BY: SR. JULIANA M. CASEY, IHM, STD, PhD, and RICHARD F. AFABLE, MD, MPH
Sr. Juliana is executive vice president, mission integration, and Dr. Afable
is executive vice president and chief medical officer, Catholic Health East,
Newtown Square, PA.
In recent years, increased vigilance for and identification of medical errors
has sparked discussion concerning the responsibility of health care providers
to disclose and discuss such errors with patients. This is especially important
for physicians, the primary providers of care. Little debate concerns the ethical
and moral responsibilities of health care organizations and physicians to make
patients aware when an error has occurred that may have affected their care.
This is especially true of, but should not be limited to, errors that result
in serious harm or even death. It is well known, however, that when and how
disclosure occurs varies greatly according to the particular patient-provider
situation. Actions may be based more on personal feelings, beliefs, and fears
than on standards of practice.
The state of patient-physician relationships becomes a prime determinant of
the events that occur after a medical error has occurred. In this article, we
will explore these relationships and look into the foundations on which relationships — and
thus behaviors — are formed. We will also relate the issues of medical errors
to the theological principles that underlie our Catholic health ministry.
The Role of Physicians
The medical profession has historically attracted talented young people who,
by their nature, are individualistic and value their autonomy. Unlike management
and business education, which emphasizes organizational behavior and systems
thinking, medical education has traditionally nurtured independent behavior
and single-minded decision making, attributes that in many ways define the profession.
Independent behavior is of obvious importance when specific patient care situations
require it.
Unfettered physician autonomy can be a problem, however, when consistency and
systematic behaviors are needed — when a medical error has occurred, for
example. Physicians, because of their nature and training, may be uncomfortable
with full disclosure of medical errors and as a result may act in a way that
could be perceived as inappropriate or possibly unethical.
Working to make decisions that are both in the best interest of patients and
acceptable to physicians is a significant challenge. Hospital and health system
leaders must create environments that allow physicians to express their concerns
and to understand the alternatives, along with expected outcomes, that ultimately
lead to decisions that are clinically appropriate, ethically sound, and maintain
professional integrity. Understanding the underlying elements of physician decision
making is key to creating such an environment.
Physician-Patient Relationships
The physician's response to medical errors, and what he or she ultimately
decides to disclose to a patient, is primarily determined by the type of relationship
existing between the physician and patient. Is the relationship a contract or
a covenant? A contract says, "I agree to provide my skills and knowledge;
you provide adherence to my suggestions and advice." A covenant joins two
parties in a common commitment and common fidelity. How does either relationship
affect the physician's obligation and willingness to disclose medical errors?
A contract is a transaction based on finite boundaries and responsibilities.
A contract is an agreement for goods or services. It has legal implications
and can generally be written in legal terms. Success and failure can be identified
and measured. For example, a request by a prospective patient to a doctor for
a surgical procedure or treatment, followed by signed informed consent, is a
contract for services. Contracts as the context for medical care have distinct
and unique value to those involved: clarity of roles and responsibilities, provision
for resource planning, and clear expectations of performance. When outcomes
fall outside contractual parameters, failed expectations are apparent and cause
is clear. Disclosure is a nonevent; the errors are there for all to see. Surgery
on the wrong limb is an example of this type of medical error.
However, health care is rarely this straightforward. Apart from purely technical
services, as in the surgery example, the delivery of health care services usually
involves shared responsibility and a measure of unpredictability. In most of
medicine, only a covenant will do.
A covenant is an agreement between individuals based on deeper meaning.
A covenant is a promise, a gift that says, "I will do what I can, based
on what you need at the time that you need it." A covenant is timeless
and does not lend itself to writing. A covenant can be described — but only
in general terms, not precisely. It is based on relationships and is steeped
in empathy, understanding, and sensitivity. Success is communal and often goes
unspoken. A covenant between patient and physician establishes a reciprocal
relationship between an empathic professional and a committed person. And, yes,
sometimes a covenant is marked by forgiveness.
Disconnection
When a medical error occurs within a covenantal relationship between patient
and physician, only timely and complete disclosure will suffice. Why, then,
is this not always the case? More often than not, medical errors are not disclosed
to patients. Many physicians prefer to mitigate the risks of disclosure by withholding
or giving incomplete information to patients. Is this a willful, unethical act?
Or might there be an explanation as to why this could occur?
One explanation suggests that physicians and patients may believe they are
working in a contractual way when, in fact, this kind of clarity does not exist.
That is to say, patients believe they know what they are getting, and while
they may be able to recognize whether a final outcome has occurred (e.g., the
correct surgical procedure was completed), they have incomplete information
concerning the many steps that lead to that outcome. This leaves errors along
the way "up for interpretation" and allows the well-intentioned physician
to make an independent judgment as to whether an unwanted event is an error
or just a "deviation from the expected."
For example, should a physician disclose the fact that an error occurred while
a patient was under general anesthesia even though the error resulted in no
serious harm? Should a patient be told when the treating physician forgets to
prescribe a medication that might have been helpful or even essential? For physicians,
these decisions are most often made in isolation, and one can easily see how
nondisclosure in this context of contract might be rationalized as neither a
violation of contract nor an unethical act. But in the context of a covenant,
nondisclosure would be viewed as violation of the reciprocal relationship. Disclosure
of medical errors and unwanted events between patients and physicians in a covenantal
relationship is an expectation, guided and understood by the participants under
the influence of trust and empathy, with an allowance for forgiveness. The problem,
it would seem, is the understanding of what it means to offer and work in the
context of a covenant. Fortunately for us, a model exists: the healing work
of Jesus taught to us in the Gospels.
The Gift
When and why would physicians choose to relate to patients in a covenantal way?
There are likely myriad reasons, but one noteworthy explanation is what we like
to call "the Gift." We all know doctors and health care providers who have "the
Gift." These are physicians and others who recognize that their work is an invitation
to participate in healing, not to cause it themselves. Such people know
that true healing is the work of a "higher being" and that they are privileged
to be called to serve. They have the ability and desire to work as equals with
patients, shunning the hierarchical traditions so prevalent in the profession.
Some may not see a religious context in "the Gift"; they are the fortunate few
who have it and use it innately. For many, however, "the Gift" is a gift from
God, known and practiced by the teaching and example of God's son as healer.
It is, as one writer has said, "the sense that one is inexhaustively the object
of gift."1
Recognition of the invitation to healing profoundly alters the physician's
concept of self and of his or her own skills. The doctor is transformed from
technician to facilitator and healer, to knowing himself or herself as a person
called to and supported in a work that is for the service of others. The goal
of the physician-patient relationship, then, is not technical expertise, not
"fixing the ailment"; it is, rather, service to another and participation
in God's activity of healing. Recognition leads to transformation, and
central to this transformation is the movement from hubris to humility, from
total confidence in one's own knowledge and skill to cooperation with and
participation in God's gift of healing. Such a shift makes room for imperfection
and frailty. Such a shift makes room for medical errors, which can be seen within
the context of the limits of humanity. They can be recognized, owned, corrected
when possible, and forgiven when appropriate.
A physician has conveyed a story that shows this well.
I recall vividly an occasion when Loraine, the daughter of one of my longtime
patients, decided that I was worthy of being her primary doctor as well. What
she was saying was, "I trust you." After doing a routine history
and physical and declaring her healthy, I sent her off for a screening mammogram;
her first despite being well into her 50s. It was almost 18 months later that
she came back to see me complaining of a lump in her breast. I examined her
and was alarmed to detect the obvious cancer. Upon looking back over her chart,
I was shocked to find the abnormal mammogram report sitting right there, with
no action having been taken on my part. My heart sunk. The consequences of
my error were clear and unavoidable. What do I do now? What are my alternatives?
How would she respond? With no hesitation, I told her what had happened and
of the missed report. I informed her that we had likely missed an early cancer
some 18 months ago and that I was sorry. I expected outrage and anger. What
I got was empathy and understanding. In short, Loraine forgave me.
As I look back on these events, it is apparent that the covenant between
us allowed for my full disclosure of the error and her forgiveness. Did it
make the mistake acceptable? No, it did not. However, it did allow for humanness;
it allowed me to make sure this would not happen again, and then permitted
us to move on. Most importantly for me, I was able to continue my practice.
How do physicians, nurses, or other colleagues survive without forgiveness?
Without a promise of hope? I am not sure, but I know many do not. I just know
that I was blessed.
Vulnerability
One aspect of humility and humanness that no one is comfortable with is vulnerability.
To us Americans, citizens of a nation of individuals, to be vulnerable is to
be weak and dependent on others. In the medical profession, vulnerability is
believed to reveal weakness and inferiority on the part of the professional;
it is a distortion of a relationship in which the physician is the expert and
the patient is the one who is in need.
It is undeniably true that the patient is in need of care and is in a very
vulnerable state. At the same time, the patient brings more than need to the
relationship. He or she also often brings strength beyond understanding, faith
beyond compare, that rare wisdom that emerges from suffering, and a hope that
endures in the face of death. Vulnerability that consists of openness to another
and to another's contribution to the work, a mutuality that recognizes
we need each other to effect the healing and that leaves room for God's
grace — this vulnerability may be the key to a truly healing relationship
for both patient and physician.
A Relationship like None Other
What does such a relationship look like? And how might these relationships affect
our understanding in dealing with the problem of medical errors? One model exists
in the Gospels and their presentation of both the healer and the healed. We
frequently say that Catholic health care seeks to "heal as Jesus healed."
If this is so, what can Jesus teach us about the healer-healed relationship
and our responsibilities in modern challenges such as the problem of medical
errors?
Each of the four Gospels devotes significant time to the healing activity of
Jesus. It was central to his mission and his identity. As Son of God, come to
proclaim God's reign, all that he did and said pointed to and made accessible
the saving, redeeming, whole-making power and love of God. Healing the suffering,
making whole those in need, restoring people to life and to each other — these
were concrete and wondrous manifestations of God's reign. When Jesus healed,
the people praised God as the healer. They knew that "something more"
was going on. Jesus himself was not the healer; he participated in the healing
given by the grace of God.
Jesus healed unlike any other healer. No one in need ever feared to approach
him; all found welcome in his presence. All were healed. Jesus entered into
conversation with those in need, asking them, "What can I do for you?"
He listened and acted appropriately. He saw needs even before people asked.
Jesus saw the real need and blessed the suffering with the good news that their
sins had been forgiven.
At the same time, Jesus was not impervious to the power of others. He was provoked,
tested, angered, and troubled by those he encountered — in many ways, not
unlike the manner in which health care workers are sometimes tested today. Jesus
was saddened by others' sorrow, troubled and moved by others' pain.
He was himself, finally, vulnerable to the attacks of those who would see him
dead. It is in his total vulnerability on the cross that life is able to triumph.
It is in his vulnerability that redemption happens.
Vulnerability makes way for healing. It is in the mutual openness, the shared
humanity, the willing vulnerability between patient and physician, that true,
whole healing can take place, for it is here that room for grace's power
exists. Like the physician in our story, openness to sharing in the common humanity
between people, each with specific gifts and needs, means "something more"
can happen.
Medical errors are common, and much is being to done to rectify and solve these
all-too-human problems. Our relationships with others and with ourselves are
tested during these times of transition. Understanding our shortcomings and
accepting our vulnerability as humans is an essential first step in dealing
with errors — errors that will continue into the indefinite future, until
the unlikely time when "perfection" is found and implemented. Until
then, a covenant among persons is needed, a covenant of understanding and caring,
modeled for us by the divine Healer and told to us so that each can glimpse
the reign of God.
NOTE
- William F. May, "Code and Covenant or Philanthropy and Contract?"
in Stephen Lammers and Allen Verhey, eds., On Moral Medicine: Theological
Perspectives in Medical Ethics, Eerdmans Publishing Co., Grand Rapids,
MI, 1987, pp.121-136.
Copyright © 2004 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.