SEOUL (NYTIMES) - South Korea has a reputation for world-class medical care. But faith in its hospitals has been shaken by years of complaints about doctors mishandling unconscious patients, including turning them over to unsupervised assistants who perform what is known as "ghost surgery".
To stem the practice, lawmakers amended the country's medical laws last year to require cameras in all operating rooms that handle patients under general anaesthesia, making South Korea one of the first countries to do so.
Ethicists and medical officials, including those at the American College of Surgeons, have cautioned that surveilling surgeons to deter malpractice may undermine trust in doctors, hurt morale, violate patient privacy and discourage physicians from taking risks to save lives.
The Korea Medical Association, which is opposed to the new mandate, has lobbied to limit its effect.
But supporters of the law said the move would help protect patients, build the public's trust in doctors and provide victims of medical malpractice with evidence to use in court.
"People are dying in operating rooms," said Mr An Gi-jong, an advocate for patients. "We cannot rely on doctors to solve problems on their own any more."
About five patients have died from ghost surgical operations in the past eight years, he said. They include Mr Kwon Dae-hee, a college student in Seoul who died of a haemorrhage in 2016 after jawline surgery.
His mother, Ms Lee Na-geum, who obtained footage of his operation and reviewed it hundreds of times, found evidence that the operation had been botched because parts of it had been conducted by an unsupervised nursing assistant.
A court convicted the surgeon of involuntary manslaughter in 2021, sentencing him to three years in prison.
Ms Lee, 62, who has held a public vigil denouncing ghost surgical procedures since her son's death, said in an interview: "Once the cameras are installed, your lies will be exposed if you're a ghost doctor. Cameras reveal truth."
South Korea is accustomed to widespread video surveillance. By 2020, the government had installed more than 1.3 million cameras in public spaces, often to deter crimes.
Demand for the camera mandate in hospitals escalated in recent years with revelations by whistle-blowers that doctors had inflicted ghost surgery, and even sexual abuse, on patients under anaesthesia.
Fears about ghost surgery were a plot point in the Korean Netflix hit Squid Game.
The surreptitious operations began occurring at plastic surgery clinics in South Korea in the 2010s, after the government started promoting medical tourism as an economic driver, according to legal experts.
Patient advocates say plastic surgeons took advantage of the high demand by deputising nurses, assistants and even medical device technicians to perform operations. That allowed physicians, they say, to pack in more patients to maximise profits.
In May last year, video footage emerged from a spinal clinic, Incheon 21st Century Hospital, that showed nursing assistants performing incisions and putting in sutures.
Mr Choi Jeong-kyu, a lawyer who has represented medical malpractice victims, said he received the footage from someone who had worked at the clinic and recorded it secretly. Mr Choi passed it on to broadcaster MBC.
Nineteen surgical procedures were captured in the footage, which showed three nursing assistants operating on patients' spines. Surgical machines buzzed as the assistants, looking through a medical microscope, used them on patients' bones and bloody gauze piled up on one side of the surgical table.
During each operation, a surgeon eventually appeared and worked on the patient for about five minutes.
"They were treating patients like objects on a conveyor belt in a factory," Mr Choi said. "It is frightening."
After the video emerged, prosecutors filed a lawsuit against the clinic. Five doctors, three of whom were the clinic's directors, and three nursing assistants were arrested in August.
In February, a court found them guilty of unlicensed medical practices and fraud. They were sentenced to up to two years in prison and fined up to 7 million won (S$7,600) each.
About 100 cases of ghost surgery were prosecuted in the five-year period before 2018, according to the Health Ministry. But between 2008 and 2014, about 100,000 patients were victims of ghost surgery, the Korean Society of Plastic Surgeons has estimated.
Under the new law, hospitals performing surgery on unconscious patients must install video cameras in their operating rooms. If a patient or a relative requests that a procedure be filmed, the hospital must comply.
Doctors can refuse for certain reasons, such as if a delay in the operation would put the patient's life at risk, or if the filming would significantly impede residents' training.
The recorded footage can be viewed for criminal investigations, prosecutions, trials, medical disputes or mediation.
Advocates for patients say the punishment for ghost surgery is too lenient in South Korea.
Under current laws, doctors can face fines and up to five years in prison, and they can lose their licences, though they may reapply after three years at most.
In the United States, charges of battery have been brought in cases where a doctor performed surgery on another doctor's patient, Mr Choi said. But South Korean courts treat ghost surgery as practising medicine without a licence, not battery, he said.
South Korean doctors' financial incentives have made ghost surgery alluringly profitable, said Dr Kwon Soon-man, a professor of public health at Seoul National University.
The health insurance system, which uses a fee-for-service payment model, has incentivised physicians to choose more resource-intensive ways to treat patients, he said.
And while about 10 per to 20 per cent of US hospitals are for-profit, he added, private hospitals in South Korea account for more than 90 per cent of all hospitals.