To Tell the Truth Ethical and Practical Issues in Disclosing Medical Mistakes to Patients Albert W

JGIM PERSPECTIVES To Tell the Truth Ethical and Practical Issues in Disclosing Medical Mistakes to Patients Albert W. Wu, MD, MPH, Thomas A. Cavanaugh, PhD, Stephen J. McPhee, MD, Bernard Lo, MD, Guy P. Micco, MD While moonlighting in an emergency room, a resident risk management committee, rather than to the patient. physician evaluated a 35-year-old woman who was 6 More recently, the American College of Physicians Ethics months pregnant and complaining of a headache. The Manual states, “physicians should disclose to patients in- physician diagnosed a “mixed tension/sinus headache.” The patient returned to the ER 3 days later with an information about procedural and judgment errors made in tracerebral bleed, presumably related to eclampsia, and the course of care, if such information significantly affects died. the care of the patient.”6 The AMA’s Council on Ethical and Judicial Affairs states, “Situations occasionally occur in which a patient suffers significant medical complica- tions that may have resulted from the physician’s mistake rrare humanum est : “to err is human.” In medical or judgment. In these situations, the physician is ethically E practice, mistakes are common, expected, and under- required to inform the patient of all facts necessary to en- standable.1,2 Virtually all practicing physicians have sure understanding of what has occurred.”7 made mistakes, but physicians often do not tell patients In this article, we analyze the various ethical argu- or families about them.3,4 Even when a definite mistake ments for and against disclosing serious mistakes to pa- results in a serious injury, the patient often is not told. In tients. We also provide practical suggestions for how to one study, house officers reported telling their attending discuss the sensitive topic of mistakes with patients. physicians about serious medical mistakes only half the time, and telling the patients or families in less than a quarter of cases.3 Highly publicized cases of fatal mis- WHAT IS A MISTAKE? takes have heightened public and professional concerns We define a medical mistake as a commission or an about how physicians and hospitals respond to serious omission with potentially negative consequences for the mistakes. When mistakes are not acknowledged in a patient that would have been judged wrong by skilled and timely manner, there may be a perception of a cover-up, knowledgeable peers at the time it occurred, independent and public confidence in physicians may be undermined. of whether there were any negative consequences. This The American Medical Association’s (AMA’s) Princi- definition excludes the natural history of disease that ples of Medical Ethics (1957) states that a physician must does not respond to treatment and the foreseeable com- report an accident, injury, or bad result stemming from plications of a correctly performed procedure, as well as his or her treatment.5 However, many physicians inter- cases in which there is reasonable disagreement over pret these requirements to mean that they should report whether a mistake occurred. to their superiors or to the hospital quality assurance or We categorize errors according to their genesis. Sys- tem errors, also referred to as latent errors,2 derive primar- ily from flaws inherent in the system of medical practice. Received from the Department of Health Policy and Manage- In such errors, the system “sets up” individuals to make ment School of Hygiene and Public Health, and the Division of mistakes, i.e., through the unavailability of medical records, Internal Medicine, Department of Medicine, Johns Hopkins Uni- by confusing labeling of medications, and the like. When versity, Baltimore, Md. (AWW); the Department of Philosophy, a system error occurs, the physician shares responsibility University of San Francisco, Calif. (TAC); and the Division of with other elements of the health care delivery system. General Internal Medicine, Department of Medicine, University Conversely, individual errors are those deriving pri- of California, San Francisco (SJM, BL, GPM). marily from deficiencies in the physician’s own knowledge, Presented in part at “Examining Errors in Health Care: De- veloping a Prevention, Education and Research Agenda,” Octo- skill, or attentiveness. For instance, a physician mistak- ber 13–15, 1996, Rancho Mirage, Calif. enly prescribed a nonsteroidal anti-inflammatory agent to Address correspondence and reprint requests to Dr. Wu: a patient with renal insufficiency, resulting in perma- Health Services Research and Development Center, 624 North nently worsened renal failure.3 In such a case of individ- Broadway, Baltimore, MD 21205. ual error, the physician has primary responsibility. 770 JGIM Volume 12, December 1997 771 The considerations in the disclosure of latent errors fered a gastrointestinal bleed. Telling patients about such differ from those in the disclosure of individual errors. For mistakes may resolve their uncertainty about the cause of example, in a latent error, the physician is often one link their condition, possibly allowing them to feel better by in a chain of causes generating the error. Accordingly, the explaining that recurrence would be unlikely. disclosure of such an error may not be the sole responsi- Disclosure of a mistake also provides patients with bility of the physician. In what follows, we consider only information needed to make informed decisions. Patients the arguments for a physician to disclose his or her indi- may develop more realistic expectations about their doc- vidual error to a patient. We also restrict ourselves to mis- tors’ interventions.9 Acknowledgment of fallibility brings takes that cause significant harm, without regard to their uncertainties into the open, reduces the possibility of detectability. misunderstandings, and encourages the patient to take Errors causing harm can be subdivided into cases greater responsibility for his or her own care. that are not medically remediable and those that are med- In the case of an injury, knowing about a mistake ically remediable. We argue that the physician has an ob- may allow the patient to obtain compensation for lost ligation to disclose mistakes that cause significant harm, earnings or to pay for care necessitated by the injury,8 or which in the judgment of a risk manager or malpractice to at least get a bill written off. Such compensation might insurer is likely to be remediable, mitigable, or compen- be obtained through settlement rather than lawsuit; un- sable. Only in rare cases would a physician be permitted der the current system, obtaining such compensation not to disclose a mistake causing harm to the patient. would be difficult or impossible without disclosure of the Specifically, physicians might be permitted not to tell if mistake. they have good reason to believe that disclosure would Finally, disclosure of a mistake can promote trust in undermine the patient’s autonomy in some way (e.g., in- physicians. Patients have a presumption of truth-telling.10 capacitate the already severely depressed patient). Or the Thus, a patient who is not informed of a mistake may feel patient might have told the doctor explicitly, “Doctor, if angry and betrayed11; the patient may think that a privi- anything goes wrong, I don’t want to know about it.” leged relationship has been violated.12 Two ethical theories assist in thinking about the disclosing of a mistake: consequentialism and deontology. A Potential Harms of Disclosure to the Patient consequentialist ethical theory holds that one ought to do that act which will realize the best overall consequences. Patients may be harmed by learning that a mistake A deontological theory maintains that one ought to do was made in their care. The knowledge may cause alarm, that act by which one fulfills one’s duties or obligations. anxiety, and discouragement. It may destroy patients’ Both consequentialist and deontological theories ground faith and confidence in the physician’s ability to help arguments for disclosure. In what follows, we first con- them. Patients may become disillusioned with the medical sider arguments based on consequences; then, we attend profession in general. This may cause them to decline to arguments based on a physician’s duties. beneficial treatments, or decrease their adherence to beneficial treatment regimens or habits.8 Not all patients want to know everything about their POTENTIAL BENEFITS AND HARMS medical care. Some would rather not be burdened with OF DISCLOSURE the complexities of their illness. The well-meaning disclo- Potential Benefits of Disclosure to the Patient sure of potentially serious, but inconsequential mistakes may cause unwelcome confusion. In such cases, patients The patient could benefit in many ways from knowing may feel they would be better off not knowing that a mis- that a mistake had occurred. Such knowledge would al- take had been made in their care. As the American College low the patient to obtain timely and appropriate treat- of Physicians Ethics Manual states, “society recognizes the ment to correct problems resulting from the mistake. Dis- ‘therapeutic privilege,’ which is an exemption from de- closure therefore can prevent further harm to the patient. tailed disclosure when such disclosure has a high likeli- In some situations, close monitoring or a medical proce- hood of causing serious and irreversible harm to the pa- dure may be necessary to mitigate the consequences of a tient.” However, the American College of Physicians offers mistake. Patients

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