Ethics M&Ms: Toward a Recognition of Ethics in Everyday Practice

High-quality care for surgical patients demands proficiency in ethics. Surgeons face obvious ethical dilemmas, such as disclosure of operative error, as well as other routine aspects of care requiring consideration of ethics, such as the introduction of novel surgical techniques. Failing to address the ethics inherent in these interactions can decrease the quality of care. Deficiencies have been noted in ethics education during surgical residency, due to a primary focus on the scientific and technical aspects of surgery, time constraints, perceived lack of faculty expertise and/or support, and a view of ethics as peripheral to the learning agenda. Currently, ethics education in surgery relies on chance encounters and the hidden curriculum. In its stead, we propose that ethics be incorporated into the curriculum in a substantive way to prepare learners to recognize and respond properly to ethical challenges.Three years ago, ethics morbidity and mortality rounds (Ethics M&Ms) were introduced into regularly scheduled M&Ms at 5 sites in the Division of General Surgery at the University of Toronto in Canada. M&M rounds are a time-honored institution in surgical culture, used to analyze and improve surgical errors, and traditionally have focused on technical errors and complications. In surgical M&Ms, every complication, no matter how common, is examined. Ethics M&Ms consist of 30 minutes per month during which ethics issues surrounding care are the complication being discussed. The scope of these issues is wide and has included belief in miracles, surgical innovation, “VIP” patients, and operating room resource allocation.Our intervention was inspired by Ethics M&Ms at the University of Chicago. While “ethics rounds” are an accepted way to discuss ethics, the novelty of this intervention is the integration of these rounds into a well-attended, well-respected institution within surgical culture. Explicitly scheduling and discussing ethics during M&Ms encourages regular reflection on ethics. Further, central placement of ethics education within the culture of surgery legitimizes the recognition of ethical dilemmas. Bioethics is commonly criticized as abstract and impractical. By grounding discussion in real cases, using an explicit framework, and citing literature rather than opinions, ethical issues become relevant and more valuable.To start, a resident prepares each case with a surgeon mentor to identify informative literature sources and review key points. Presentation and discussion follow an established framework adapted from the book Clinical Ethics by Jonsen and Siegler. Mentorship skills simply involve an interest in bioethics as it relates to surgical practice, and the ability to perform a literature search. Presentation styles have been adapted to fit the existing M&M model at each site and range from formal slides to a roundtable discussion. A faculty member moderates the confidential discussion. Participants include learners of multiple levels, various health disciplines, and practicing surgeons.The table shows preliminary findings from a qualitative study involving interviews with Ethics M&Ms learners and faculty. The findings suggest a reconceptualization of clinically based ethics in both practicing physicians and residents, enabled by (1) increasing awareness of the ethics inherent in all aspects of patient care; (2) developing a common language to discuss ethics issues; and (3) creating a safe physical and intellectual space to debrief these difficult cases.Due to positive reception at the 5 pilot sites, we plan to institute these rounds in surgical specialties at several community and academic teaching sites. We expect that a formal, case-based, scheduled discussion of ethics issues will influence learners' moral development and capacity to respond to ethically important moments in practice. In particular, Ethics M&Ms broaden learners' approach to ethical reasoning by fostering the ability to identify ethical tensions, increasing available resources for dealing with these tensions, and changing surgical culture to promote explicit, open discussion of ethically complex events. All disciplines of medicine require ethics proficiency. Our innovation is feasible, easily replicable, and promising. We hope Ethics M&Ms will become a model for ethics education that can be expanded into departments locally and internationally.

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