Moral courage in medicine

John Banja is associate professor
clinical ethics at the Emory Center for Ethics

Although health providers have openly acknowledged and studied the occurrence of medical error over the last two decades, last year’s Institute of Medicine annual report, To Err Is Human, captured the public’s 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 aren’t 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 importance—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. 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 fashion.

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 children’s hospital in London. 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 the anesthesia and the chemotherapeutic drug (Vincristine) directly into Richie’s 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.

Here’s how it happened: Richie’s 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 anesthesia.

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 Lee’s 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 Richie’s 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, Ky.

The 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, five settlements occurred with harmed parties that “would probably never have resulted in a claim without voluntary disclosure to patients or families.” Yet the facility’s 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 blame—especially when the harmed party might not even know error occurred—the 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 norm.

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 facility’s yearly liability costs; happier, more satisfied people sue less.

It’s 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 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 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 warranted.

This essay first appeared in the Center for Ethics’ Spring 2001 Ethics News & Views and is reprinted with permission.