March 19, 2001
Moral courage in medicine
is associate professor
Although health providers have openly acknowledged and studied the occurrence of medical error over the last two decades, last years Institute of Medicine annual report, To Err Is Human, captured the publics attention by claiming that 44,000 to 98,000 deaths are caused by medical error each year.
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 arent reported either.
I have joined what is now a national movement to reduce the incidence
of medical error and develop an ethically based practice of error disclosure.
Of fundamental ethical importanceand what explains why the practice
of intentional error concealment is so shockingis 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. Disclosure
of harm-causing error is morally obligatory; 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 and so accommodate his
or her right of redress.
Of course, it would be unfair to dismiss or gloss over the need for moral
courage in disclosing serious medical errors. The threat of 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 disclosure. But if the sine qua non of professional
ethics requires subordinating the self-interests of the professional to
the welfare of the patient, then the primary question is not whether to
disclose error but how to disclose in the most productive and ethical
Surprisingly, most serious errors require multiple causes. In April 1997,
a 12-year-old boy with lymphatic cancer was scheduled to receive his last
dose of chemotherapy at a famed childrens hospital in London. Because
he couldnt 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 the anesthesia
and the chemotherapeutic drug (Vincristine) directly into Richies
spine. Richie died in agony five days later. The label on the vial of
Vincristine was clearly marked for intravenous use only, and
Lee was prosecuted for manslaughter.
At first blush, this seems a slam-dunk example of medical negligence.
Yet, after considerable analysis of the case, it was apparent that this
remarkable error was similar to the majority of other seemingly egregious
mistakes made at hospitals: not resulting from a single individual making
a discrete mistake, but rather an error facilitated by a host of mistakes.
Heres how it happened: Richies tragedy began with his eating
a cookie the morning of his treatment. When he mentioned this upon arriving
at the hospital, 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 treated by his usual physician
(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
When Richie arrived at anesthesia, he was greeted not by his usual morning
team, but by the afternoon team along with Lee, an anesthesiologist
with no experience in providing chemo-therapy. Lee called Murphy to ask
if he would like to do the injection. Thinking Lee was referring only
to the anesthesia and not the Vincristine (which Murphy had no idea was
in Lees presence), Murphy said Lee could do the procedure himself.
Consequently, although Lee appeared to be the villain in this story,
analysis showed a complex picture of slip-ups and misunderstandings that
the hospital subsequently confessed had happened on previous occasions
but without such tragic results.
Eventually, all charges were dropped against Lee because a fairer ascription
of blame lay with the entire hospital for permitting a system through
which both of Richies drugs were allowed to go to the anesthesia
room and be injected together. Indeed, often when such tragedies are more
closely analyzed, the villain seems conspicuous only because
he or she was the last agent in a complex chain of events. Rather than
offer up the apparent perpetrator as a sacrificial lamb to the press and
the harmed parties, a more ethical approach is for the institution to
take collective blame.
A primary, probably fundamental reason why professionals 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 1999 issue of the Annals
of Internal Medicine, physician Steve Kraman and attorney Ginny Hamm
described the disclosure policy at the V.A. Medical Center in Lexington,
The policy outlines not only the facilitys 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, five settlements
occurred with harmed parties that would probably never have resulted
in a claim without voluntary disclosure to patients or families.
Yet the facilitys liability payments over that period have
been moderate and are comparable to those of similar facilities.
How can this be?
The reason appears to be that when the hospital comes forward and admits
blameespecially when the harmed party might not even know error
occurredthe harmed party is much less likely to go to court and
ask for the sun, moon and stars in damages. Out-of-court settlements,
whose damage awards are more amicably and reasonably reached, are the
Such open policies might also encourage more open communication in general.
Most patients appear to appreciate open and honest responses to their
concerns and feel more positively about their care. It is interesting
to speculate, therefore, whether such conversations might diminish a facilitys
yearly liability costs; happier, more satisfied people sue less.
Its fair to say that most U.S. hospitals would respond to a policy
of extreme honesty with considerable reluctance. In order to realize such
a policy, 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 increasedindeed, might even be reducedby
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
errors is, at bottom, an enormously caring and even loving act. Unless
the harm-causing parties themselves feel protected and respected, however,
it will be harder for them to act lovingly and caringly for others and
to find the courage they need when heartwrenching conversations are morally
This essay first appeared in the Center for Ethics Spring 2001 Ethics News & Views and is reprinted with permission.