When someone other than the person agreed upon in Informed Consent performs an operation, a Ghost Surgery is said to have taken place. That is the common understanding of the phrase, and rightly so to a large extent. But the term has many more layers, it is much more nuanced, and there are multiple addenda to its definition. For instance, many believe that if the surgeon who obtained the Informed Consent in his name was scrubbed in, it does not tantamount to ghost surgery.
With the advent of invasive interventional procedures in non-surgical disciplines such as Cardiology, Radiology, Neurology etc., the term has acquired an extended meaning. The scope of the phrase applies equally to all the interventions practiced in aforesaid specialties.
Typically, a large number of ghost surgeries are carried out in teaching hospitals. Striking a fine balance between letting students learn hands on and making sure the patient’s interest in receiving standard care is not compromised, is not easy. The only way this balance is effectively struck is through vigorous and assertive supervision. Many of these teaching institutions are attached to public hospitals, where patients undergoing treatment are typically poor and not so aware of their right to standard care. Hence it is all the more imperative that the vicariously responsible surgeon takes the responsibility and does not delegate it to a ghost surgeon.
Another reason, albeit unethical, why surgeries are delegated to junior resident doctors is that some senior surgeons feel they aren’t ‘sufficiently’ rewarded financially. Their main interest is to attend to only the ‘note cases’. The principal issue in these categories of ghost surgeries is that the patient is kept in dark about the true identity of their operating surgeons.
Ghost surgeries are not confined to public hospitals alone. Private set-ups too see a significant number of such procedures, though the reasons could be entirely different. In their zeal to increase the number of surgeries and thereby increase their earnings, some surgeons line up more procedures than they can personally cope with. In the process, they end up delegating some surgeries to their assistants. Or, they perform only the ‘main part’ of the surgery and leave the rest to their subordinates. The crucial question is, as stated earlier, whether or not the patient is kept informed about these moves.
Then there are surgeons who are not sufficiently trained and hence not competent enough to perform a particular type of surgery; they invite other surgeons to operate on their behalf. One glaring example in this regard is laparoscopic or robotic procedures – these surgeries are many a time performed by ghost surgeons and the patient is kept completely in dark about their identity. Even on consent form, the name of the primary surgeon is mentioned as the operating surgeon and the operating surgeon’s name is either not mentioned at all or is cited as the assistant. Since the patient is under general anaesthesia, he remains oblivious to the identity of the real operating surgeon.
This brings us to a pertinent question: Why do surgeons willingly perform ghost surgeries? They know they will not get the credit for a job well done. They are aware they will, in all probability, not be compensated adequately. The answer is not far to seek – most of these doctors are greenhorns, who do not yet have an established practice. Or, they may be sufficiently senior but struggling to set their practice.
The problem is that the ghost surgeries come to light only when something goes drastically wrong. As long as they are uneventful, nobody knows about them.
Group practice is slowly catching up in medical profession. And it is quite likely that the operating surgeon may be one from the group, but not necessarily the one in whose name the Informed Consent was signed. It is imperative in such cases that the patient is informed about the arrangement and consent taken accordingly. The other option is to take the Informed Consent in the name of the group of doctors and not an individual name.
Like guest editorials or articles, there are times when expert surgeons are invited to demonstrate a surgery for educational purposes, or operate upon a complicated case. In such instances too, an appropriate informed consent is essential.
There are numerous ethical implications of the ghost surgery that need to be flagged. To begin with, the precise identity of the operating surgeon is the most important part of Informed Consent. The ghost surgery violates that provision by concealing the identity of the real surgeon. It amounts to misrepresentation and deception of the patient. Moreover, the doctor-patient relationship is held by a thin thread of trust. And substitution of the performing surgeon without the knowledge and consent of the patient is a serious breach of that trust. Taking an informed decision after considering the surgeon’s professional profile is patient’s absolute right. His autonomy is violated by imposing an unknown surgeon on him.
Then there are multiple legal ramifications of the Ghost Surgery. Broadly speaking, they fall in four categories:
1. Violation of Informed Consent
2. Medical negligence
3. Breach of contract between the doctor and patient
4. Battery
Unfortunately, here in India, Ghost Surgery is not a well-defined legal concept yet. In the United States, it is not only described and defined very well, but it is also categorized as a penal offense. Furthermore, even if a ghost surgery works to the benefit of the patient, it still remains an offense. Additionally, any non-consensual performance of surgery, as it happens in ghost surgery, is categorized as Battery and punished accordingly.
So there is an urgent need to legally define Ghost Surgery here in India too. Even the National Medical Commission needs to proscribe the practice by making it a part of the Code of Conduct.
In conclusion, it is imperative that the patient is kept informed about every detail of his surgery. That is his non-negotiable right. Any deviation from this practice is ethically wrong and legally punishable.
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