Sunday, March 9, 2008

Teaching Medical Ethics - (Individual Virtue and Organizational Integrity)

The topic for a recent class in the Harvard Medical School course on "Medical Ethics and Professionalism" was truth telling. (See this earlier post for a description of the course.)

The case the students found most challenging involved what to say about a medical error:

"An 80 year old man with severe hypertension comes into the hospital in a hypertensive crisis. Confused by an ambiguous label, you administer 1,000 mgm of a medication rather than the intended dose of 100 mgm. Shortly thereafter the patient's blood pressure drops. Despite resuscitative efforts, he dies. You conclude that you accidentally administered a fatal dose. What do you say to the family?"

The students were deeply torn. They felt the family had a right to know what had happened. Unless the family said something like "Dad was ready to go…the only thing we want to know is whether he suffered…”, they should be informed of the facts. But they feared that disclosure would destroy their careers.

Some felt they would/should disclose the truth no matter what the consequences. Others felt that prudence called for withholding the information, but felt some shame at having reached this conclusion. It looked like a question about the individual - who had good ethics and who didn't.

But when we reviewed the experience at the Lexington, Kentucky, Veterans Affairs hospital in systematic disclosure of medical errors, we shifted from seeing the case as an ethical biopsy of the individual to a broader view. Starting in 1987, the Lexington facility began a systematic program of disclosure. It accumulated important empirical evidence: (1) patients and families want to know the truth; (2) disclosure appeared to reduce malpractice litigation and payouts; and, (3) staff felt good about the policy.

The case we considered focused on the physician as an individual. At Lexington, the system responds. A harried intern would not be left out on a limb, Hamlet-like, anguishing over whether "to be (ethical) or not to be." The actual disclosure would be done by senior staff, and only after a thorough investigation.

I took two major points from the discussion. First, integrity should not be seen simply as a characteristic of individuals. The organizations we are part of can facilitate or impede our penchant for doing the right thing. Second, this observation has a bearing on the debate over the value of teaching ethics. Skeptics argue that if family life and experience haven't instilled virtue, a semester-long course won't do it either. But the usefulness of ethics education doesn't rest on the question of whether a class can alter one's character. If our students, and we, become more self-understanding with regard to motives and temptations, we can demand that the organizations that we are part of support our doing the right thing.

Ethics education may not alter our characters, but it can help us become skillful self-observers and effective organizational activists. That's not a bad accomplishment!

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