To err is ethical?

By Deborah Bowman

THIS morning I was cornered by a colleague. Had I drafted the job description we’d discussed earlier in the week? I looked blank, then embarrassed and finally apologetic. No, I hadn’t done as I had promised. In fact, I had forgotten I had ever promised it in the first place, despite making a note on a growing ‘to do’ list. I was fortunate. Drafting a job description in an academic department is not the sort of error that impacts on human life (although it probably did little for the stress levels of my colleague). In medicine and dentistry, readers will not need reminding that mistakes hover like a professional sword of Damocles over all practitioners.

If error is inevitable, the ways in which we conceptualise error is not. For a long time, the medical profession, in particular, has been criticised for the ways in which it responds to error. Last month, the website TED posted a talk by Dr Bryan Goldman, a Canadian physician specialising in emergency medicine, in which he described his own experiences of medical error during his career and argued that the profession continues to be poor at being truthful about its mistakes. Dr Goldman’s talk has been viewed 299,561 times since it was posted. This week, Professor James Reason presented a programme on Radio 4 – Doctor, Tell Me the Truth – that looked at the ways in which a culture of ‘deny and defend’ has evolved and more open approaches to clinical error are emerging. It is available on iPlayer and is highly recommended.

The ways in which clinicians understand and respond to error are ethical judgements. The conceptualisation of what constitutes a mistake has a moral dimension. About a decade ago, I conducted research in which I asked general practitioners about error. It was a thought-provoking and often moving experience. I have been fortunate to be involved in many fascinating projects, but that work remains amongst the most memorable. As GPs shared their experiences, I learned that the ways in which error was understood varied considerably. For some, an error was about demonstrably poor outcome. Others included near misses and disasters averted, often by luck rather than design, when talking about mistakes. Finally, there were those who felt that the term error encompassed more than that which was easily measurable including, for example, poor communication and breakdowns in the doctor-patient relationship. What does it mean to you to make an error?

I heard about the burden on those who make a mistake. Emotions ran high in many of the interviews and even recollections of events that happened many years ago were often vivid and haunting. We rightly talk about the moral obligations owed to the patient or family following clinical error but we tend to pay little attention to supporting the person who erred. Critical and significant event analyses, if well-facilitated, may have the potential to support the clinician, but the ways in which individuals spoke about such processes and formal debriefing suggested that, in practice, they provide little in the way of support. Caring for those who have made mistakes does not equate to a closed cover-up or a defensive approach to error. Rather it acknowledges that error affects clinicians too and that there is a duty to ensure that professionals are themselves well enough to continue to practise safely and with confidence.

Finally, there was considerable difference of opinion about the extent to which error should be admitted and shared with patients and families. Where it was clear that things had gone awry and there was a defined process within which to meet patients and families, disclosure was seen as inevitable, if not always welcome. Yet, where patients were perhaps unaware that an error had occurred or there was pressure from colleagues to cover up, or at least remain silent, about a mistake, there was little appetite for candour. Perhaps it is these sorts of findings that inform the campaign for the law to be changed to establish a statutory ‘duty of candour’. How might such legislative change affect your practice? Are there mistakes that you have not shared with patients?

It would be misguided to believe that legislation will address the ethical challenges of putting someone else’s interests before one’s own personal and professional interests. To do so is difficult, painful and frightening. It is also a challenge that will face every single clinician at some stage in his or her career. Unless and until that is acknowledged, all the patient safety initiatives, clinical risk seminars, policy documents, legal reform and compulsory training will be of limited effect. A duty of candour should perhaps begin with honesty about the inevitability and complexity of clinical error. That is the ethical challenge for us all.

Deborah Bowman is Professor of Bioethics, Clinical Ethics and Medical Law at St George’s, University of London