Surgical Accountability and Controls

SURGICAL ACCOUNTABILITY AND CONTROLS CHARLES G. CHILD, 3rd, M.D* AND GEORGE D. ZUIDEMA, M.D.f From where he [the consumer] sits, it looks . . . like a case in which public funds and third-party insurancepayments have spawned the civilian equivalent ofthe defense establishment. And no matter how strongly the providers of medical care insist that the analogy is spurious, that nobody can, in good conscience, compare what goes on inside a hospital with what happens in a weapons plant, or equate the work of a surgeon with the duties of a battlefield commander, the two industries still look very much alike to the consumer. Both have an apparently insatiable appetitefor money and an enormously well developed talentfor avoiding public accountability and controh.—Senator Abraham Ribicoff with Paul Danaceau [1] Sick people have always had a special place in society. Illness suddenly disturbs their daily routines, throws them out of work, and makes them dependent upon their fellow men and women. Societies have responded to the needs of their sick in many ways. In primitive and archaic times sickness, religion, evil spirits, and magic were often inextricably intertwined , and sometimes disease was even regarded as a punishment for wrongdoing. Today countries the world over discuss the care of their sick in terms of science, doctors, facilities, and millions and even billions of dollars. But as man and society developed, physicians, surgeons, psychiatrists, clinics, hospitals, and research laboratories emerged for prevention, treatment, and investigation of disease. As health resources multiplied and became more complex, societies pari passu developed laws, statutes, codes, and voluntary agreements to protect their members from misuse of physician's powers and privileges. A practitioner's liabilities for his actions were recognized, even as these were for architects, bridge builders , shipwrights, lawyers, and a variety of other public servants as well. Of special interest to medicine is the direction taken by these primitive statutes and codes; they have always been more concerned with the activities of surgeons than with those of physicians. It seemed more important that the highly visible manual and intellectual dexterities of ?Professor of surgery, University of Michigan Medical School, Ann Arbor, Michigan 48104. fProfessor of surgery, The Johns Hopkins University, Baltimore, Maryland 21205. Perspectives in Biology and Medicine · Autumn 1974 | 109 surgeons be controlled than that the thoughtful medicinal ministrations of physicians be regulated. One of the earliest experiments in controlling surgeons and holding them accountable is reflected in the Code of Hammurabi [2, pp. 433, 444], developed in Mesopotamia in the second millennium b.c. It includes a fee schedule and is the earliest known proponent of liability. Specific charges were determined by operation and by the social status of the patient. Success and failure were clearly recognized as outcomes of the surgeon-patient relationship. A successful operation on the eye or treatment of a serious wound merited a fee of 10 shekels of silver if the patient was a patrician or 2 shekels if he was a slave. If an eye was lost or the treatment of a serious wound ended fatally, the surgeon's hands were cut off. Such draconian laws as these are perhaps hard for us to understand today. Historians have learned, however, that statutes are often formulated on paper but never widely applied. Their greatest usefulness seems to be to serve as a warning against abuse. After all, a surgeon without his hands is not really a very useful member of any society, young or old. Nevertheless, Hammurabi's famous code is an extremely important document; it represents one of society's first legal attempts to reward its physicians for their efforts and to protect itself by legislation against abuse of surgical power. Almost 4,000 years later, the United States of America finds itself struggling to resolve its problems of surgical ethics, liability, and economics. Surgery today is a multimillion-dollar industry devoted to patient care, education, and research. Public access to it is, by recent federal fiat, a right ofall rather than a privilege for the affluent few [3]. As American surgery has progressed from a cottage industry to a public utility, accountability and control have become essential ingredients of its present operation as well as...