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
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