Also, it’s probably worth considering whether this sort of experimental design is even capable of detecting the effects of chronic sleep deprivation, since the two cohorts would be expected to have similar medium- and long-term sleep schedules. Even so, the lack of clear outcome-based data strikingly and rightfully complicates our response to the issue.
Patient autonomy has, particularly in recent years, become a commonly accepted principle of medical ethics. Our profession has been moving decisively, if somewhat methodically, away from the paternalistic notion that doctors know best and that it’s our way or the highway.
We might still think that we know best, but the customer — that is, the patient — is always right. A fundamental aspect of respect for autonomy, especially in the context of operative medicine – is informed consent, which, in turn, depends on disclosure of risks to the patient by the surgeon. A truly autonomous, informed decision would incorporate consideration of whether the surgeon might be sleep deprived.
Surgeons are obligated to disclose any material risks associated with the proposed operation — a term that has long been taken to include impairment as a consequence of alcohol, drugs, or disease. It’s difficult to see why impairment secondary to sleep deprivation should be treated any differently. A common counterargument is that such disclosures would set us down a slippery slope that would end with gross invasion of our privacy by patients.
However, putting aside for a moment the question of whether more comprehensive disclosures would truly be deleterious — requiring surgeons and patients to discuss, as part of the informed consent procedure, whether the surgeon had been up all night before the operation seems to be both easily limited and clearly circumscribed. And, in all honesty, concerns about opening Pandora’s box are probably beside the point, since it’s not just sleep deprivation that patients should be concerned about — it’s any external factor that can affect a surgeon’s ability to focus and perform anything, really.
It’s tempting to suggest that these concerns can, or should, be obviated by a mere appeal to our professionalism. A maximally professional surgeon, the argument goes, would decline to perform an elective procedure if [she] was too tired, or if some other factor might potentially prevent [her] from operating safely and effectively. Inclusion of such a discussion in the informed consent process would thus be redundant.
Sadly, as much as this line of reasoning appeals to my perception of surgeons as knights, rather than pawns or knaves, it’s not clear that it’s useful in a practical sense. For one thing, financial and, just as important, cultural pressures constrain our ability to reschedule elective procedures. And even aside from whether we would step away from the operating table when we’re exhausted — and there’s no evidence that this is a common practice — there’s the further question of whether we can even recognize when our performance is at risk. In fact, there’s a significant body of evidence showing that, like drinkers, people who are sleep deprived lack insight into their own impairment.5
The law surrounding informed consent has evolved from asking what a reasonable surgeon would have disclosed to focusing on what a reasonable patient would have wanted to know. But, of course, surgeons, and our families, can sometimes be patients, too. Before letting your mother, grandmother, or even yourself, be wheeled into the operating room for an elective procedure, would you want to know if the surgeon slept last night? That’s not a trick question.
- Williamson AM and Feyer AM. Moderate sleep deprivation produces impairments in cognitive and motor performance equivalent to legally prescribed levels of alcohol intoxication.” Occup Environ Med. 2000;57:649-655.
- Roehrs T, Burduvali E, Bonahoom A, et al. Ethanol and sleep loss: a “dose” comparison of impairing effects. Sleep. 2003;26(8):981-985.
- Rothschild JM, Keohane CA, Rogers S, et al. Risks of complications by attending physicians after performing nighttime procedures. JAMA. 2009;302(14):1565-1572.
- Chu MW, Stitt LW, Fox SA, Kiaii B, et al. Prospective evaluation of consultant surgeon sleep deprivation and outcomes in more than 4000 consecutive cardiac surgical procedures. Arch Surg. 2011;146(9):1080-1085.
- Van Dongen HPA, Maislin G, Mullington JM, et al. The cumulative cost of additional wakefulness: Dose-response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation. Sleep. 2003;26(2):117-126.