Ghosts in the Operation Theater

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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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About the author

Dr Arshad G Moh'd is a Consultant General Surgeon. He has completed his Masters in General Surgery from T N Medical College and B Y L Nair Hospital and has been practising General Surgery for 41 years. He has been a past President and PastTrustee of the Indian Medical Association, Mumbai West. Dr Arshad is also the General Secretary and Trustee of T N Medical College Global Alumni Association

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Comments

  • Mukund Jagannathan April 22, 2025 at 8:06 pm
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    There are several aspects of this. It is not as cut and dried as made out to be.
    1. The “ownership” of the patient in a private setup belongs to the consultant surgeon who has examined, assessed and counselled the patient. The consent form has both the patient’s name as well as the surgeon’s. Of course it should include Dr. X and his/her team/associates. Here whether the surgeon is physically present or not, any and all responsibility is his. It is in his own interest to ensure that he is there for the full course of surgery. It is an implied contract between two people. He takes the credit and/or the cudgels.
    2. In a public hospital setting, the patient has a right to proper diagnosis and treatment to the best possible extent. There is no right the patient enjoys to be operated by a particular doctor. Yes, the patient can request for a senior, but that decision is left to the seniors in the unit. If they entrust it to a junior and something goes wrong, again, it is the senior who is responsible along with the junior. Here it is a vicarious responsibility. But teaching and guidance have to take place in the public hospital setting. This needs to be explained to the patient that yes, another person may assist actively or even do a major part of the procedure but the senior will be overseeing every step. That is being fair to the patient.

    Reply
  • PP April 22, 2025 at 9:44 pm
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    Succinctly presented and well-written piece.

    Thank you Dr Arshad G Mohd for highlighting an important but neglected aspect of surgical practice in India. Although widespread, there is limited knowledge of this fact, not only among the poor and illiterate masses but also among the elite.

    It is necessary to spread information about ghost surgeries as described in this article. Best wishes, Dr Arshad.

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  • Niloufer Shaikh April 23, 2025 at 11:19 am
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    Agreed. We need more transparency and information before giving consent and it’s horrific to think of being experimented on by greenhorns.

    Reply
  • Rouen Mascarenhas April 23, 2025 at 6:30 pm
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    I thought that the term ‘Shadow Surgeons’ is more appropriate, as ghost sounds fright-ful at the least. It gives an impression of a non-existent surgeon.
    The patient ‘must’ be informed and consent taken accordingly, with the reason for the shadow surgeon’s need thereof.
    Many patients have trust in a surgeon, more so that he will do, or arrange to do what is best for the patient.
    If these two criteria are met, shadow surgeons can be important players in the field of surgery.

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  • Prasad Wagle April 23, 2025 at 6:54 pm
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    Nicely written article Arshad.
    A few thoughts that I can pen.
    Ghost surgery has existed in the private sector for decades and stems perhaps from the fact that the primary Surgeon does not want to ‘let go off’ the patient. Inadvertently a young dynamic Surgeon is involved who knows how to deliver the goods, many a times not knowing of the antecedent morbid conditions of the patient as the patient is invariably under anaesthesia.
    So long as everything goes off well there are no issues but if the cushion gets pushed therein starts the blame game & the buck is promptly passed onto the Ghost Surgeon….how unfortunate.
    In the public sector it’s a problem less faced as the Unit is operating as a whole though the valid consent is of the Boss/Lecturer who is always around when perhaps a resident is operating. Moreover the patient is often not bothered as to who is operating as also knows that it being a teaching hospital residents under supervision would be operating upon him. The blame of course in case of bloopers is on the Boss’s shoulder.
    Agreeable that this practice needs to change particularly in the private sector.
    Who will/should make the reforms forms the crux.
    Should start at the referring surgeon level & rather than invite a ghost surgeon a bit of transparency would be welcome & would save the day for everyone if things do go south.

    Reply
  • Shrikant Rao April 23, 2025 at 8:52 pm
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    GHOST’BUSTER DOC

    Thank you Dr Arshad for this illuminating piece on the prevalance of ‘unethical’ medical practices in the surgeon community. There should be no departure from original written ‘operating’ commitments, and it is only fair that the patient ought to have the right to know of any change of the level of involvement of the surgeon in the said procedure — there is also the matter of patient’s faith in play here, which must never be neglected. That ghost surgeries are a common occurrence – in my personal view this is less than honest — ought to a matter of concern both for patients, who entrust their life and limbs to surgical specialists riding on personal and public reputations, as also medical practitioners who diligently follow the Hippocratic Oath.
    In my view serious note ought to be taken of such ghost excursions to and away from operating tables. In the event of such an inevitability it’s only appropriate that the patient knows beforehand and is prepared for such an exigency. Such transparency is also necessary from the point of view of doctors’ accountability.

    SHRIKANT RAO

    Reply
  • Shrikant Rao April 23, 2025 at 10:39 pm
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    GHOST’BUSTER DOC

    Thank you Dr Arshad for this illuminating piece on the prevalance of certain ‘unethical’ medical practices in the surgeon community. There should be no departure from original written ‘operating’ commitments, and it is only fair that the patient ought to have the right to know of any change of the level of involvement of the surgeon in the said procedure — there is also the matter of patient’s faith in play here, which must never be neglected. That ghost surgeries are a common occurrence – in my personal view this is less than honest — ought to a matter of concern both for patients, who entrust their life and limbs to surgical specialists riding on personal and public reputations, as also medical practitioners who diligently follow the Hippocratic Oath.
    In my view a serious note ought to be taken of such ghost excursions to and away from operating tables. In the event of such an inevitability it’s only appropriate that the patient knows beforehand and is prepared for such an exigency. Such transparency is also necessary from the point of view of doctors’ accountability.

    Reply
  • Bindu Varma April 25, 2025 at 2:47 am
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    I have heard of some bizarre cases, patients being abandoned mid-surgery for weird reasons and this according to me is just as unconscionable. I am not a medical ethicist but I’d be traumatised if I were at the receiving end. I wonder if there are any sanctions in place for this kind of breaches of trust.

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  • Harshal Nandurkar April 25, 2025 at 3:44 am
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    Delegation of surgeon or the person doing an invasive procedure is common in teaching institutions. It is the foundation of teaching. It is not necessarily wrong if the mentor (or principal surgeon or similarly capable) is supervising. In a full public hospital system it will be difficult to have a nominated surgeon to allows be the operator. There will be other responsibilities that come up, or emergencies. We could extend the argument to say chemotherapy. Is the senior haem-onc (my profession) going to be the person who charts the chemo as she/he are the primary consultant for the patient? Most often the consultant is not in the room when chemotherapy us administered as it is all done by fellows and trainees.
    The practice of using a senior surgeon in a willing ‘ghost role’ because the surgeon who has brought in the patient is less competent is uncommon in my country of practice (Australia).

    Reply
  • Salil Kamat April 26, 2025 at 4:08 am
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    Very well written and an eye opener. Ghost surgeries should become a penal offence in India as well.

    Reply

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