Upon admission a sixty-five-year-old diabetic female with a urinary tract infection and mental status changes asked not to receive pork-based insulin: "You got that straight? You people mess up all the time." Her request, based on a religious prohibition against eating pork, was clearly documented on the chart and honored—until day four, when pork-based insulin was given. This mistake caused no adverse physical effects. Should she be informed?
Traditionally, physicians have maintained a fierce ethic of personal responsibility. Individual conscientiousness, competence, and integrity are inextricably linked to quality medical care. In this view, errors result from poor judgment, lack of knowledge, or bad character. While practitioners have a particular duty to be scrupulous in adhering to standards of care, and should be held responsible for negligent harm, not all errors flow from individual shortcomings.
This incident should be investigated to determine what happened and how to prevent future mix-ups. Perhaps the pharmacist who mistakenly provided the medication or the nurse who administered it failed to follow procedure, but finding someone to blame is not the only consideration.
Health care delivery systems provide a context in which the potential for individual errors can be increased or minimized. Miscommunication, unclear lines of authority, and inadequate checks and balances can cause harm despite the best efforts of good practitioners. Time and resource constraints, such as understaffing or long hours, may foster conditions conducive to human error. Therefore, buffers should be created so that medication errors of this sort can be identified and prevented before they cause harm.
This patient was not hurt physically, but what about the potential for emotional damage or other fallout resulting from the mix-up? Should she be told that an error was made with her insulin? Consider these arguments:
No, she should not be told:
All errors are not the same. Some are benign. From a medical perspective, beef and pork insulin provide the same physical benefit with no harmful effects. If informing this patient of a relatively harmless but irreversible error will only upset her, then not disclosing the mistake is a minor and justifiable violation of the obligation to be truthful. In this case silence may produce a good for the patient that outweighs the wrong of breaking a moral rule.
This patient might demand punitive action that disproportionately embarrasses caring professionals. The hospital can deal internally with those responsible and take steps to prevent recurrence. Informing patients of non-injurious errors discourages voluntary reports by staff, thus inhibiting corrective action before harm occurs.
Knowledge of the error might damage this patient's tenuous confidence in the hospital and its care providers. She has already communicated her skepticism about "you people." Revealing the mistake will only entrench that distrust.
Yes, she should be told:
Technical errors need not become moral wrongs. Patients have a right to know about their medical condition and treatment. There is no doubt that this patient's explicit preference for a specific treatment was dishonored, albeit unintentionally. Physical damage is not the only consideration when determining harm. While knowledge that she has unknowingly received pork-based insulin will no doubt affront her religious belief and practice, remaining silent constitutes deception. Justifying nondisclosure by appealing to "the patient's own good" as defined by others and not herself violates her right of self-determination. Without clear evidence that revelation will cause serious distress, she should be told.
Explanation and apology are not likely to provoke retaliation. Leonard Marcus, director of the Program for Health Care Negotiation and Conflict Resolution at the Harvard School of Public Health, analyzed malpractice mediation sessions and concluded that patients harmed by medical errors want three things: an explanation of what happened, an apology from whomever was responsible, and an assurance that changes have been made to prevent harm to others. This patient should be offered the same. She should be informed that she received pork-based insulin, offered an apology, and told why the mistake occurred as well as what has been done to prevent future errors.
Medical uncertainty sometimes makes it difficult to determine whether mistakes have occurred, but in this case the patient's request was definitely abrogated. The physician-patient relationship is based on a fundamental trust, including reliance on physicians' honesty. Revealing this mistake runs the risk of fueling this patient's belief that providers "mess up." But the risk of silence is arguably greater. If she finds out about the medication error in spite of purposeful silence, she may well wonder what else she has not been told, and be left with the impression that not only do providers mess up, they are also deceitful.
Deciding whether or not to reveal a medical error raises additional ethical considerations. One problem with the decision not to reveal mistakes, for example, is preventing inadvertent disclosure down the line. Resolving that the error should be divulged does not address when, how, or by whom disclosure will occur. In this case, the basis for the patient's request was religious. Knowing she was not physically harmed may not be what matters most to her. Acknowledging any spiritual or emotional distress caused by the mistake may make a difference in her ability to accept and even forgive the error.
Patients should not equate all error with negligence. They should have confidence that practitioners are committed to caring and doing their best, not only with regard to physical outcomes, but also in maintaining honesty and integrity in the therapeutic relationship.
