Bioethics of Reporting Intra-Operative Errors - Essay Example

Bioethics of Reporting Intra-Operative Errors Powerful forces are working to transform the US healthcare provision system. For instance, there are numerous ongoing public debates about sustainable healthcare financing as well as enhanced insurance coverage. Underneath it all, a subtler transformation process is ongoing. This change revolves around the issue of healthcare delivery and management systems. Such change not only involves health professional operations but also greater education research to foster desired learning outcomes. The goal of this change is to move forward the quality of healthcare. Quality improvement with regard to healthcare in the U.S. has borrowed heavily from reform methods successful in other industries. Quality improvement in the contemporary healthcare setting is essentially driven by the wide body research into medical errors. More so, the research studies have further revealed that there is an astonishing lack of professional consistency in the standards of care accorded to patients by different practitioners in different facilities. Quality improvement can be described as an innovative, interdisciplinary effort to change ingrained practices, attitudes and management paradigms which fail to address patient needs and those of their families. Through quality improvement initiatives, the healthcare systems within the US are beginning to show significant progress in standards of care. This change process also integrates knowledge sourced from diverse healthcare disciplines such as clinical and bedside care and healthcare management. This has created an enabling environment for different professions within the care-giving setting to collaborate thereby improving the current standards of medical service delivery. Focused and disciplined quality improvement efforts present favorable increases in the safety and effectiveness of standards in the healthcare system. More importantly, it seeks appraise professional sensitivity concerning the interests and rights of patients and more so, ethical responsibility by all players in the system. Prior to 2000, the aspect of ethics about quality improvement was not comprehensively addressed. It is also critical to point out that issues like the ethical values of disclosing medical errors were previously vaguely addressed. The ethical under consideration with respect to quality improvement in the healthcare sector include non-maleficence, beneficence and autonomy. As such, the bioethics of reporting intra-operative errors has been unsatisfactory in the past thus diminishing the general public’s confidence and trust in the entire healthcare industry in the country. This paper seeks to discuss means through which the reporting of intra operative errors is indeed a critical imperative that compels physicians to manifest practices, attitudes and management paradigms that reflect respect for patient autonomy. This will play a pivotal role in encouraging patients and their families and by extension, the general public in gaining trust as well as confidence in the services delivered by this particular industry. Medical Ethics The fiduciary nature of physician patient relationships supports that it’s a physician’s responsibility to ensure disclosure to a patient concerning a medical mistake. This fiduciary nature also conforms to the principles of patient autonomy, beneficence, justice and non-maleficence. The non-maleficence principle expressly states that the caregiver is solemnly responsible to ensure no harm affects a patient. The beneficence principle points out that physicians should always act in the interest of a patient’s health. This is the case regardless of the fact that the physician fails to benefit from doing everything possible towards ensuring optimum patient health outcomes. For instance, is during a medical procedure such as a surgery a medical instrument remains in the patient, the physician has to ensure the foreign matter is professionally removed and infection controlled. Such an action however, calls for the physician to ensure full disclosure and a subsequent apology to the patient. Regarding patient autonomy calls on physicians to ensure full disclosure where a mistake results in a patient suffering harm. According to Wu et al. (2007), full disclosure enables patients to become free from mistaken beliefs about their present, past or future medical conditions. This implies that even when a mistake is insignificant, disclosure can play a pivotal role in future medical interventions as he or she will be able to make informed decisions concerning their health. Respecting patient autonomy implies that medical professionals are ethically obligated to communicate incidence of medical error to patients. Adedeji, Sokol, Palser and McKneally, (2009) critically address the issue of ethics concerning reporting medical mistakes. By looking at issues about surgical complications, the authors describe medical errors as undesirable outcomes of a surgical procedure. Four primary medical ethics principles are discussed herein. They are in essence derived from four fundamental moral principles that are combined or used discretely to enable the medical profession to identify and consequently resolve arising ethical issues. As such, these principles are not considered as binding or hierarchically superior to each other. For instance, a surgeon or physician may opt to bypass prima facie obligations like seeking informed consent in situations requiring emergency surgery towards ensuring the health of a patient. The four basic principles which have been briefly described above are respect for a patient’s autonomy, beneficence, non-maleficence and justice. Autonomy relates to aspects of an individual’s freedom to reach decisions founded on personal values and beliefs. As such, a physician is expected to honor a capable patient’s considerate wishes and thus, avail information that serves to enable patients reach logical decisions. Beneficence appertains to a physician’s Hippocratic vow towards ensuring services offered to patients are offered while ensuring these clients’ best interests. It is important to note that the concept on individual perceptions as to harm and benefit and thus, encompasses respecting patient autonomy. The non-maleficence principle appertains to the moral endeavor to ensure no harm comes to a patient in a physician’s care. It, however, has to be related to the beneficence principle as it involves ensuring physicians partake all options possible to avoid patients suffering harm. The justice principle involves the commitment towards the fair distribution of scarce healthcare resources. It also positively relates with respect for the universally accepted human rights and legislation. It is from these 4 principles of ethics that more discrete rules and ethical standards are founded. Rules like respect for patient confidentiality, obtaining consent as well as avoiding deception are derivatives of the autonomy principle. The above stated principles cannot solve all ethical dilemmas in the medical profession conclusively. They, however, play a central role in creating fundamental moral considerations when systematically addressing the issue of medical errors. Respecting patient autonomy With reference to medical ethics, the primary autonomy related aspect appertains the prima facie obligation to acquire appropriate informed consent. Given that surgery is a medical procedure which is in essence a grave act of invasion to privacy, respecting patient autonomy is an issue held with high regard in the healthcare industry. This is especially the case as a patient is in most instances in an unconscious state, though for a temporary duration and as such, also results in short-term impairment. As Adedeji, Sokol, Palser and McKneally (2009) provide, a significant challenge associated with informed consent revolves about the issue of what amount of disclosure is sufficient to adequately satisfy consent conditions. According to Adedeji, Sokol, Palser and McKneally (2009), availing to much information to a patient may result in a situation where it compromises patient autonomy by disorienting a patient. There have also been some reported cases where divulging to much information to a patient concerning a medical procedure only results in refusals to go ahead with a proposed medical procedure. As such, this implies that a physician has to have desirable communication skills and judgement so as to balance the information which for a specific client can be discerned as beneficial. There are 3 central factors which determine the degree of disclosure concerning a medical error. These are the gravity of a complication, the probability of a similar complication to recur and the information preferences which may vary from one patient to another. In an effort to present a good balance of judgment when making disclosures, legislation in nations like the UK include a reasonable person standard. This standard provides physicians with information needed for disclosure towards considering the circumstantial needs for each specific patient. The standard also serves to incorporate a patient’s situation towards determining what such an individual would seek to know. This implies that a physician’s judgement is of critical significance when making informed consent decisions. It is only in the case of some very rare occasions where a patient prefers to decline all the possible information concerning a medical error. In such situations, it is common to find a patient delegating the power to ensure informed consent to the physician. With reference to medical standards practiced in the United Kingdom, in such rare occurrences, there is a prescribed process offering guidance as to what can be deemed as sufficient information for informed consent. The minimum information concerning informed consent is dependent on seriousness of medical procedure risks, the graveness of the medical condition and the dynamics of the situation at hand. These are some of the upsides of concerning medical ethics which serve to dispel any challenges that may result in a compromise to the doctor patient relationship. In some instances, a physician or surgeon for this matter, can encounter an unforeseen procedure intraoperatively. In such a situation, a surgeon will most definitely be in a quagmire as to where to gather explicit consent from. Such a situation may involve immediate action even where informed consent is absent. In such a situation, it is expected that the physician seeks the advice of a more experienced colleague. It is of critical importance to understand that it is impossible for a patient to be accorded information concerning all possible outcomes. It is often advised that general consent should be declared in an effort to pave way for problems that could arise during a surgical procedure. Alternatively, a physician can endeavor to employ a wider scope from consent to allow for patients to appoint a proxy. As such, the US healthcare system has sort to appraise it service delivery outcomes such that it is ethically irresponsible for a physician to lowly regard the seriousness of given surgical complication. More so, the medical associations within the US have worked out processes diminishing the probability of physicians terming a medical error as a surgical complication. There have been concerted effort towards integrating principles of quality improvement concerning the reporting of all medical mistakes regardless of severity. Openness and honesty are traits considered most desirable among healthcare professionals towards ensuring a patient’s autonomy remains highly regarded. Challenges to Full Disclosure Lo (2012) approximated that about 40,000 patients within the US die annually as a result of medical errors. One research study provided evidence that over 40% of Americans and about 35% of medical professionals reported errors during the provision of healthcare services to them or some other family member. The same study provided that in instances where a medical error was noted, only 30 % of similar cases was duly recounted to patients or family. The most common defense towards such outcomes is that most medical professionals deem it overly challenging to make known the occurrence of medical errors to colleagues and more so, patients is diminishing professional repute and malpractice lawsuits. Recrimination by affected patients is also cited as a reason for professional healthcare providers to fail to accurately report on medical errors. As such, it is widely accepted that patients seek more disclosure of medical errors than the healthcare professions typically offer. A medical error relates to an act or omission that culminates with the failure to complete a medical procedure as intended or applying the wrong procedure to achieve a specific end. A medical error may or may not cause harm to an effected patient and as such, some errors tend to be unavoidable. A close call or near miss relate to situations where an error does not result in harm occurring in a patient. Medical errors will in most instances result in unwanted patient outcomes resulting not from an underlying disease but from the process of offering medical care. Wu, Huang, Stokes and Pronovost (2009) state that all professional organizations, medical or otherwise are obligated to reveal errors which have the potential to affect the public good. Similarly. Professionals in the healthcare apparatus have to consider the issue of medical errors with a markedly higher degree of responsibility. Whether a medical error or an adverse outcome occurs during the process of health care provision, it is mandatory for professionals in this industry to disclose such information. Research studies offer evidence that full disclosure serves to appraise the patient physician relationship and by extension, diminishes a client’s need to sanction the professional. Given that there are a variety of medical error disclosure procedures, patients tend to gain a higher degree of confidence and trust in a professional’s efforts for full disclosure. The same case applies for physicians who take on an active role towards the disclosure of grave medical errors. In instances where patients get the perception that a physician failed in his or her duty to fully disclose the occurrence of a medical error in mostly results in malpractice lawsuits. In a research study led by Wu, Huang, Stokes and Pronovost (2009), a full apology followed up by accepting responsibility showed that patients tend to project more trust in physicians who did this. Interestingly, the research study also provided that such disclosure does not diminish the patient or patient’s family to pursue a legal discourse after such an event. More importantly, the study revealed that patient understanding of the communication from the physician was the dominant factor towards building trust and confidence as opposed to what a physician actually said. It is important to point out that Wu, Huang, Stokes and Pronovost (2009) found out that offering full disclosure and ignoring the presentation of an accompanying apology failed to have a similar effect. Failure to apologize was seen to result in negative judgement. This research study therefore provided vital information’s towards appraising confidence and trust in the US’ medical services industry. Wu, Huang, Stokes and Pronovost (2009) provide that it is important for physicians to work towards understand communication techniques. Such aspects as posture, sentence structure, wordings, demeanor, and so on, were critical to ensuring better outcomes in patient perception concerning information availed. Wu, Cavanaugh, McPhee, Lo and Micco (1997) point out that is common to encounter situations where medical professionals commit errors arise. As such, these are not only common but are expected to happen and arguably understandable within the medical profession. These authors provide that in some point in their career, a medical professional is bound to commit an error. The most disturbing aspect concerning the occurrence medical errors is the non-compliance towards making known such events to a patient or the immediate family. The fact that some of these outcomes have resulted in some high profile cases underscore the seriousness with which the American public regards the issue. In most instances, failure to appropriately report such medical mistakes in a timely manner is associated with attempts to cover up such a case. Wu et al., encourage physicians to consider reporting medical mistakes to patients and their families not based on detectability but out of respect for the professions and more so, clients overall wellbeing. Some medical mistakes can be medically corrected others cause irredeemable harm. Wu et al. (1997) conducted a study on the subject matter founded on the premise that physicians ought to feel obligated to disclose medical mistakes which a risk manager judges that the harm caused is remediable, compensable or litigable. However, there are few instance whereby physicians may not be expressly required to bypass reporting a medical error. One such instance involves a situation where disclosing such information to a patient could undermine autonomy. The other instance is whereby a patient expressly informs the physician that he or she would not want to be informed on any situation gone wrong in course of a medical procedure. According to Wu et al. (1997), two ethical standpoints guide a physician’s thought process towards medical error disclosure. One theory is consequentialism while the other is deontology. The consequentialist theory provides that the physician should act towards the best outcome. On the other hand, the deontology theory provides that a physician should ultimately seek to professionally fulfil duties as well as obligations. Advantages of Disclosure There are numerous ways in which a patient benefits from knowing that a medical error has occurred. The greatest benefit is that such disclosure enables affected patients or family members to within an appropriate timeframe remedy problems associated with the mistake. In accordance with the consequential theory, such an action translates to the prevention of further anguish to the patient. Some medical errors could require a patient to be put under a monitoring regime or more medical procedures to mitigate the consequences of a noted error. It is critical to understand that a patient can fail to appreciate the need of such remedial medical procedures if the patient is unaware of reasons necessitating such actions. More so, in instances where such remedial treatment is deemed as necessary, a physician has to ensure full disclosure to obtain consent. Failure to disclose the occurrence of an error can put him or her at the risk of misdiagnosis leading to inadequate or improper treatment. As Wu et al. (1997) underscore, disclosure also presents significant benefits to physicians. To begin with, the failure to appropriately inform patients or the immediate family of a medical error can result in compounded emotional distress. As such, a medical physician can only get emotional relief by doing the right thing that he is obligated to do. It can also translate to a lower chance of legal action by a patient or family. From a professional standpoint, disclosure of any medical mistake regardless of severity allows the physician to learn from such errors and improve his or her professional practice. Other than ensuring disclosure concerning patients, it has been noted that reporting medical mistakes to other physicians also benefits other physicians vicariously. As such, they can be able to institute measures that prevent similar mistakes from occurring within their profession. Disadvantages of Disclosure Patients may end up suffering harm upon learning that a medical error occurred when they had dedicated their care to a physician. Such knowledge may result in alarm, discouragement and anxiety. It may also result in the patients and families losing confidence, faith and trust in the medical profession. This can eventually lead to patients opting to decline medical interventions thus reducing quality of life. It is important to note that there may be some patients that do not embrace the need to understand everything concerning their medical care. To some, having such information only serves to increase complexities associated with their illness. In some instances, a physician’s well-meant disclosure of a medical mistake may result in a sense of confusion that may adversely affect a patient. As such, ethical principles require a physician to recognize therapeutic privilege but this should be interpreted narrowly so as not to compromise on informed consent (Wu et al., 1997). Similarly, disclosure can cause harm to a medical professional. It is not only a painful and challenging process but also may result in erratic emotions from patients which may severely stress physicians. Lawsuits and the risk of mal-practice premiums can be physiologically damaging to a physician thus increasing the chances of failure to admit to such errors. Gallagher, Mello, Levinson, Wynia, Sachdeva, Sulmasy, Truog, Conway, Mazor, Lembitz, Bell, Sokol-Hessner, Shapiro, Puopolo and Arnold (2013) provide that a general consensus has been attained concerning open and honest communication to victims of medical errors. However, physicians still project challenges in fully executing this medical responsibility. As Lo () provides, is situations where a physician is found to have clearly committed a medical error resulting in the patient suffering grievous harm, then it’s the medical professional err which resulted in such an outcome. Such circumstances dictate that the physician’s professional; responsibility over a patient should take precedence. Such an outcome is deemed as taking prevalence over any associated self-interest towards concealing a medical mistake. Quality improvement initiatives in the American health care sector provide that the medical practitioner or professional should own up to such a medical mistake and by extension, reveal to the patient, relevant medical information. Ethical and moral responsibilities of professionals with the US healthcare industry provide that a physician should begin by explicitly accepting and acknowledging the occurrence of a medical mistake. Subsequently, the said medical professional should endeavor to offer a credible apology for the adverse outcome. Secondly, the physician is expected to offer explanations as to situations leading to the medical mistake and all known consequences that could result thereof. As much as such reporting may not serve to absolve the physician from blame, it is a professional obligation expected of the physician to ensure patient autonomy is duly respected. By extension, it allows the medical physician as well as other fellow physicians to study causes of such error and work towards ensuring they do not recur in future. Thirdly, the physician is obligated to appropriately explain what should be put into action to mitigate adverse consequences that may be suffered by the patient and ensure that further negative incidences associated with the error do not arise. It is professionally and ethically unacceptable for a physician to offer narrow disclosures concerning errors. It is equally unacceptable that a physician offers an apology for mistakes realized without accepting responsibility for the adverse outcome. It common to find that in the event that a physician is observed as making a partial apology, the patient or the family may perceive it as a mean spirited or evasive action. In many instances, such outcomes result in the healthcare institution also suffering for such medical errors. In an effort to minimize the adverse eventualities concerning an institution’s public image, they take the ethical responsibility towards compensating affected patients. As such, a growing number of healthcare institutions opt to ensure that physicians working within their institutions openly and honestly to reveal medical error occurrences. It is also common to find that most healthcare institutions within the US to opt for early settlement for medical errors reported. As Gallagher et al. (2013) provide, the contemporary situation today is that complex groups in healthcare provision enterprise also deliver services to patients. On the same note, quality improvement endeavors have resulted in more emphasis on system breakdowns leading to medical errors. As such, there is the high probability that other healthcare provision experts in the different fields could have caused commissions or omissions leading to medical mistakes. Therefore, medical professionals within the American healthcare system have to look into a myriad of possibilities leading to a medical mistake. These include ascertaining whether a reported error actually occurred, examining how such an error occurred and ultimately, how to relay information concerning a medical mistake to a patient or his/her family. It is without a doubt that discussing an error by a colleague obviously results in the overall significance of reporting medical mistakes. It is also worthy to note that as Gallagher et al. (2013) provides, the healthcare industry’s healthcare organizations offer insufficient professional guidance concerning disclosure of medical errors by fellow colleagues. References Lo, B. (2012). Resolving ethical dilemmas: a guide for clinicians. Lippincott Williams & Wilkins. Wu, A. W., Huang, I. C., Stokes, S., & Pronovost, P. J. (2009). Disclosing medical errors to patients: it’s not what you say, it’s what they hear. Journal of general internal medicine, 24(9), 1012-1017. Adedeji, S., Sokol, D. K., Palser, T., & McKneally, M. (2009). Ethics of surgical complications. World journal of surgery, 33(4), 732. Gallagher, T. H. (2009). A 62-year-old woman with skin cancer who experienced wrong-site surgery: review of medical error. JAMA, 302(6), 669-677. Read More