“Four Evils” Plagued Surgical Practice in the Early 20th Century

Over the past year, we delved into the ACS Archives to better understand the College’s role in guiding surgical ethics.

Initially, we approached the research with a broad scope, uncertain whether “surgical ethics” would be explicitly defined within the archives. We considered the possibility of needing to identify an ad hoc committee that addressed ethical issues, as the term “ethics” might not have been formally used in the earlier records. However, to our surprise and satisfaction, we discovered a robust surgical ethics section within the archives, providing a direct and comprehensive resource for our investigation.

In this article, we focus on one particularly noteworthy initiative that demonstrates the ACS’s early recognition of, and response to, critical ethical challenges in surgery.

Changing Landscape of Surgery

In the early 1900s, the ACS Board of Regents (BoR) set out to confront what it termed the “four evils” plaguing surgery: unjustified surgery, ghost surgery, fee-splitting, and exorbitant fees.

To grasp the full scope of ethical challenges at this time, it is necessary to understand that surgical practice was not the field we know today. The early 20th century was a period of rapid change and transformation in the field of surgery.

The introduction of antisepsis, anesthesia, and a new conceptual understanding of diseases between 1880 and 1910 led to a rapid expansion in the scope and complexity of surgery. Before these innovations, surgery was largely limited to procedures such as lancing of abscesses, mass excisions, and amputations. By the end of this transformative period, surgeons routinely were performing complex operations on the thoracic, abdominal, and pelvic organs.

Despite the increasing sophistication of surgical procedures, there was not yet a clear distinction between surgeons and other medical practitioners. In other words, it was possible for doctors to perform surgeries without specialized training or accreditation. The absence of clearly delineated professional standards fostered a permissive environment where questionable practices could be carried out with little scrutiny or consequences.

Complicating matters further, these transformations in surgical practice coincided with a time of economic hardship and financial crises. This created a situation in which some practitioners could be tempted to prioritize financial gain over ethical considerations and patient welfare.

Filling the Ethical and Regulatory Void

The ACS was founded in 1913 to fill this “regulatory and ethical void.” Other surgical associations existed at the time, but they had not yet acted on the new challenges facing the profession. One way the ACS addressed these challenges was through the establishment of an active surgical ethics committee that engaged with the surgical community and tackled a wide range of issues. While the surgical ethics committee was involved in numerous initiatives, one particular campaign consumed a significant portion of the organization’s time and resources over a period of several decades.

The Four Evils

The ACS BoR identified what it termed the “four evils” facing the profession, and these issues would remain a central focus of the ACS’s activities and a topic of intense discussion and debate for the better part of the century. The “four evils” exemplify the ethical challenges that emerged as a result of the changing social, economic, and institutional contexts of surgery in the early 20th century.

The ACS Archives provides a unique window into the development of surgical ethics, offering a more complete picture of the discussions surrounding complex ethical issues than can be surmised from public announcements and newspaper articles. Unlike public presentations, where the College leadership must present their consensus on any given issue, private correspondence allows members to discuss their differences of opinion more freely.

The College’s approach to each issue generally followed a similar pattern: defining the problem, discussing solutions, and implementing strategies. But the process also was marked by unique challenges and debates specific to each issue. By examining the committee’s deliberations and responses to these four core issues, we were better able to understand the factors that influenced surgical ethics not only during this period but also today.

Unjustified Surgery

According to the BoR, “an unjustified operation is one in which either the indications were inadequate, or the procedure was one which is contrary to generally accepted practice.”

This issue exemplifies the ways in which surgery at the time was not as we know it today. Debates about “unnecessary surgery” these days have to do with whether a double mastectomy is indicated for unilateral breast mass or whether appendicitis should be treated with an appendectomy or antibiotics. However, at the time, the cases were much more complicated.

The gravity of this issue is best exemplified by a letter written to the BoR in November 1929 by Rose Climenko, the widow of a prominent neurologist in New York. After losing multiple family members to unnecessary surgeries, Climenko wrote a letter to the board, pleading that it act on the still highly prevalent issue of unnecessary surgical procedures.

In her letter, Climenko provided details of these cases. The first case, from 1917, involves a 32-year-old man who was “neurotic, maladjusted, unhappy, and introspective.” He suffered from nerve strain and headaches until a neurologist believed he had found symptoms of a brain tumor and advised an operation. The patient and family were led to believe the operation was fairly routine and that it would resolve the patient’s difficulties. They were not informed of the high mortality risk associated with such an invasive procedure. Not surprisingly, the man died on the operating table, and an autopsy revealed no tumor. Climenko posed poignant questions: “It is a typical case­—­how is it to be answered? Can surgery offer any justification that will remove the injustice done this family?”

The second case, from 1924, describes a 31-year-old father of two. Although generally healthy, he experienced stomach issues. A doctor advised an exploratory operation, assuring him it was safe and that he would be back to work within 10 days. Trusting in the procedure’s safety, the man did not inform his parents. However, during the operation, he suffered a hemorrhage and died on the table. Climenko noted that this, too, was a typical case. These two cases were just the first of two personal examples Climenko used to illustrate the human cost of unjustified surgery and to urgently plead for reform.

The ACS addressed these ethical challenges through massive undertakings, such as the standardization project. In 1920, the organization published a minimum standard for hospitals, which included requirements for organized medical staff, accurate record-keeping, and adequate facilities. The ACS also established guidelines for surgical practices.

These efforts by the College laid the groundwork for future programs, such as the National Surgical Quality Improvement Program, which aims to measure and improve the quality of surgical care in the US. What are now considered quality issues in surgical practice were not always seen as matters of ethics or even standard practice within the profession. The ACS’s initiatives played a crucial role in establishing and enforcing these standards, ultimately leading to improved patient care and outcomes.

Ghost Surgery

The ACS defined ghost surgery as “that surgery in which the patient is not informed of, or is misled as to, the identity of the operating surgeon.”

There was a consensus that patients had the right to know who would be operating on them. However, the issue became complicated when considering the involvement of surgical assistants and trainees. The BoR was trying to define ghost surgery in a way that would protect patients’ rights while still allowing for practical surgical training.

Sensationalized articles in newspapers like The New York Times, with headlines such as “Patients Unaware Surgeon May Be a Beginner” from 1978, stoked fears and raised questions about the identity of the person wielding the scalpel. These articles oversimplified the issue, causing widespread concern among the public and putting pressure on the medical community to address the problem.

The BoR was divided on how to respond to the public pressure. The BoR fielded questions from constituents, discussed the issue at multiple conferences, and sent a survey out to program directors across the country. While some Board members took a more rigid stance, stating that any involvement of assistants was a violation of the patient’s trust and the principle of informed consent, others took a more nuanced stance, arguing that the definition should not be so rigid as to be impractical.

Fee-Splitting

ACS defined fee-splitting as “the refunding of any portion of the total fee for the care of a patient to either the surgeon or the referring physician.”

The primary ethical concern with fee-splitting is that it can create financial incentives that prioritize profits over patient care. When physicians receive compensation for referring patients to a specific specialist or facility, they may be more likely to make referrals based on financial gain rather than the patient’s best interests. The ACS took a strong stance against fee-splitting, even considering the submission of a joint bill, whether itemized or de-itemized, by the surgeon or referring physician as a form of fee-splitting.

This position was rooted in the fundamental principle that medical decisions should not be influenced by financial incentives, and the ACS’s strict policy against fee-splitting was intended to protect patients from unethical practices. Fee-splitting has been extensively discussed in the literature examining the history of surgical ethics. The ACS Archives confirms that fee-splitting was indeed a significant issue during this period. However, the archives also reveal some underrecognized aspects of the issue. While some instances of fee-splitting were indeed unethical and driven by financial gain, others were a product of the evolving nature of surgical practice.

This balancing act is exemplified by a letter from a concerned ACS Fellow seeking advice on whether his group practice arrangement would be considered unethical. In his letter, the Fellow described a scenario in which surgical fees were distributed among the group members based on their involvement in the patient’s care. The College’s response, which approved of the arrangement, illustrates that there were instances in which a joint bill was appropriate given the realities of group practice arrangements.

The letter from the concerned ACS Fellow illustrates the active communication between the ACS and its constituency regarding ethical issues. This ongoing dialogue demonstrates the commitment of both surgeons and the ACS to navigating the complexities of evolving surgical practice while upholding the highest ethical standards. The ACS’s responsiveness to these inquiries and its efforts to provide guidance on a case-by-case basis highlight the important role the organization played in shaping the ethical landscape of surgical practice during this period.

Exorbitant Fees

This concept is defined as “a fee [that] is excessive when it is greater than the patient is reasonably able to pay or higher than justified by the service rendered.”

At the time that the ACS was founded, the responsibility to charge fair fees was conceptualized as a responsibility of the surgeon. In fact, the original ACS Fellowship Pledge in 1916 included a direct commitment to “make fees commensurate with the service rendered and with the patient’s rights.” However, the pledge was written at a time when surgeries were procedures that could be done primarily by a single surgeon and financial arrangements could be more directly negotiated between the two parties.

Since then, the scope of surgery changed, so too had the site of practice and the size of the care teams. Because procedures involving the abdomen and chest required better lighting and more involved postoperative care, the primary location of surgeries shifted from homes to hospitals, where teams of nurses and other physicians were involved.

While the BoR said it was confident that the majority of fees were reasonable, the Regents also recognized that “scarcely a day passes that I do not hear of one or more outrageous fees.” As an example, it mentioned the case of a patient making $40 per week being charged $1,500 for a cast. Part of the motivation to address the issue was also to help preserve the public’s trust in the surgical profession. The issue of exorbitant fees was an issue that received significant public attention, with magazines like Better Homes & Gardens publishing articles about how to negotiate fees with your surgeon.

The BoR established a committee to investigate the matter and gather data on the prevalence of overcharging, seeking to understand the scope of the problem and identify potential solutions. One of the proposed solutions was to create a standardized fee schedule that would provide guidance on reasonable charges for various surgical procedures.

Some factors the committee discussed that should influence fees were duration of operation, difficulty, mental and physical strain, and pre- and postoperative care. While this was not implemented, these discussions revealed the values of the ACS. Interestingly, many of these items parallel factors used to calculate the relative value units per procedure in modern healthcare reimbursement systems.

Despite its efforts to address the issue of exorbitant fees, the College did not ultimately arrive at a consensus regarding this matter. There was hope that health insurance policies, which were becoming more common at the time, would serve to alleviate the issue of cost.

In one of the final letters about the issue, the BoR stated that the College would “refrain from taking positions upon the economics of medical practice.” Although much of the early ethical questions were intertwined with the financial aspect of medical care, the records show that the increasing complexity of the healthcare system made it challenging for the profession to establish a clear stance on the matter. The responsibility for ensuring fair and reasonable fees became a shared one rather than an individual one.

Unfortunately, health insurance does not always alleviate patients’ massive financial burdens when seeking medical care. High deductibles, copayments, and coinsurance can result in considerable out-of-pocket expenses, while limited provider networks and uncovered services can leave patients with even higher costs. The passage of the No Surprises Act in 2022 underscores the ongoing relevance of financial accessibility in surgical care even today.

A Long History of Quality

Our research in the ACS Archives challenges the notion that the early years of the profession lacked formal ethical considerations. The ACS played a crucial role in shaping surgical ethics since its founding in 1912. As the profession grappled with the rapid advancements and changing social, economic, and institutional contexts of the time, surgeons found themselves confronting a series of thorny ethical issues that defied easy resolution.

The ACS’s efforts to address the “four evils” and establish ethical standards is a part of the larger process of the consolidation of professional authority in medicine. As the profession gained greater social and cultural status, it also faced increasing pressure to regulate itself and maintain high ethical standards.

While the specific practices and contexts may have changed, many of the underlying issues—such as the tension between innovation and safety, the challenges of professional boundaries, the impact of financial pressures on surgical practice, and the relationship between surgery and society—remain as relevant as ever. By engaging with this history, we can gain valuable insights into the ongoing challenges and opportunities facing the surgical profession in the 21st century.

Acknowledgments

We would like to express our gratitude to the ACS Archives for its diligent work in preserving the College’s history. Its careful stewardship of these records made it possible for us to explore the rich history of surgical ethics and gain valuable insights into the evolution of the surgical profession.

Julia Chavez is a fourth-year medical student at the Pritzker School of Medicine at The University of Chicago in Illinois. She will be starting psychiatry residency at the University of Texas Southwestern Medical Center in Dallas this summer.

Dr. Peter Angelos is the chief of endocrine surgery and director of the MacLean Center for Clinical Ethics at The University of Chicago. He also holds the Linda Kohler Anderson Professorship of Surgery at The University of Chicago.

Editor’s note: This article follows the completion of the 2022–2023 ACS Surgical History Fellowship by Julia Chavez.