Ethics

You made a "technical" error. Should you tell your patient?

A mistake can come back to bite you — or not.
A surgeon's struggle to do the right thing

By Mark Bernstein, MD

THE DILEMMA
A colleague recently asked for my advice. He was in a quandary about whether he should disclose a medical error to the family of one of his patients. He knew of my interest in bioethics and confided to me that he had performed a complex operation on a young patient and that a "technical" error had transpired during the surgery. The mistake had been recognized shortly after it happened but could not be rectified without risking serious injury. The overwhelming likelihood was that there would be no negative sequelae from the mistake, but there was, at least in his mind, a very small chance of a serious complication that might arise several months after surgery. My colleague had not slept the night after the operation, lying awake tossing and turning and wondering what he should do.

THE DELIBERATION
On the surface it seems the right thing to do would be to divulge the mistake to the parents without ascribing blame, while reassuring them that the error had a very low likelihood of hurting their son. It would be disrespectful not to disclose it. After all, wouldn't most reasonable people want to know? Wouldn't duty- based or deontological theory dictate that the surgeon was morally bound by a sense of duty and obligation to inform them of the truth? Wouldn't it be at minimum paternalistic and, at worst, a form of lying not to tell them?

On the other hand, the unintended mistake was very unlikely to produce any ill-effect and it could be argued that informing the parents would only add unnecessarily to their burden of anxiety and suffering. Wouldn't the surgeon's informing them of the error simply be a way for him to assuage his conscience at their expense? Also, why should the physician take on unnecessary grief by telling them — after all, the mistake was an accident? The utilitarian or consequentialist ethical approach dictates that the morally correct act is the one that produces the best outcome or the least harm for the greatest number of people. So, why not spare everyone from needless anguish by not telling them?

I heard his voice tremble as he told me of his dilemma and I was impressed by his trust in confiding this tale to a colleague; it's not as if we were close friends. I advised him to disclose the error while being certain to reassure the parents that their son's outcome was not at all likely to be negatively affected by the mistake. The guiding tenet for doctors is respect for patients and to not tell them just seemed dishonest and disrespectful. There were also important practical implications — if the unlikely but serious complication did arise months later, then he would inevitably have to divulge the mistake. The family would then suffer the added tragedy of knowing they had been deceived by someone to whom they had entrusted the life of their precious child. This would only deepen their emotional and psychological scar and add to their anger and the degree of vehemence with which they would seek reprisal.

THE DECISION
After our conversation he told me that he had already made up his mind to disclose the error but felt more comfortable having his decision validated — especially since a few other colleagues had advised him against disclosure.

Accompanied by the charge nurse, he went to the patient's bedside and informed the family of the error. He told me later that it was the most emotionally exhausting conversation he had ever had. But he felt better. He had shown that he was an honest and conscientious surgeon who was worthy of trust.

There may be short-term pain, but we must resist the temptation to take the easier route. Major medical errors should be disclosed to patients promptly and in a straightforward manner. It's the right thing to do.