Truth Telling Nondisclosure and Disclosing Medical Error by alicejenny

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									  Truth Telling, Nondisclosure, and
     Disclosing Medical Error:
    Bad Outcomes vs. Bad Work


Three angles:

  Telling the truth to our patients
  about their condition.
  Informing our patients when we
  commit medical errors.
  The distinction between bad
  outcomes and bad work. Also, the
  problem of what do to when we
  discover bad work on the part of a
  dental colleague.


     Telling the Truth to Patients
Consider the case from last time when
the dentist discovered the lesion on the
patient’s tongue. He informed the patient
that this was generally symptomatic of
an autoimmune deficiency. Should he
have gone that far? The patient
immediately inferred that the dentist was
talking about AIDS. The dentist went so
far as to tell him that it was LIKELY to
be HIV related. We didn’t question that
last time, but I want to now. Should he
have told the truth to that degree?

The traditional argument regarding
disclosure:

  Departures from the general
  principle of truth telling are justified
  when information disclosure itself
  carries serious risks for patients.
  Truth telling is limited by the
  more ultimate principle of
  nonmaleficence. If disclosing the
  truth will ultimately harm the patient,
  then the practitioner is justified in
  withholding that truth.
  It is held that when the risk from
  nondisclosure is small, and the risk
  from disclosure is large, then we
  should withhold.
  Those who hold this position will
  distinguish between our duties not to
  lie or deceive (which is one thing)
  with the duty to disclose (which is
  another).

But, most will argue today that there is a
strong duty of veracity in medicine due
to the more recent emphasis on
autonomy, of respect for persons. Can
we reconcile our duty to veracity with
justified nondisclosure? Not an easy
question.

Telling the Truth to Patients: A Clinical
           Ethics Exploration
           David Thomasma

Thomasma outlines three big reasons for
telling the truth:

  Respect for persons demands it.
  Kantian considerations.
  It allows for proper decision
  making. Utility considerations.
  It’s a kindness to be told the truth.
  Virtue considerations.

Clearly when we are incapacitated (no
longer autonomous) then the truth isn’t
necessary—we can’t act! He calls this
“necessary paternalism.” Among
autonomous people, there could be times
that other principles will outweigh the
prima facie principle of veracity--
“temporary trump cards.”

    The goal of all healthcare: to
receive/provide help for an
illness/condition such that no further
harm comes to the patient, especially in
that patient’s vulnerable state. The
vulnerable person, who has come to your
for help, should be assisted back to a
state of human equality, if possible, free
of that dependency. Dependency
compromises autonomy. Thus:

  The goal of the relation between
  the healthcare giver and the patient is
  essentially to restore the patient’s
  autonomy. Respect for the patient’s
  right to truth is measured against this
 goal. Tell if it helps, withhold if it
 hinders.
 Interventionist healthcare
 relationships are generally temporary
 and require a greater degree of
 veracity than long term relationships.
 Compassion is more likely to grow
 out of the long term relation, and
 compassion may require temporary
 withholding of information.
 The goal of healthcare is the
 treatment of an illness or condition.
 An illness is broader than a disease,
 as it can include the whole person.
 Helping someone through an illness
 is a greater task than simply treating a
 disease or condition. Again, that may
 require the withholding of certain
 information.
Conclude this article with the four points
at the end, page 152.

            To Tell the Truth
               Wu, et al.

To err is human. In medical/dental
practice, mistakes are common,
expected, and understandable. When do
we tell?

What is a mistake? Our authors define it:

  A commission or an omission
  with potentially negative
  consequences for the patient that
  would have been judged wrong by
  skilled and knowledgeable peers at
  the time it occurred, independent of
  whether there were any negative
  consequences.
We distinguish between systemic errors,
for which the doctor may share
responsibility, and individual errors, for
which the practitioner has primary
responsibility.

We also distinguish between errors that
are remedial (the damage can be
repaired) and those that are not (as a
result, the tooth must be extracted). The
authors argue that disclosure is an
obligation for any cases of significant
harm, and that it is rarely excusable not
to disclose. Those cases are limited to
cases in which, in the good judgment of
the practitioner, disclosure would
undermine the patient’s autonomy in
some way.

Consequentialist considerations:
   Potential Benefits to the Patient

 Disclosure is essential to future
 informed consent. The uninformed
 patient may be at risk of future
 misdiagnosis.
 The uninformed patient may
 worry needlessly about the potential
 side effects of a medical mistake.
 Knowing about the mistake may
 allow the patient to obtain
 compensation for lost wages or to pay
 for needed follow up care.
 Disclosure promotes trust in
 medical practitioners.


   Potential Harms to the Patient
 May destroy the patient’s faith in
 the medical profession
 May cause stress and anxiety
 The disclosure of inconsequential
 mistakes may cause unwelcome
 confusion. Some patients may feel as
 if they would have been better off not
 knowing.

 Potential Benefits to the Physician

 The practitioner may be relieved
 getting the mistake “off my chest.”
 In a serious mistake, the patient or
 a family member may be the only
 ones able to forgive the mistake.
 Many patients appreciate honesty
 on the part of the doctor.
 Candid disclosure may (and has
 been shown to!) decrease the
 likelihood of legal liability.
  Disclosing mistakes can help us
  learn and improve our practices.

     Potential Harms to the Physician

  It hurts to admit a mistake.
  Admitting a mistake may expose one
  to a legal suit.
  Disclosure may result in loss of
  referrals, preferred provider status,
  etc.



Duty considerations:

    This one is relatively simple. The
fiduciary relationship between doctor
and patient demands disclosure. All of
the principles point to it. If the patient is
harmed, the patient has a right to know it
so that the patient can make an informed
decision about the appropriate course of
action. Remember nonmaleficence: first,
do no harm. A caregiver has a grave
responsibility to avoid harming the
patient. This principle and
professionalism enjoin the doctor to act
for the best interests of the patient,
EVEN IF the doctor’s own professional
or financial well-being is not benefitted
by so acting. Remember autonomy:
disclosure is necessary to preserve
patient autonomy.

      Practical Issues in Disclosure

  Deciding whether to disclose:
  who should decide? Probably not the
  individual who made the mistake. Get
  a second opinion.
  Timing of disclosure: make sure
  the patient is stable enough to handle
  the disclosure.
  Who should disclose? In the case
  of dentist, generally the dentist
  her/him self.
  Incompetent patients: Depending
  upon the degree of competence, one
  of diminished competence can still
  appreciate an apology. As would the
  family.

Evidence is becoming strong that
disclosing mistakes actually reduces the
risk of litigation. Imagine the mistake
coming to light later. That is when the
possibility of litigation becomes very
real.


 Part III: Bad Work or Bad Outcomes?
    First, we want to make a clear
distinction between bad outcomes and
bad work. The former is a possibility in
any dental procedure. There are quite
simply too many factors involved in this
process to claim that any bad outcome is
the result of bad work. Some teeth
simply cannot be saved! Any practicing
dentist will tell you this.
    Let’s imagine that you are an
endodontist and you have a referral for a
root canal. You notice that the work done
on the patient doesn’t look so good.
Consider the three possibilities: 1) you
judge that this bad outcome is not the
product of bad work. 2) The question of
bad work cannot be resolved with the
available evidence or from the patient’s
reports. 3) On the basis of the evidence,
this is clearly a case of bad work. What
do you do?
    First duty: The ADA principles
clearly state that you are obligated in all
of the circumstances to inform the
patient of his or her “present oral health
status” (4-C). Doesn’t this require that
we divulge that the patient has a “bad
outcome”? Notice the complexity of this
situation: You do have co-professional
obligations to the first dentist, but you
also have obligations with the patient—
he or she is now your patient also. Which
comes first, your obligation to your
colleagues or your obligation to the
profession as a self-regulating profession
and to society as a professional? What do
you tell the patient about the first
dentist? Do you report to the state
regulating board?

								
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