Trauma is the leading cause of death among people aged 1–44 years and the fourth most common cause of death in the western world [1]. When managing trauma cases, the member of an emergency and trauma surgical team must work under tremendous pressure in a stressful and complex environment while aiming to communicate effectively, and decisions must often address ethical dilemmas [2]. Indeed, trauma teams must deal with extreme stress and time constraints, not rarely with no awareness of the trauma causes nor the patients’ identity, current circumstances or conditions, or patients’ desires about the treatment options, and must cope with the risk of unanticipated incidents. Within this context, traditional organizational practices are less effective, and integrative mechanisms such as team assembly decisions might be the only opportunity to coordinate team member actions and increase performance [3].

In such scenarios, urgent decision-making in trauma surgery raises a number of ethical concerns. When faced with ethical dilemmas, clinicians must rapidly consider the potential outcomes of their choices, as well as the limited information they have about their patients [4]. Ethics also involves communication and sharing of eventual options and decisions to patients and their loved ones with consistency and compassion. The emergency situation rarely allows time to investigate recommendations from the relevant literature or guidelines or ask other colleagues for second opinions. As a result, there is a high risk of making mistakes or facing ethical dilemmas when managing injured patients, and this seems to be particularly true during the early assessment and resuscitation processes when lifesaving procedures are made [5]. Similarly, the time or opportunity to inform the patient might be limited or completely lacking. In this perspective, the topic of consent is critical. Because of the sudden and unexpected nature of trauma or the emergency, healthcare providers must be trained to think and respond fast in the patient's best medical interest. Trauma patients frequently have transitory impairments in their ability to make autonomous and informed decisions. This often results in presumed consent for medically necessary treatment [4].

Emergency surgery teams are made up of a multidisciplinary group of people from different specialities such as anesthesia, emergency medicine, surgery, nursing, and supporting staff, all of whom provide simultaneous inputs into the trauma assessment and treatment, with a team leader who will be coordinating their activities [1]. Therefore, in trauma and emergency situations, team dynamics are critical [6].

A crucial aspect refers to the role of the trauma leader who, as an ethical leader and guided by strong ethical principles, “can experience conflicting obligations to stakeholders during these emotional and complex debates and must lead with strength, compassion, fairness, and justice while eliminating implicit and explicit biases” [7]. Indeed, while decision-making is often seen through the lens of an individual's internal cognitive process, the ability to put certain decisions into action necessitates the ability to seamlessly organize all team members to achieve the desired objective [5]. Trauma leaders have the challenging role of managing their team through potentially challenging ethical situations.

Interestingly, current teaching and assessment approaches for these advanced cognitive skills are subjective, lack standardization, and are vulnerable to errors [5, 6]. Therefore, knowledge translation and knowledge transfer mechanisms are cornerstones to allow team members to bridge their differences and communicate effectively, boosting the potential of multidisciplinary teams [8]. Fostering a continuous learning requirement on these matters is essential to enable trauma teams to overcome ethical dilemmas in an efficient and effective way [9].

Diversity in surgery is a rising topic within the surgical community. It has been defined as “a broad representation of viewpoints, socioeconomic backgrounds, gender, sexual orientation, disability status, race, and ethnicity” [10]. Emergency surgery teams are diverse by definition, as they include professionals of different specialities and variable backgrounds [1], who do need interpersonal skills [5, 6] to ensure effective care to trauma patients. The literature highlights how global performance has been shown to be better when the environment of medical care is diverse, and patient satisfaction is also improved in such contexts [11, 12]. Still, recent studies have also underlined how diversity needs dedicated organizational and management policies to reach its full potential [8, 11, 13]. Interestingly, to the best of our knowledge, little has been said about the possible influence between diversity and ethics in emergency and trauma teams.

To fill this gap, this study aims at investigating the different perceptions of trauma surgeons on three ethical-related matters. First, the study investigates the feelings of surgeons regarding the importance of patient consent. Second, the research focuses on their perceptiveness of the ethical role of the trauma leader. Third, the study deepens the perceived importance of ethics as an educational subject. This study builds on these foundations by undertaking an international survey under the auspices of the World Society of Emergency Surgery (WSES) to investigate the factors that can enhance these three ethical aspects in trauma and emergency surgery. The dataset is analyzed focusing on the role of gender, kind of institution (academic or not), and membership to an officially set trauma team and to a diverse group.