ethics news & views

Moral courage in medicine: disclosing medical error

Although health providers have openly acknowledged and studied the occurrence of medical error over the last two decades, the Institute of Medicine’s year 2000 report To Err is Human captured the public’s attention and concern in an unprecedented way. Claiming that between 44,000 to 98,000 deaths are caused by medical error each year, the study noted how unfavorably health care errors compared with those occurring in other industries, especially the airlines.

Just as disconcerting was the fact that few harm-causing medical errors are routinely disclosed to the harmed parties. Thus, it is tempting to suppose that in addition to fatal harm-causing errors are tens if not hundreds of thousands of nonfatal but nevertheless serious harm-causing errors that aren’t reported either.

I have had the opportunity to study this literature, talk with some its major spokespersons, and become part of what has now become a national movement to reduce the incidence of medical error and develop an ethically based practice of error disclosure. What is of fundamental ethical importance in all of this–and what explains why the practice of intentional error concealment is so shocking–is that such concealment is entirely without moral justification. Professional ethics is unequivocal in insisting that the interests of clients must override the self-serving interests of professionals.

Most state licensing laws, for example, begin with a statement that the purpose of the licensing law is to foster the welfare of the public and the consumers of the professional services. Thus, disclosure of harm-causing error is morally obligatory because patients have the right not to be maltreated; but if they are, they have the right to consider some form of redress for the harm they suffered–which can only happen if they are informed of error. The health provider or institution that fails to inform harms the patient twice: first, by failing to deliver care that met a professional standard (i.e., that involved a negligence), and second, by failing to alert the harmed party to the error and so accommodate his or her right of redress. By failing to disclose, then, the health provider is conspicuously placing his or her self-interests above the patients. Because that motivation is as obvious as it is ethically unacceptable, the media takes an enormous, almost vulpine, interest in sensationalizing examples of error cover-ups, as the intentional act of concealment squarely contradicts a patient-centered ethic.

Of course, it would be unfair to dismiss or gloss over the need for moral courage in disclosing serious harm-causing medical error. The threat of professional censure, institutional penalty, malpractice litigation, reduced ability to compete in the marketplace if the error is leaked to the public (not to mention the humiliation), and the need to perpetuate the myth of perfectionism in health care all militate against error disclosure. But if the sine qua non of professional ethics is its other-regarding posture demanding the professional to subordinate his or her self interests to the welfare of the patient, then the primary question is not whether to disclose error but how to disclose error in the most productive and ethical fashion. Interestingly, though, there are at least two dimensions of error occurrence that deserve attention, not only because these findings are counterintuitive, but because they suggest a different model of culpability than the usual approach of looking for someone to blame and then offering up a “sacrificial lamb.”

Error as systemic
In April 1997, a 12 year-old boy with lymphatic cancer was scheduled to receive his last dose of chemotherapy at a famed children’s hospital in London, England. Because he couldn’t stand the sight of needles in his arm, Richie Williams was always sedated with anesthesia and was asleep before a nurse would start an intravenous, chemotherapy line. But on that day, a physician named John Lee who had never treated Richie before injected both Richie’s anesthesia and his chemotherapeutic drug—Vincristine—directly into Richie’s spine. Richie immediately cried out when the Vincristine was injected and died in agony five days later. The label on the vial of Vincristine was clearly marked “for intravenous use only.” Dr. Lee was subsequently prosecuted for manslaughter.

At first blush, this seems a “slam-dunk” example of medical negligence: a doctor’s injecting a chemotherapeutic drug that is clearly labeled “for intravenous use only” directly into a patient spinal canal, causing the patient’s death. Yet, after considerable analysis of this case, it was apparent that this remarkable error was similar to the majority of other seemingly egregious mistakes made at hospitals. That is, the error does not result from a single individual, making a discrete, inexplicable mistake. Rather, the error is facilitated by a host of mistakes or mishaps that facilitate or enable the error to occur.Here’s how it happened: Richie’s tragedy began with him eating a cookie the morning of his treatment. When he mentioned this upon arriving at the hospital a short time later, his treatment team chose to delay giving him the anesthesia for fear he might vomit while sedated and suffocate. Consequently, rather than go to anesthesia where he would be anesthetized by his usual physician, Dr. Dermott Murphy, and then be sent to the chemotherapy unit where a nurse would inject the Vincristine into his arm, Richie went instead to a general ward, where nurses unfamiliar with his care ordered both drugs sent to anesthesia.

When Richie arrived at anesthesia, he was greeted not by his usual morning team, but by the “afternoon” team along with Dr. Lee, who was an anesthesiologist with no experience in providing chemotherapy. Dr. Lee then called Dr. Murphy, and asked if he would like to come over to do the injection. Thinking that Dr. Lee was referring only to the anesthesia and not the Vincristine (which Murphy had no idea was also in Dr. Lee’s presence), Dr. Murphy explained that the injection was a simple procedure that Dr. Lee could do himself.

Consequently, although Dr. Lee appeared to be the villain in this story, analysis showed a much more complex picture of slipups and misunderstandings which the hospital subsequently confessed had happened on previous occasions but without ever proceeding as far as what happened to Richie Williams.

Although the hospital confessed to past number of “near misses,” it did nothing to correct the problematic sequence of events. A fairer ascription of blame, then, would lay with the entire hospital for allowing a system to exist where both of Richie’s drugs were allowed to go to the anesthesia room whereby they might be injected together. Eventually, all charges were dropped against Dr. Lee.

Interestingly, then, when medical errors are rigorously analyzed, we find that our first reaction, which is to blame and penalize the “error perpetrator,” is unwarranted. Indeed, the “villain” seems conspicuous only because he or she was the last agent in a complex chain of events, each of which contributed to the error. Rather than offer up the apparent error perpetrator as a sacrificial lamb to the press and the harmed parties, a more ethical approach to error disclosure is for an institution to take collective blame for the mistake.

Error Disclosure Can Lower Malpractice Costs
A primary reason why hospitals do not disclose error to harmed parties is their fear of malpractice litigation. Some recent research suggests, however, that hospitals might lower their overall malpractice experience and its associated costs by instituting a policy of “extreme honesty.” Reporting in a recent issue of the Annals of Internal Medicine, Dr. Steve Karman and Attorney Ginny Hamm described the disclosure policy at the Veterans Affairs Medical Center in Lexington, Kentucky. That policy outlines not only the facility’s practice of error disclosure, but also how the facility assists harmed parties to secure compensation for the wrong that was suffered. During a seven year period which the authors studied, five settlements occurred with harmed parties that “would probably never have resulted in a claim without voluntary disclosure to patients or families.” Yet, the authors found that their facility’s liability payments over that period “have been moderate and are comparable to those of similar facilities.” Despite the fact, then, that this hospital has maintained a policy that almost seemed designed to increase malpractice claims, its malpractice experience has not been excessive. How can this be?

The reason appears to consist in the fact that in instances where the hospital comes forward and admits blame—especially where the harmed party might not have even known error occurred—the harmed party is much less likely to go to court and ask for the sun, moon and stars in damages. Indeed, out-of-court settlements, whose damage awards are more amicably and reasonably reached, are the norm. On the other hand, in instances where harm causing error was intentionally concealed from the harmed party but who found out anyway, he or she will very likely request punitive damages in addition to the usual request for compensation for pain and suffering. It may also be the case that a policy of disclosure inspired by extreme honesty has a spillover effect that enhances overall patient-professional communications. That is, such a policy might encourage more open communications in general whereby the professional feels more at ease in discussing information that might otherwise be uncomfortable. In turn, this allows professionals to become more skillful and confident in conducting emotionally painful or awkward conversations, which are often omitted or conducted ineptly precisely because the health provider is uncertain how to proceed. Most patients, however, appear to appreciate open and honest responses to their queries and concerns and feel more positively about their care. It is interesting to speculate, therefore, whether such conversations might diminish a facility’s yearly liability costs since happier, more satisfied patients sue less.

Conclusion
While some hospitals in the United States appear to be taking serious steps to deal ethically with harm-causing error, it seems fair to say that most would respond to a policy of “extreme honesty” with considerable reluctance. In order to realize such a policy, it seems that a significant change in the core beliefs of hospital supervisors and institutional representatives must occur that at least includes the understanding of error as systemic; the notion that liability costs might not be significantly increased—indeed, might even be reduced—by disclosure; the realization that serious error will occur in medicine and that blaming involved parties is not a constructive response; and an effort to make medical training less punitive and more humane.

Because of the moral courage it requires, the act of disclosing harm-causing error is, at bottom, an enormously caring and even loving act. Unless the harm-causing parties themselves feel protected and loved, however, it will be harder for them to act lovingly and caringly for others and to find the courage they need when heart wrenching conversations are morally warranted.

About the Author

John Banja, PhD is an associate professor working in clinical ethics at the Center for Ethics.

This year he will be presenting at a number of national symposia on the ethical and psychological dimensions of disclosing harm-causing error.

He is currently completing an invited paper for publication that describes skills and techniques health providers might use in communicating serious harm-causing medical error.

You may contact Dr. John Banja at jbanja@emory.edu or (404) 712-4804.

[ Posted by John Banja at February 1, 2001 05:09 PM | More Health Science Ethics articles ]

© 2000-2001 by the Center for Ethics, Emory University. Some rights reserved.