science), so I spend a lot of time with people who are generally highly sceptical of technology, regarding it as "part of the problem" rather than part of the solution. I disagree with them, but I also think that those of us who regard technology as a potential gateway to spectacular improvements in our quality of life need to listen to alternative points of view, and not be too quick dismiss them as "irrational". Perhaps that's what I really like about moral subjectivism: it's lack of certainty and openness to alternative points of view.

  • Peter Wicks says:

    Hi Anthony, I don't have a problem with defining philosophy as rationality (though I'm sure that some, especially non-anglosaxon, philosophers would disagree), and there are circumstances where it really is important to be rational. In fact I will go further and say that a degree of rationality is extremely important, and there is generally too little of it in political debate or other debates on ethics outside the realm of (rationalist) philosophy. But equally well rationality is not everything: qualities such as tolerance, understanding and empathy are also important. If I had to choose between someone who was totally rational but cold as ice and somebody who was somewhat irrational but also loving and caring I'd generally choose the latter.

    Two further points. Firstly, rational argument is something we should be able to get computers to do relatively easily, so this should be something we can outsource (if we want to). Secondly, I think the real difference between apparently "rational" people and apparently "irrational" people is that the former tend to make their motivations implicit, seeking to justify them and if necessary refine them to fit into some kind of logical structure, whereas the latter tend to leave them implicit. I think it is possible to be successful and good – and also to be uunsuccessful and/or bad – using either approach.

  • Peter Wicks says:

    Sorry again: the first mention of the word "implicit" should of course read "explicit".

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