When I visited the clinical ethics department at Washington Hospital Center some years back, I was impressed by how acute ethical dilemmas, once resolved, led to presentations in the affected department to reflect on the problem and find ways to minimise its recurrence. These ways included imparting factual knowledge, whether medical, ethical, or legal, or changing the manner in which things were done. Thus a mixup about a patient’s resuscitation status resulted in a talk to the multidisciplinary team about DNAR orders and their notification in the records. These sessions helped the clinicians appreciate the practical value of the clinical ethicists, and of ethics generally.
The downside of this sort of post-incident feedback is that it relies on mistakes or problems that arise in one’s own institution. Yet, throughout the country, in the hands of lawyers, there are thousands of cases with valuable lessons for clinicians. There are dozens on my desk alone. The vast majority of those cases will be settled and their lessons lost to all but the few people involved. The opportunity for colleagues to learn from them dies with the case. Only the very few cases that make it to trial (and are reported), and those that find their way in the magazines of indemnity organisations, such as the Medical Protection Society’s Casebook, may live on to benefit others.
This is a terrible waste of knowledge. A repository of cases, anonymised and sorted by specialty and even individual procedures (e.g., carpal tunnel operations; hernia repairs; laser eye surgery; etc.), would be a valuable learning tool for clinicians, with obvious benefits for patients. The patients involved in the case, keen to avoid others suffering the same fate at another healthcare facility, would probably also support the idea.
The lawyers, working in conjunction with the medical experts who have assisted them, would need to volunteer the cases to the database, much as they already do for cases involving the monetary valuation of injuries (i.e “quantum”). These quantum cases, submitted by lawyers to databases such as Lawtel, are used by lawyers and judges up and down the country to value certain aspects of personal injury cases.
The submission process to the proposed clinical database would need careful thought. In some cases, defendants will be reluctant to cooperate, perhaps because the case was settled to avoid a court judgment on a certain point. The submission would probably need to be approved by both parties and it is unclear if time-pressed lawyers would bother spending time drafting a report to the database, even if for the greater good. A modest payment for each submission may be a necessary incentive.
The database, replete with mistakes and oversights and avoidable harm, would doubtless make for sobering reading but best to think of it as a database of hard-earned wisdom and an opportunity to learn the lessons of others without a single lawyer or hospital manager in sight.
Daniel Sokol is a barrister and medical ethicist at 12 King’s Bench Walk, London.