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Moral courage is therefore needed if doctors are to do the right thing when medical errors occur. This moral courage can be facilitated by institutions having policies and guidelines on disclosure of errors in place, training doctors and other hospital staff on how to disclose medical errors and providing emotional support for doctors who make mistakes in their efforts to treat patients and save lives. Humans are fallible and as such they will make mistakes in their lives and work be they builders, bankers or doctors. Of these events, an estimated caused patients serious harm, while between 44 and 98 led to death in hospitals in the United States.

According to this report, more people die annually from preventable adverse events related to healthcare than from motor vehicle accidents 43 , breast cancer 42 , or AIDS 16 in the United States. This grim report indicates how common it is for medical practitioners to make errors in their day to day clinical practice.

Although medical errors will likely continue as long as clinicians remain fallible humans, it does not mean that it should be accepted as a matter of fact. The cultural change in acceptable medical behaviour from a paternalistic stand of not wanting to upset the patient to that of open discussion makes it imperative that doctors tell their patients the truth since deception in medical practice is no longer acceptable.

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This change is supported by the fact that the codes of ethics of most medical associations address disclosure of errors and incompetence. Such ethical requirement is supported by both deontological and consequentialist perspectives. Although most doctors do believe that errors should be disclosed to patients when they occur, in reality, most doctors and institutions do not disclose such mishaps to patients and their families.

This is supported by evidence in the literature that doctors disclose errors to patients in less than half of instances when a serious error occurs. The doctor-patient relationship, unlike an arms-length transaction, is a fiduciary relationship. The principle of respect for autonomy is more than not interfering in others affairs, according to Beauchamp and Childress.

It includes, at least in some contexts, obligations to build up or maintain others' capacities for autonomous choice while helping to allay fears and other conditions that destroy or disrupt their autonomous actions. Respect, on this account, involves acknowledging decision-making rights and enabling persons to act autonomously, whereas disrespect for autonomy involves attitudes and actions that ignore, insult or demean others' rights of autonomy.

Autonomy which protects patient self determination goes hand in hand with truth telling.

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Non-disclosure of medical errors to patients therefore ignores, insults and demeans their rights of autonomy. In addition, deceiving patients interferes with the doctrine of informed consent since patients may not understand the reason or need for additional interventions or a longer hospital stay that becomes necessary as a means of rectifying an undisclosed error.

It is therefore important to disclose errors in order to respect autonomy and facilitate the giving of informed consent. Although an error may harm a patient, failure to disclose the error to the patient makes the situation worse. A patient may worry needlessly about his or her prolonged stay or worsening condition thinking it is a result of the underlying disease. Knowing that what is happening is a result of an error that occurred may prevent this psychological distress from impacting negatively on the patient's condition.

Rather than adding insult to injury, the doctor can subtract insult from injury by doing whatever is necessary to prevent further harm to the patient.

Introduction Bioethics in Court

Such legitimate interests include the prevention and removal of harms. Failing to disclose a medical error that has occurred to a patient and letting the patient assume that what he or she is going through is due to the disease is unkind and violates the principle of beneficence. On the other hand, the patient's knowledge and understanding that a mistake or error has occurred may relieve anxiety about slow recovery or complications and will certainly bring benefits.

The principle of justice therefore dictates disclosure of an error in order to ensure compensation to patients. Patients may be owed compensation for increased health care costs or lost wages in addition to an apology, which nearly all patients demand as the minimum. Obligations of fidelity in medical practice can best be understood as norms that specify the moral principles discussed above, in particular, those of autonomy and justice. However, since most patients want to know about even minor errors, 6 claiming that nondisclosure protects patients is false. Given that the heart of the doctor-patient relationship is honest communication, deceiving patients not only undermines the veracity of the individual doctor; it also casts serious doubt on the trustworthiness of the medical profession as a whole.

These arguments show that disclosure of medical errors to patients is justified on moral grounds and upholds principles of autonomy, nonmaleficence, beneficence, justice and fidelity that are fundamental to the fiduciary nature of the doctor-patient relationship.

Although several reasons such as legal liability, patient distress, and loss of reputation and privileges as well as license revocation among others have been cited as reasons why doctors fail to disclose errors to patients, 13 these do not justify the non-disclosure of errors to patients. It must be rational to favour everyone being allowed to violate the rule in these circumstances. A violation is justified only if it is rational to favour that violation even if everyone knows that this kind of violation is allowed. Since deception of patients in the form of non-disclosure of medical errors does not satisfy any of the above conditions, it is an unjustified violation of an important moral rule.

Doctors get sued when things go wrong or outcomes are unexpected. In as much as bad outcomes and medical errors are some of the reasons why patients may seek a legal redress, there is evidence to the fact that poor communication after an error has occurred is a very significant factor in malpractice litigation.

This is embodied in one lawyer's observation: In over 25 years of representing both doctors and patients, it became apparent that a large percentage of patient dissatisfaction was generated by doctor attitude and denial, rather than the negligence itself. In fact, my experience has been that close to half of malpractice cases could have been avoided through disclosure or apology but instead were relegated to litigation. What the majority of patients really wanted was simply an honest explanation of what happened, and if appropriate, an apology.

Unfortunately, when they were not only offered neither but were rejected as well, they felt doubly wronged and then sought legal counsel. Although malpractice litigation aims at getting compensation for patients who have been injured as a result of negligence, a concept which is supported by the principle of justice, it also has the effect of inhibiting the disclosure of medical errors.

The question that needs answering is whether disclosure pacifies potential litigants or leads to a surge in litigation. Despite the fact that there are no definitive studies evaluating the effect of disclosure on litigation, there are indicators to the fact that communicating openly with patients decreases the claims and compensations sought by patients. The Veterans Hospital of Lexington, Kentucky, for instance, reported reduced liability payments compared with comparable facilities after instituting a full disclosure policy.

In addition, the time from opening to closing of a case decreased markedly from 3 years to 1 year. Another reason why doctors refrain from disclosing errors to patients is causing patients distress. The argument is that patients are more likely to become distressed to the point of becoming irrational or being severely damaged psychologically when they get to know about the errors that have occurred, rather than if they had remained ignorant of such errors. As such, they may be unable to make the appropriate decisions regarding their care.

The doctor is therefore able to uphold the ethical principles of nonmaleficence and beneficence instead of violating them.

This argument, however, is untenable. The fact that patients may be distressed on being told about medical errors does not justify keeping such information from them. It is natural for patients to get upset when preventable errors occur during their care but that does not mean that their ability to make rational decisions is impaired.

In any case, emotional factors do not necessarily impair an individual's decision making ability. Thus, they tend to equate upset with harm. A lack of appreciation on the part of some doctors about the usefulness of patients' emotional states may also cause them to overlook the positive aspects of disclosure. However, when information is sensitively disclosed to patients, it may actually prevent the psychological harm that has been readily used by doctors as an excuse to withhold information from patients.

Introduction Bioethics in Court - Ben A. Rich,

In addition, there is evidence to the fact that informing patients truthfully and compassionately about errors does not result in an increase in their distress. While patients indicated they would be less upset if the disclosure was done honestly and compassionately with an apology, they also indicated that their distress would be increased with error explanations that were evasive or incomplete. What increases patient distress is evasive or incomplete disclosure and not honest and compassionate disclosure of medical errors. Medicine with its tradition of handling errors by assigning blame contributes to the tendency by doctors to not disclose errors when they occur.

Doctors are rightly concerned about whether the benefits of disclosing errors to patients are worth the risks they may experience.

In particular, nobody wants to lose their livelihood if it can be avoided. Thus although the temptation to protect one's reputation may be high, it is worth remembering that the doctor will likely find himself or herself in a worse situation when the patient eventually gets to know that not only was an error made, but insult was added to injury by the doctor failing to disclose this error. In addition, the medical profession and society at large need to accept and recognize mistakes as unavoidable, albeit, unfortunate part of clinical practice.

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As such, the right measures in dealing with such errors must be instituted. With the proper guidelines in place regarding what doctors must do when an error occurs, training doctors in how to disclose medical errors as well as the proper structures for emotional support in place for doctors who make mistakes, 4 a lot more doctors would be willing to disclose errors when they occur.

Strange Bedfellows: How Medical Jurisprudence Has Influenced Medical Ethics and Medical Practice

Medical errors will continue to be an unfortunate but unavoidable aspect of medical practice. While many doctors under the guise of concern for patient welfare do not disclose medical error, such behaviour is not ethically justified. The fiduciary nature of the doctor-patient is such that the doctor is ethically obligated to disclose medical errors to patients. The principle of respect for autonomy directs the doctor to disclose errors to patients since it gives patients an insight into what is going on.