By Daniel Tigard.
Healthcare professionals are only human—at least, for now. As such, they are prone to simple oversights, or even occasional acts of gross negligence. What makes errors in medical contexts especially concerning is, of course, that any failure can have devastating effects. Patients come to healthcare facilities needing attention for some ailment and they leave in a poorer condition, or in the worst cases they don’t leave, not as a result of their ailment but because we make mistakes. I assume we all agree that medical errors are a problem. So, what should we do about them? I’ve suggested there might be good reasons for practitioners to take the blame, and here I knew I might find disagreement.
The Institute of Medicine’s 1999 report helped to draw much-needed attention to the idea that, very often, errors are system-wide failures. Hospitals are chronically understaffed, for instance, and individual practitioners often lack necessary experience. How should we respond? In many ways, this is simply a practical matter requiring extensive empirical research. We must work to better understand and eliminate the causes of errors. While I’m mostly optimistic that improvements in patient safety can be made, either by reducing human error or harnessing state-of-the-art technologies, patients will likely continue to suffer preventable harms. What, then, should be our response? It seems to me that this question calls for both empirical work and ethical analysis.
We must reflect carefully on what we value and on the values held by those for whom we are committed to caring. In some cases, we will want to assure patients who come to harm—or families who are grieving the loss of a loved one—that the system-wide issues that contributed to the error are being investigated and addressed. In other cases, this approach may well exacerbate the problem by giving the impression that responsibility is being pushed off onto an abstract “system”. According to some research, patients or families affected by errors often wish to see improvements in standards of care, so that similar future incidents are prevented. They also wish for someone to offer an apology. For these reasons, I support a pluralistic approach, whereby we can work to improve the systemic issues at stake, while at the same time recognizing the importance of interactions between individuals which, I believe, remain at the heart of the patient-practitioner relationship.
In thinking back on the recent critique of my work—offered by Duthie, Fischer, and Frankel—it appears we are largely in agreement, not only on the need for more empirical research in service of systemic improvements, but also on the ethical values which support meaningful interactions between individuals. Those who are harmed, either personally or by a family member’s injury, should have the opportunity to receive an apology or expression of regret from someone who is connected to the event. This person need not be directly at fault for the harm—he or she may simply be ‘taking’ the blame. In many cases, the practitioner or clinic representative taking the blame should not be the one who was directly at fault. These caregivers have likely been through enough, having suffered a sort of guilt or self-blame on their own. Thus, we cannot expect all practitioners to have heartfelt interactions with harmed patients and families. Indeed, practitioners who are truly suffering—namely with ‘burnout’ or ‘compassion fatigue’—have themselves become patients, in a sense, and certainly should not be charged with additional blame, either from others or from themselves.
Perhaps it is simply the term “blame” that gets a bad rap. Whether it comes from others or from ourselves, blame is commonly regarded as a painful emotional response, one that should not be encouraged, particularly in professional domains. Yet, this intuition is precisely what I want to challenge. Self-directed responses, in particular, can motivate positive change and show that harms are being taken seriously. For that matter, they seem to play a central role in many positions of leadership. Picture Obama’s tears in response to the 2012 Sandy Hook Elementary School shooting. In short, even if blame is generally painful, there are often good reasons at least to not discourage it.
I suspect that even those wanting to avoid blame in healthcare might still be in favour of taking responsibility in situations where doing so can help others. In personal contexts, there will be occasions—as Mason highlights—where harms are ambiguous but we can nonetheless show that we empathize with the loss. In professional contexts, particularly in the emerging use of medical technologies, it seems likely that we will increasingly encounter situations where the source of harm is unclear. Here too, we will need resources for helping victims—such as the ‘harm mitigation bodies’ recently outlined by McMahon, Buyx, and Prainsack—where patients and families can seek financial support or simply come to better understand how they came to harm. Medical errors, along with ambiguous harms generally, are undoubtedly problematic, considering the injury itself and the psychological discomfort for victims. Accordingly, we must anticipate and remedy ambiguous harms, and work to assure that victims are not left alone to blame the system.
Daniel W. Tigard
Human Technology Center, Applied Ethics, RWTH Aachen University
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