After Harm: Medical Error and the Ethics of Forgiveness

4. Disclosure

c h a p t e r f o u r Disclosure There is basic intellectual agreement within the medical profession that telling patients the truth, including the truth about medical mistakes, constitutes a professional obligation for physicians. Since 1981, the Code of Medical Ethics of the American Medical Association (AMA) has included the following ethical opinion on truth telling: It is a fundamental ethical requirement that a physician should at all times deal honestly and openly with patients. Patients have a right to know their past and present medical status and to be free of any mistaken beliefs concerning their conditions. Situations occasionally occur in which a patient suffers significant medical complications that may have resulted from the physician’s mistake or judgment. In these situations, the physician is ethically required to inform the patient of all the facts necessary to ensure understanding of what has occurred. Only through full disclosure is a patient able to make informed decisions regarding future medical care. . . . Concern regarding legal liability which might result following truthful disclosure should not affect the physician’s honesty with a patient.∞ Disclosure 41 Yet the nature of the practice of disclosure—what is meant by the phrase ‘‘telling the truth’’ in cases of medical error—continues to be among the most highly contested and emotionally fraught issues within conversations on patient safety in the United States and other developed nations. According to researchers who have closely examined physicians’ attitudes toward disclosure, because physicians know that ‘‘truth telling has been the standard [of their profession] for many years,’’ most will, if asked, ‘‘declare that they are always truthful with their patients.’’≤ These same physicians ‘‘may or may not’’ include the disclosure of medical mistakes as relevant to their own practice of truth telling.≥ The reasons for failing to disclose may depend, as philosopher Sissela Bok has argued in another context, on how one defines ‘‘truth telling’’ conceptually, or, as examples in the literature on medical error suggest, on self-deception or fear.∂ If physicians understand telling the truth narrowly as ‘‘not lying,’’ when patients do not ask and physicians do not tell them about errors, physicians have not ‘‘lied’’ and there has been no breach of the truth-telling obligation. Some physicians may not be able to admit that they are capable of making errors, and so tell themselves and others that there was a ‘‘complication’’ or that the patient was ‘‘noncompliant.’’ Or they do not investigate the possibility of error and take refuge in ‘‘not knowing ’’ what happened—and thus have nothing to disclose. Finally, fear is often at the root of failure to disclose: If I disclose an error, the patient will sue me, ergo, I will not disclose errors.∑ Medical educators are familiar with the ways in which the hidden curriculum, discussed in chapter 2, teaches students and residents how to think and talk about their own mistakes and those of their colleagues. Observing more senior physicians, students learn that their mentors and supervisors believe in, practice , and reward the concealment of errors. They learn how to talk about unanticipated outcomes until a ‘‘mistake’’ morphs into a ‘‘complication.’’ Above all, they learn not to tell the patient anything. Given the depth of physicians’ resistance to disclosure and the lengths to which some will go to justify the habit of nondisclosure—it was only a technical error, things just happen, the patient won’t understand, the patient does not need to know—there is a pressing need for fresh conceptual tools that can help physicians confront and change deeply entrenched beliefs, fears, and practices, and to weigh their moral and professional obligations, including their obligations to the next generation of physicians , against their terror of being found out, humiliated, and destroyed. The preceding three chapters proposed ways to use personal narratives about medical mistakes as tools for exploring physicians’ obligations and patients’ and families’ 42 After Harm expectations in the aftermath of medical harm. This chapter will explore a littleknown essay by Dietrich Bonhoeffer, together with the historical circumstances of this essay’s composition, as a text on disclosure, and suggest how the text may constitute a further resource both for understanding what is meant by telling the truth and for overcoming the powerful temptation to avoid doing so. The Text in Context In a letter to his friend Eberhard Bethge in mid-November 1943, Dietrich Bonhoeffer writes that he has drafted...