truthtelling and error martin mckneally department of surgery and joint centre for bioethics...

Truthtellingand Error

Martin McKneally

Department of Surgery and

Joint Centre for Bioethics

University of Toronto

Principles of Surgery

November 2009

Ethics….What’s an Ethic?

• A set of values, principles, and beliefs, standards of conduct

• Guides the behaviour of a specified group – journalists, lawyers, monks, physicians, surgeons.

• “What we should do”

Ethics

Policy Lawusually must

should

Ethic of Surgery

Trustworthiness:

Competence

Commitment

Surgical CompetenceKnowledge timely and appropriate

Judgment balanced attentive to the particular needs and circumstances of an individual patient the right operation for the right patient at the right time

Skill sufficient to perform the surgical intervention minimum of risk

high probability of benefit

Trustworthiness: Living up to Obligations

Fiduciary: what is best for the patient

Professional: competence, commitment

Team: integrity, coworker care

Commitment

Constancy – warrior energy

Personal responsibility - unique

The Case: “Don’t Tell My Husband…”

Gwen Jones is the wife of a man who has been diagnosed as having inoperable pancreatic cancer. The patient is terminally ill, and is still in hospital. Both the wife (who is currently completing her PhD) and the patient’s father (who is a medical doctor) do not want you to tell the patient his diagnosis or the fact that he is dying.

Questions:

1. Is this a realistic situation?

2. Should we tell the truth?

3. What are the reasons that we ought to tell the truth?

4. Are there arguments for withholding the truth?

5. What is the best resolution?

Should we tell?

Yes• Rights• Will find out • Loss of trust• Affairs in order• Consent for treatment

No• Harm from

disclosure• Violates family

relationship• Violates cultural

norms

Management

Offer the opportunity

Mistakes / Adverse Events

Complication - worsening caused by disease or treatment

Error - wandering from the path

Incompetence - failure to meet accepted standards

Should I tell the patient?Con: Patient may worry about all aspects of care

-may avoid necessary care

-may become confrontational

Physician may suffer emotional distress,

remorse, guilt, inadequacy

-Punitive colleagues and supervisors

-Damage to reputation, career, privileges, license

-Lawsuit

Should I tell the patient?

Pro: Patient may benefit from knowing

-may be harmed by reliance on misrepresentation

-has a right to know

-implied contract to reveal findings

-compensation may be needed/justified

Should I tell the patient?

Pro: Physicians’ sense of integrity maintained

Strengthens trust in DPR through honesty

Natural response to say “I’m sorry”

Blocking response exacerbates guilt

Liability greater if negligence is concealed

Ethical Foundationfor Disclosure of Error

Truthtelling

Promise keeping

Respect for autonomy

Justice

How to do it?

Forewarn – this is a tough problem

“We’re in this together.”

“Here’s what I’ll be worried about.”

End on a positive note – “Here’s how we minimize the risks”

How to do it?

Disclosure: Tell what happened

Apology: Say I’m sorry

Remedy: Explain what can be done

Provide compensation

Practice Insurance

Prevention: Show how it will be prevented in the future

Atul’s Case

Ethics talks for R1, R2

1. Truth Telling2. Ethics of Innovation3. “Don’t transfuse my daughter” –

Religious Issues4. Surgical Competence5. Doctor Patient Relationships6. Conflict of Interest7. Resource Allocation8. End of Life

Ethics

Policy Law

ReligionCulture

Next: “Don’t transfuse my daughter”

Religious and Cultural Issues

martin.mckneally@utoronto.ca

phone: 416-223-7609

Acknowledgements

Paintings by Joe Wilder

Slides by Deborah McKneally, The Ravine Research and Education Centre

Your Cases

Ethics Research

• Courses at JCB

• Daar – biotechnology

• McKneally – innovation

• Bernstein – error

Ethics Education• Principles of Surgery: R1, R2

RSPSC Curriculum

• Research Ethics Day: Surgeon Scientists June 2, 2006

• Clinical Ethics Day: any interested residentJune 1, 2005

• Case conferences: Senior Residents

• www.rcpsc.medical.org/english/ethics• www.utoronto.ca/jcb

Graded Responsibility• Resident (adj.) a resident surgeon resides in

the hospital to provide on site care & emergency treatment

• Residents are responsible for the procedures performed at their level of proficiency

Graded Responsibility in Operative Surgery

U of T Dept of Surgery

Graded Responsibility• Residents are expected to be able to operate

as independent specialists at the completion of their training.

• Staff surgeons are expected to supervise the independent operative experience of

residents according to their level of proficiency.

Graded Responsibility in Operative Surgery

U of T Dept of Surgery

Trust: Reliance on others’ competence and willingness to look after rather than harm things one cares about.

Annette Baier

Trust provides an alternative to vigilance and rational calculation of risks, benefits, and alternatives.

Annette Baier

Disclosure policy

CMPA

JCAHO

Dana Farber

US VAMC

SWCHSC