2. Truthtelling and Error Martin McKneally Department of Surgery and Joint Centre for Bioethics University of Toronto Principles of Surgery November 2009

3. Ethics….What’s an Ethic? A set of values, principles, and beliefs, standards of conduct Guides the behaviour of a specified group – journalists, lawyers, monks, physicians, surgeons. “What we should do”

4. Ethics PolicyLaw usuallymust should

5. Ethic of Surgery Trustworthiness: Competence Commitment

6. Surgical Competence Knowledge timely and appropriate Judgment balanced attentive to the particular needs and circumstances of an individual patient the right operation for the right patient at the right time Skill sufficient to perform the surgical intervention minimum of risk high probability of benefit

8. Trustworthiness: Living up to Obligations Fiduciary: what is best for the patient Professional: competence, commitment Team: integrity, coworker care

9. Commitment Constancy – warrior energy Personal responsibility - unique

11. The Case: “Don’t Tell My Husband…” Gwen Jones is the wife of a man who has been diagnosed as having inoperable pancreatic cancer. The patient is terminally ill, and is still in hospital. Both the wife (who is currently completing her PhD) and the patient’s father (who is a medical doctor) do not want you to tell the patient his diagnosis or the fact that he is dying.

12. Questions: 1.Is this a realistic situation? 2.Should we tell the truth? 3.What are the reasons that we ought to tell the truth? 4.Are there arguments for withholding the truth? 5.What is the best resolution?

13. Should we tell? Yes Rights Will find out Loss of trust Affairs in order Consent for treatment No Harm from disclosure Violates family relationship Violates cultural norms

14. Management Offer the opportunity

17. Mistakes / Adverse Events Complication - worsening caused by disease or treatment Error - wandering from the path Incompetence - failure to meet accepted standards

18. Should I tell the patient? Con: Patient may worry about all aspects of care -may avoid necessary care -may become confrontational Physician may suffer emotional distress, remorse, guilt, inadequacy -Punitive colleagues and supervisors -Damage to reputation, career, privileges, license -Lawsuit

19. Should I tell the patient? Pro: Patient may benefit from knowing -may be harmed by reliance on misrepresentation -has a right to know -implied contract to reveal findings -compensation may be needed/justified

20. Should I tell the patient? Pro: Physicians’ sense of integrity maintained Strengthens trust in DPR through honesty Natural response to say “I’m sorry” Blocking response exacerbates guilt Liability greater if negligence is concealed

21. Ethical Foundation for Disclosure of Error Truthtelling Promise keeping Respect for autonomy Justice

22. How to do it? Forewarn – this is a tough problem “We’re in this together.” “Here’s what I’ll be worried about.” End on a positive note – “Here’s how we minimize the risks”

23. How to do it? Disclosure: Tell what happened Apology: Say I’m sorry Remedy: Explain what can be done Provide compensation Practice Insurance Prevention:Show how it will be prevented in the future

25. Atul’s Case

26. Ethics talks for R1, R2 1.Truth Telling 2.Ethics of Innovation 3.“Don’t transfuse my daughter” – Religious Issues 4.Surgical Competence 5.Doctor Patient Relationships 6.Conflict of Interest 7.Resource Allocation 8.End of Life

27. Ethics PolicyLaw ReligionCulture Next: “Don’t transfuse my daughter” Religious and Cultural Issues

28. martin.mckneally@utoronto.ca martin.mckneally@utoronto.ca phone: 416-223-7609

29. Acknowledgements Paintings by Joe Wilder Slides by Deborah McKneally, The Ravine Research and Education Centre

31. Your Cases

32. Ethics Research Courses at JCB Daar – biotechnology McKneally – innovation Bernstein – error

33. Ethics Education Principles of Surgery: R1, R2 RSPSC Curriculum Research Ethics Day: Surgeon Scientists June 2, 2006 Clinical Ethics Day: any interested resident June 1, 2005 Case conferences: Senior Residents www.rcpsc.medical.org/english/ethics www.utoronto.ca/jcb

34. Graded Responsibility Resident (adj.) a resident surgeon resides in the hospital to provide on site care & emergency treatment Residents are responsible for the procedures performed at their level of proficiency Graded Responsibility in Operative Surgery U of T Dept of Surgery

35. Graded Responsibility Residents are expected to be able to operate as independent specialists at the completion of their training. Staff surgeons are expected to supervise the independent operative experience of residents according to their level of proficiency. Graded Responsibility in Operative Surgery U of T Dept of Surgery

36. Trust: Reliance on others’ competence and willingness to look after rather than harm things one cares about. Annette Baier

37. Trust provides an alternative to vigilance and rational calculation of risks, benefits, and alternatives. Annette Baier

38. Disclosure policy CMPA JCAHO Dana Farber US VAMC SWCHSC