Recently, I began a new series for General Surgery News focused on Nobel Prize-winning surgeons. The series explores the personal stories, pivotal moments, and notable accomplishments and controversies that catapulted this select group of nine surgeons into the spotlight.

While researching their lives, I began to wonder how and why these particular surgeons were selected from the vast pool of viable candidates considered each year. I went to the official Nobel Prize Web site for some answers. The Web site only provides a vague overview of the process, but I learned that the Nobel Committee first sends confidential forms to about 3,000 qualified individuals, including members of the Nobel Assembly at the Karolinska Institutet in Stockholm, former Nobel Laureates in Physiology or Medicine and esteemed professors at universities around the world. The Committee sifts through the candidates and compiles a list of 250 to 350 names, which it subsequently sends to designated experts who assess each candidate’s work. After receiving this analysis, the Nobel Committee comes to a consensus on the final candidates and issues a report, which it submits to the Nobel Assembly. In early October, the Assembly decides on the winner by majority vote and the new Nobel Laureate in Physiology or Medicine is announced. This decision is final; there are no appeals.

Although this process sounds deliberate and structured in theory, it is actually quite muddled in reality. One major issue is that there is no consistency or standardized method when it comes to delineating how nominators or the Nobel Committee should conduct themselves when selecting candidates. Some nominators mull over the decision on their own, while others talk to colleagues or fellow Nobel Committee members. Throughout this process, nominators have admitted to letting their personal allegiances or preferences sway them. In some cases, Committee members have exhibited a clear agenda, by pushing one candidate to the forefront or preventing another from receiving recognition. According to Robert Marc Friedman, PhD, professor of history of science at University of Oslo, who has studied the first 50 years of the Physics and Chemistry awards, Nobel Committee members have confessed that, in a given year, several candidates were equally worthy of the Prize.

In some cases, it is difficult to discern why certain candidates won a Nobel. For instance, when combing through the Nobel archives, I found that Emil Theoder Kocher, the first surgeon to win a Nobel Prize in 1909, only received one nomination (out of 89 nominators) and Allvar Gullstrand, the second surgeon to win a Nobel Prize in Physiology or Medicine, only received two nominations (out of 74 nominators) the years they both won. How, then, did these two men come away with the Prize when other candidates received many more votes? For Dr. Gullstrand, the fact that he was Swedish made a difference. Additionally, the Committee was reacting to rumors that Dr. Gullstrand's colleagues in Uppsala wanted to award him the Nobel Prize in Physics (also based on minimal nominator support).

 “Clearly, what specialties should receive consideration, and what specific works should be rewarded, have been greatly influenced by what committee members have considered important,” Dr. Friedman wrote.

Additionally, there is little to no transparency when it comes to choosing a Nobel Laureate. The Nobel archives were kept secret until 1976, and today, those seeking more information can only uncover the list of candidates and nominators from 50 years ago, no sooner, and only in certain categories. The true nature of the process may come to light many years later, if ever.

“Without insight into who was judging and who was proposed for the prize, informed critical discussion about the prizes had been precluded,” Dr. Friedman wrote.

The actual final reports of the Nobel Committee sent to the respective large assemblies that vote do not reveal unambiguously the truth behind the choice either: The reports are often written after the Committee's decision-making process has ended and fail to mention any bias present during these deliberations, as these reports are meant to persuade the Assembly to accept the Committee's recommendations.

The cracks in the process become particularly apparent with Dr. Gullstrand who served on the Nobel Committee in physics from 1911 to 1929. Dr. Gullstrand successfully prevented Albert Einstein from receiving the Nobel Prize in Physics on many occasions, asserting that Einstein’s theories of special and general relativity were bogus. Dr. Gullstrand, who wrote detailed evaluative reports on relativity, used his incredible sway over the Nobel Committee to ensure that Einstein never received the Prize for this tremendous accomplishment. The Committee obliged because its members, for the most part, held a similar bias and did not want a “political and intellectual radical, who—it was said—did not conduct experiments, crowned as the pinnacle of physics,” Dr. Friedman noted.

Eventually, in 1922, after intense debate and a little finagling, Einstein did receive the Nobel Prize in Physics, though not for his most monumental work in relativity; he won for his discovery of the law of the photoelectric effect. (Read more about Dr. Gullstrand in the next column of GSN).

The key to understanding the Nobel deliberation process is to acknowledge that it is far from objective, with those involved often allowing their political, personal and professional biases to influence their decisions.

“Scholars who have analyzed the actual deliberations within historical context have shown that the Nobel medallion is etched with human frailties,” Dr. Friedman wrote.

Despite the flaws in the process, a Nobel Prize carries a powerful mystique. For many, the Prize represents the ultimate accolade a person can achieve in his or her lifetime, and as such, one might assume that the winners outshine their colleagues in any given year. But, as Dr. Friedman noted, this elevated status is not necessarily deserved.

“There are no grounds for assuming the winners of the Nobel Prize constitute a unique population of the very ‘best’ in science, in literature, and in the pursuit of peace,” he wrote. “Some of the greatest intellectual triumphs of the century, including many also within the realm of physics, chemistry, and medicine, have not been celebrated in Stockholm … It is perhaps asking much too much of any selection process to define a single group of the alleged “best” in science.”

Thus, although it is important to acknowledge the incredible achievements of Nobel Prize-wining surgeons, it is equally crucial to remember and reflect on the many pioneers in medicine who have pushed the boundaries in relative obscurity, not for the glory that comes with a prize but for the love of their craft.

The first article in the series, on Emil Theodor Kocher, appeared in the June 2014 issue of GSN.