Learning Surgery’s Moral Questions: Mentorship,Reflection,and Professional Formation

I was not sure what to expect when I first encountered the article titled “Surgeon Perspectives on Daily Presentations of Ethical Dilemmas: A Qualitative Study.” ¹ As a medical student still early in my clinical education, I had only a distant sense of what an ethics consult entailed. Perhaps something discussed in policy documents or handled behind closed doors after fraught cases. But this paper offered something far more intimate: a candid window into how surgeons reflect on the ethical ambiguities that shape their day-to-day practice. The persistent dilemmas that unfold in operating rooms, ICUs, and team discussions that often go without formal acknowledgment. It reframed how I understood ethical decision-making in surgery: not as a theoretical discipline, but as a lived, personal experience.

In speaking with both authors—Dr. Katherine Fischkoff, a general surgeon and intensivist at Columbia University, and Dr. Steven Char, who conducted the original study as a medical student and is now a surgery resident at Mount Sinai—I came to understand the collaborative, improvisational process of studying something as nuanced and personal as surgical ethics. What emerged was a story about mentorship and the intentional work to make space for reflection in this field that does not often pause.

Together, they designed a qualitative study to ask what ethical dilemmas surgeons face day-to-day, and how they make sense of them. “We just started asking questions,” Char explained. “Not just, what are the ethical issues, but do people even recognize them as ethics? Do they think of them as just problems? What keeps them up at night?”

Ultimately, Char interviewed 30 surgeons. Despite being a medical student—at times interviewing people he hoped might one day write him letters of recommendation—he found that most were eager to talk. The stories that emerged were deeply personal. “They wanted to get it off their chest,” he said. “It felt like they had been waiting for someone to ask.”

Common themes emerged: moral distress, disclosure, conflict between colleagues, discomfort with family dynamics, and the challenge of learning new technologies. One attending described the discomfort of disclosing intraoperative errors: “You lose more blood than you expected. Maybe not enough to transfuse, but more than typical. Do you tell the family? What if the patient doesn’t ask?” Another shared being asked to place a tracheostomy and percutaneous endoscopic gastrostomy in a brain-dead patient whose family had religious objections to brain death testing. “You’re being asked to operate on someone who is, legally, dead,” Fischkoff said. “Can you say no?” Newer dilemmas surfaced, ones not fully captured in the literature at the time. Fischkoff recalled her own learning curve with robotic surgery: “I was keeping patients under anesthesia for way longer than they would’ve been otherwise. I didn’t have complications, but it felt bad.”

The study revealed a culture where surgeons often learned how to handle ethical complexity not through formal training, but through stories, shared experiences, and mentorship. “People turn to their senior partners, to colleagues,” Fischkoff explained. “Not necessarily to the ethics committee.”

The experience affirmed that the ethical dilemmas surgeons quietly carry could be named, studied, and shared—and pushed Char to keep the conversation going. By then, Char had begun residency and found himself again surrounded by ethical quandaries—only now, he was the one expected to manage them. There were disagreements with attendings, tough end-of-life decisions, and subtle challenges around disclosure. One relatively healthy patient was admitted with acute cholecystitis. The attending recommended a percutaneous cholecystostomy tube, a technically less invasive option performed by another team, but one that would leave the patient with an uncomfortable external drain for several weeks. Char wondered whether the patient truly needed that approach or if the decision was influenced more by timing and convenience than by clinical necessity. “What do you do? It felt wrong, but I was just an intern.”

Rather than let those questions linger, Char began developing a surgical ethics curriculum for his residency program, modeled in part on the themes from the Columbia study. He created six modules based on residents’ perceived knowledge gaps and ethical concerns, including disclosure, end-of-life care, and conflicts with attendings. ² In one session on error disclosure, he asked residents to debate which mistakes warranted a conversation with the patient and which might not. “Obviously, you disclose a wrong-site surgery,” Char said. “But what if you lose a little extra blood? What if you convert a case? Where’s the line?”

When it came time to invite guest speakers, Char reached out to Fischkoff, who gladly accepted.

I could see that this project had come full circle. From a research question rooted in curiosity to a novel intervention in surgical education. From a mentorship rooted in a shared interest to a professional collaboration spanning institutions.

In surgical training, ethical awareness develops through both formal instruction and the informal learning that occur within clinical teams. ³ These day-to-day experiences play an important role in shaping how trainees interpret disclosure, hierarchy, professionalism, and responsibility in practice. This context helps explain why mentorship has ethical significance in addition to its roles in technical instruction and career development. Work on professional identity formation similarly argues that trainees are formed through socialization, role modeling, and participation in professional communities that shape judgment, values, and ways of responding to uncertainty.^4-6 Studies in reflective practice make a related point: ethical growth depends in part on opportunities to revisit experience, examine discomfort, and assign meaning to situations that remain unresolved after the event itself. ⁷ Therefore, the conversations I describe illustrate a recognizable educational process in which ethical awareness in surgery is cultivated through narration, interpretation, and guided reflection.

When I asked Fisckoff what ethical advice she’d offer to students like me, she paused. “Everybody has a story,” Fisckoff said. “Sometimes in surgery, we forget that. But when you actually sit down with a patient—especially one whose choices you don’t understand—you may start to hear about poverty, trauma, lack of support. And then we treat them, send them back into the same life, and wonder why they come back. So, I think one teaching point is to open yourself up to hearing the story, because sometimes it really matters.”

And Char? “Just pay attention,” he told me. “Learn from every case. Every attending. Every mistake. Keep asking why something bothers you. And don’t forget the stuff that sticks.”

The stuff that sticks. Like the moment you wonder whether to speak up, or stay silent, when a decision doesn’t feel right. Like a mentor who made space for your questions and stood beside you to answer them.

Through Char and Fischkoff’s reflections, I came to see ethical awareness in surgical training as something shaped not only by formal teaching but also by mentors who help trainees learn what to do with uncertainty: how to notice it, how to reflect on it, and how to let it sharpen rather than silence their moral judgment. Ethics lives in the stories surgeons carry, the tensions they revisit long after a case is over, and the questions trainees learn to ask when someone more experienced makes space for reflection. These are the lived dilemmas that shape how surgeons learn to practice, to teach, and to become.