 |
 |
|
Health Care Ethics USA Physicians and the Burden of Medical Error Dr. Albert W. Wu, a prominent contributor to the literature on medical error, paints the following portrait of a physician coping with such an event: You feel singled out and exposed—seized by the instinct to see if anyone has noticed. You agonize about what to do, whether to tell anyone, what to say. . . .You question your competence but fear being discovered. You know you should confess, but dread the prospect of potential punishment and of the patient’s anger. . . .Reassurance from colleagues is often grudging or qualified.1 The title of Wu’s article is a clarion call to us all: “Medical Error: The Second Victim—The Doctor Who Makes the Error Needs Help Too.” The fact that he wrote these words in 2000 may be surprising, given health care’s emerging perspective on error—a perspective that focuses more and more on identifying and analyzing root causes or underlying systems failures, rather than on finding a person to ‘blame’. When this approach works, health care personnel function together to address and rectify errors after the fact, as well as to develop policies and procedures to prevent similar errors from happening in the future. The tragic case of Jesica Santillan, who received donor organs in February, 2003 that were not properly matched to her blood type, demonstrates this new process. Surgeons at Duke University Hospital immediately disclosed the error to Jesica’s family; the administration promptly admitted responsibility for the error without attempting to explain precipitously how it occurred; and the hospital then developed and published new procedures to ensure that a similar error would not happen again. While it is clear in the statements of the surgeon involved that he agonizes over the error, careful reading of documents surrounding the event indicates that he has not been made to stand alone as scapegoat. Instead, other organizations, departments, and persons involved share responsibility with him, not only for the error itself, but also for identifying what went wrong and ensuring that it will not reoccur. Unfortunately, a number of factors still sometimes impede the implementation of these new truth-telling policies. This is a problem that health care personnel and the public need to understand, since some of these factors are burdens that must be lifted from physicians’ shoulders and shared, in order to enable doctors to more easily admit and speak freely about medical errors. Principles Some of these burdens involve practical issues that cannot be discounted, even in an ethical analysis, and these will be discussed shortly. Nevertheless, even when physicians set pragmatic considerations aside in thinking about medical error, they can have trouble discerning which ethical principle to focus upon. Honesty? Respect for human persons? Beneficence and nonmaleficence? This quandary is exacerbated by the fact that principles can conflict with one another. For example, honesty might be the first principle to come to mind in regard to the disclosure of medical errors. When people do not trust others to be honest with them, commitments and promises of all sorts fall apart. Honesty sustains relationships as personal as the solemn vows between husband and wife or as broad in scope as the pacts and treaties among nations. After considering the importance of maintaining a trusting relationship with the patient, a physician might choose honesty as a good principle to focus upon. On the other hand, physicians have an obligation not only to be truthful with their patients, but also to act in their best interest and to do them no harm. Primum non nocere! If a physician believes that knowing the truth about a particular error will harm the patient, then deciding whether or not to disclose the error to that patient creates an ethical conflict between the principles of honesty and beneficence. In addition to the obligation of beneficence to their own patients, some doctors also strive to act in accordance with an ideal of general beneficence, extended to those beyond their own limited sphere of relationship and influence.2 When responding to questions about medical error, these doctors relate additional concerns about adding to what they perceive to be the damage already done by widespread news accounts of recent medical errors. They worry that if people continue to hear about more and more errors, they will conclude that doctors are not fulfilling their promises to protect the well-being of their patients. If this undermines the trust felt for physicians in the community as a whole, some fear that individual physician/patient relationships will eventually be negatively affected. For all these doctors—whether focusing solely on the ‘obligation’ to act with specific beneficence toward their own patients, or attempting to balance this with what is usually considered to be the ‘ideal’ of general beneficence toward the wider community as well—there is fear that attempts to do good (beneficence) and to avoid harm (nonmaleficence) may become mired down under the weight of honesty. Discussion Medical literature makes it clear that despite the development of root cause analysis policies, physicians are still wondering when and to whom they should disclose errors, and how much to say. A few hold the highly principled position that lying, or even withholding truth, is always wrong; that there is a duty to disclose even medical “near misses” and minor errors. For them, the duty to tell the truth maintains, regardless of the consequences. The AMA Code of Ethics (8.12) takes a less rigorous position, stating that, “when a patient suffers significant medical complications that may have resulted from the physician’s error or judgment. . . . the physician is ethically required to inform the patient of all the facts necessary to ensure understanding of what has occurred (italics added).” Similarly, the Joint Commission on the Accreditation of Healthcare Organizations only requires health care workers to inform patients who have actually been harmed by medical error. Nevertheless, serious errors continue to go unreported, and failure to disclose them does not pertain only to telling patients what has happened. A landmark 1991 study led by Wu found that house officers withheld the truth about serious errors from families or patients 75% of the time, but also from attending physicians roughly 50% of the time.3 Reasons offered for this include humiliation, shame, and fear of punishment or loss of position. Reflecting the argument that the medical profession values perfection, and that many have been trained to think that errors are forbidden in a perfect world,4 one physician writes that, “ . . .we tend to view most errors as human errors and attribute them to laziness, inattention, or incompetence . . . [yet] we privately think, ‘There but for the grace of God, go I.’”5 Still others report that they fear that admission of error could damage their professional reputations, and that referrals would dwindle if the truth were known, and that patients might leave their practices or bring legal action against them.6 A1997 article in Medical Economics states that doctors also feel external pressure not to disclose medical errors. The article states that managed care organizations sometimes put pressure on doctors not to reveal errors, and threaten to drop their coverage if they are sued, and that some insurers pressure physicians by instructing them not to admit any liability without the insurer’s consent.7 Whatever physicians’ reasons might be for not disclosing medical errors, a 1996 study found that 98% of patients interviewed were unequivocal in saying that they want acknowledgment of even minor errors. Twice as many respondents said they would report or sue a doctor who fails to disclose, as one who volunteers the information, and the more serious the error, the greater the desire of those surveyed to be told about it. Eighty-seven percent said they would ask for a referral to another doctor if they found out that a physician did not inform them about a minor error; but 97% said they would find another physician if a serious one were not disclosed.8 Unfortunately, a later survey shows a reverse inclination on the part of medical students and physicians. Contrary to patients’ increasing desire to be told about errors as their seriousness increases, researchers found that physicians’ willingness to disclose medical errors instead declines as the severity of the error increases. Ninety-five percent say that they would disclose minor errors, but only 79% would disclose an error that led to the death of a patient.9 This data is significant, because root cause analysis cannot work unless everyone in health care, especially physicians, feels an acceptable comfort level for disclosing errors. It shows that there are aspects of doctors’ reticence to do so that they alone can address, but because of the importance of the issue all health care professionals bear responsibility for facilitating that goal. In addition, the public must modify its often unreasonably high expectations of doctors—a change that might, in turn, affect the legal system, managed care, and insurers. Effecting this attitudinal change, however, may be a function of physicians’ willingness to accept their own weaknesses. David Hilfiker writes that, “The medical profession seems to have no place for its mistakes . . . And if the medical profession has no room for doctors’ mistakes, neither does society.”10 Perhaps a profession that places such high value on perfection leads others to overlook its members’ human vulnerabilities. Wu writes that “confession is discouraged . . . in part by lack of appropriate forums for discussion,” and this suggests one positive step that can be taken by health care systems to assist physicians. More poignantly, his statement that “the kind of unconditional sympathy and support that are really needed are rarely forthcoming,” suggests another. System-wide analysis of errors is good for health care, good for physicians, and good for patients, but it cannot work until unrealistic expectations, and the personal barriers they bring, are broken down. Conclusion Physicians bear the burden of being on the front line when it comes to disclosing medical error. Given that errors rarely happen in a vacuum, there is an ethical obligation on all within health care, as well as on the public, to make the task of addressing them less physician burdening and blame-oriented. A Harvard School of Public Health study finds that patients harmed by medical error want three things: an explanation of what happened, an apology from whomever was responsible, and assurance that changes have been made to prevent harm to others. These points cannot be satisfactorily addressed without the cooperation and contributions of all involved. Removing the weight of the burdens that are outlined above from the shoulders of physicians would be a significant step toward realizing the ideal of addressing error in a collegial, constructive, and blame-free manner. 
Ann K. Suziedelis, PhD (c)
Suggested Readings Paul M. McNeill and Merrilyn Walton, “Medical Harm and the Consequences of Error for Doctors,” The Medical Journal of Australia 176 (4 March 2002): 222-25, at http://www.mja.com.au/public/issues/176_05_040302/mcn10333.html “Personal Views: Looking Back,” British Medical Journal 320 (18 March 2000): 812, at, http://bmj.com/cgi/content/full/320/7237/812 Questions For Discussion
|
|
 |