Ghost surgery — the unauthorised performance of a surgical procedure by a substitute operator while the consented patient remains anaesthetised and unaware — constitutes one of the most serious violations of patient autonomy in modern healthcare [1]. While sustained protests in South Korea have brought this practice to international attention, its dimensions in Indian private hospitals remain inadequately studied and dangerously under-regulated. As a nursing professional, I write to highlight the ethical responsibilities of theatre nurses who witness such substitutions, the moral distress this imposes, and the urgent need for institutional policy reform.

Ghost surgery is enabled by structural conditions unique to Indian private healthcare: surgeons operating across multiple facilities, commercial pressures prioritised over ethics, and vague consent forms authorising “the surgeon and their team” — language routinely exploited to justify unauthorised substitution [1]. The experience of witnessing ghost surgery without the institutional capacity to intervene generates what nursing ethics scholars term moral distress — the psychological suffering that arises when a nurse knows which ethically correct action to take, but is constrained by institutional power dynamics from taking it [2]. Theatre nurses who witness ghost surgery and remain silent — whether from fear of reprisal, uncertainty about reporting pathways, or learned institutional acquiescence — carry this moral burden silently and alone. This distress is not a personal failing; it is a structural consequence of the absence of protected reporting mechanisms and a non-punitive safety culture in Indian operating theatres.

Ghost surgery violates all four bioethical principles: patient autonomy is violated categorically, non-maleficence is undermined if the substitute is less competent, beneficence is compromised when efficiency overrides patient-centred care, and justice demands that this violation not fall disproportionately on patients least equipped to seek redress [3].

The Supreme Court’s ruling in Samira Kohli v. Prabha Manchanda (2008) is unambiguous: consent must be specific, informed, and real. Yet no systematic regulatory guidance currently prohibits surgical substitution or mandates disclosure to patients. [3]

Theatre nurses occupy a uniquely exposed position in ghost surgery. Scrub nurses, instrument nurses, and anaesthesia assistants are often the only witnesses to an unauthorised substitution — the sole professionals present throughout the procedure who are neither the substitute operator nor the unconscious patient. Yet the professional and ethical responsibilities of these witnesses are rarely acknowledged. When theatre nurses witness ghost surgery, they face a profound conflict: their professional duty to advocate for patient safety collides directly with a hierarchical culture that discourages challenges to senior clinical authority — a culture of silence deeply embedded in Indian hospital structures. [4]

Addressing this crisis requires action at regulatory, institutional, and professional levels. The National Medical Commission must prohibit surgical substitution without specific patient consent, mandate named-surgeon identification on all consent forms, and classify ghost surgery as serious professional misconduct. At the hospital level, private institutions must implement policies to protect patient rights and support theatre staff: mandatory operator-linked surgical records identifying every individual who performed any surgical step; anonymous, protected reporting mechanisms accessible to nursing and paramedical staff; mandatory pre-operative briefings confirming the operating surgeon’s identity; and a formal safety culture in the operating theatre that empowers nursing staff to raise concerns and protects them from retaliatory action [4]. Nursing leadership has a particular responsibility: scrub coordinators and senior theatre nurses should be formally designated as patient safety advocates with defined authority to escalate concerns about unauthorised substitution.

The anaesthetised patient is among the most defenceless individuals in any clinical encounter. Theatre nurses — who are often the only witnesses to what happens to a patient on the operating table — must be empowered, protected, and morally supported to advocate for that patient. The culture of silence in Indian operating theatres must end; the professional courage of nursing staff in speaking up must be institutionally recognised, not punished. The silence must end.

Author: Dhiraj Lakshakar ([email protected], https://orcid.org/0009-0004-3173-6544), Associate Professor, Department of Mental Health Nursing, INSSR, ITM University, Gwalior, Madhya Pradesh, 474 001, INDIA.

Conflict of Interest: None declared                                                                                                                                                                                       Funding: None

Acknowledgments: The author used OpenAI’s ChatGPT for language editing, grammar correction, sentence restructuring, and improvement of academic writing clarity during manuscript preparation. The author reviewed, verified, and is fully responsible for the final content of the manuscript.

To cite: Lakshakar D. Ghost surgery in Indian private hospitals: A silent ethical crisis. Indian J Med Ethics. Published online first on September 26, 2026. DOI: 10.20529/IJME.2026.058

Submission received: April 17, 2026

Submission accepted: September 1, 2026

Manuscript Editor: Vijayaprasad Gopichandran

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©Indian Journal of Medical Ethics 2026: Open Access and Distributed under the Creative Commons license (CC BY-NC-ND 4.0), which permits only noncommercial and non-modified sharing in any medium, provided the original author(s) and source are credited.