Integrity

Abstract

Integrity is the dedicated commitment to an accepted conduct and form of living … is the honest response to professional attitudes and values.

Since the dawn of civilization, integrity has represented the base on which respectable societies are built [[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11]]. The society of surgeons is no exception. Surgeons require integrity to remain firm in the execution of the surgical act and in the care of the surgical patient. Integrity leads to respect, which, in turn, leads to understanding and agreement. Integrity is honesty with something else, the opportunity to reiterate your position under normal and difficult circumstances. What can we say about integrity that has not been said before? How can we emphasize integrity and maintain interest in its practices and evolution? Where can we reach for continuous support? These are just a few of the questions that appear in our search for integrity.

Now, let us concentrate on the surgical arena and evaluate the importance of integrity in the surgeon's life and career. Let us define the character of integrity and advance its effect. As the senior surgeon was getting ready for his daily rounds, the inexperienced first-year resident had an important question. “Dr. Mackey,” he said, “do you think we should tell the patient everything that occurs in the operating room during the surgical act?”

Replied Dr. Mackey, “I believe you have the professional responsibility to mention to the patient all important and significant parts of the operation.”

“What about discussing with the family the mistakes that occurred during the operative event?” asked the junior resident.

“I am of the belief, since the early times of my surgical training, that surgeons need to communicate to their patients any negative developments that take place during surgery,” added Mackey. “This is an important issue that speaks to the integrity and moral fiber of the surgeon-in-charge.”

Integrity is not a simple state but a complex condition reflecting an individual attitude towards a strict and accepted way of living. Surgeons with integrity are surgeons who keep their promises in spite of difficult situations. Surgeons with integrity are surgeons who speak the truth. Surgeons with integrity are surgeons who respect others and attend to their needs. Surgeons with integrity are surgeons who maintain an accountable and precise record. Surgeons with integrity are surgeons who follow their patients' needs.

Integrity is fully developed after dedicated teachings and persistent examples are given pertaining to the do's and don't's following the surgeon's world and interactions with patients, residents, and fellow surgeons. The history of surgery gives us excellent examples of the value of integrity in the surgeon's practice and academic teachings.

An unique and pertinent example of integrity is that of the first inoculator in America. Zabdiel Boylston (1680–1766), well-recognized pioneer American surgeon, had an extraordinary force of character and “strict adherence to the standard values and a way of conduct” [[12]]. He remained loyal to his principles of defending the special virtues of inoculating patients with smallpox during the Boston epidemic of 1721. Several prominent physicians of the time such as Douglass and Dalhonde greatly opposed and ridiculed Boylston's practice [[12]]. Many in the city of Boston followed the stance of the medical attackers. Boylston, without hesitation, defended his just cause until the epidemic ravages temporarily terminated in the second half of 1722 [[12]]. His conduct testified as to the force of character and integrity, without reproach, that marked his professional life and was demonstrated in an immaculate manner and at all times.

Another example of surgical integrity in America involves the great figure, Kentuckian surgeon master Ephraim McDowell (1771–1830) [[13]]. Against all odds, in the backwoods of undeveloped Kentucky, he performed in 1809 the first successful abdominal operation in the world [[13], [14]]. With dedicated interest and uncontested integrity, he explained to his doubtful patient, Jane Todd Crawford, the potential outcome of an operation such as the one she needed. With uncanny honesty, he indicated to her that no successful abdominal operation had been completed before and that her operation was an experiment that had never been accomplished with positive results [[13], [14]]. In spite of these unsettling premonitions, Mrs. Crawford decided to proceed with the surgery with the hope that her surgeon was ready. McDowell and Crawford went through the surgical act with great strength and determination. The operation was a resounding success, the patient tolerated the procedure well in spite of the lack of anesthesia, her ovarian tumor was fully excised, and the surgeon removed it in one piece! Other successful similar operations were performed by McDowell in subsequent years [[13], [14]].

In addition to the integrity exhibited by the courageous behavior of Boylston and McDowell, many other American surgeons demonstrated identical strong qualities [[15], [16]]. Suffice it to say that in equal terms, Beaumont, Mott, Warren, Gross, and Halsted are just a few of a large number of nineteenth century American surgeons who demonstrated the enormous importance of integrity in their professional careers.

Dr. Mackey, our fictional senior surgeon, concerned with the proper demonstration of the value of integrity for surgical residents throughout the whole surgery program, began a careful study pertaining to the better understanding of integrity as a philosophical entity. In his exhaustive library search through evidence-based surgery [[11]], he encountered the Stanford Encyclopedia of Philosophy [[8]] with the following fundamental concepts:

“Integrity is one of the most important and oft-cited of virtue terms. It is also perhaps the most puzzling. For example, while it is sometimes used virtually synonymously with ‘moral,’ we also at times distinguish acting morally from acting with integrity. Persons of integrity may in fact act immorally—though they would usually not know they are acting immorally. Thus one may acknowledge a person to have integrity even though that person may hold importantly mistaken moral views. When used as a virtue term, integrity refers to a quality of a person's character; however, there are other uses of the term. One may speak of the integrity of a wilderness region or an ecosystem, a computerized database, a defense system, a work of art, and so on. When it is applied to objects, integrity refers to the wholeness, intactness or purity of a thing—meanings that are sometimes carried over when it is applied to people. A wilderness region has integrity when it is not corrupted by development or by the side-effects of development, when it remains intact as wilderness. A database maintains its integrity as long as it remains uncorrupted by error; a defense system as long as it is not breached. A musical work might be said to have integrity when its musical structure has a certain completeness that is not intruded upon by uncoordinated, unrelated musical ideas; that is, when it possesses a kind of musical wholeness, intactness and purity. Integrity is also attributed to various parts or aspects of a person's life. We speak of attributes such as professional, intellectual and artistic integrity. However, the most philosophically important sense of the term integrity relates to general character. Philosophers have been particularly concerned to understand what it is for a person to exhibit integrity throughout life. Acting with integrity on some particularly important occasion will, philosophically speaking, always be explained in terms of broader features of a person's character and life.”

Surgeon Mackey was extremely pleased with the surgical residents exposure to integrity. However, the practicality of teaching this virtue was not completely clear. It was necessary then to develop a program that conveyed the best means of teaching the extraordinary importance of integrity. This potential program would include theoretical principles as well as practical examples—as indicated before—of the characterization of this significant professional and personal trait. Mentors dealing with this issue should utilize all opportunities available for referring to the presence of integrity at work and in their lives. A dedicated and long-term task!

The University of Illinois Core Curriculum program [[17]] considers honesty and integrity as two of seven very important qualities that characterize the “true medical professional.” In their words, “a physician should keep his or her word, regardless of personal cost, and speak truthfully. Also physicians should avoid situations that place their own interests in conflict with those of others” [[17]].

In closing, we need to remember that integrity is identified in someone who remains true to his/her own principles, someone who maintains a crystalline pure expression of character, as well as someone who exudes honesty in personal and professional behavior. Without integrity, the life of a surgeon, researcher, or academician is not possible, because trust, belief, and understanding would be completely eliminated and every action would be entirely meaningless.