The Ethics of Medical Error

By John Mustol,
M.D., Fuller Theological Seminary, Pasedena, CA

            Surgeon Atul Gawande wrote what all physicians know in their hearts is true, “All doctors make terrible mistakes.”[1] I was a general surgeon for twenty years, and I can testify that this is true. To be responsible for a patient’s life, knowing just how fallible I am, knowing that inevitably sooner or later, sometime in my career (probably more than once), I would be responsible for a patient’s serious injury or death – is a spiritual and ethical challenge for doctors. Doctors are human beings and medicine is a human endeavor. Errors are part of life for doctors. So how should doctors deal with their mistakes? How should the “patient-victims” be managed? What are the ethics of medical error? What is the spirituality of medical error?

            Medical mistakes are common. The Institute of Medicine’s (IOM) report in 2000 estimated that there are 44,000 to 98,000 deaths per year “as a result of medical errors.”[2] Leape estimated that “preventable injuries afflict 938,000 hospitalized patients annually.”[3] Waterman and colleagues surveyed 3,171 doctors in the U.S. and Canada and found that 92% admitted to being involved in an error of some kind: 7% in a near miss, 36% in minor errors, and 57% in major errors.[4] I suggest that Waterman’s statistics are wrong. Gawande is right. Some of the doctors he interviewed are good liars. The true numbers are 100% across the board. The reality is that American medicine is a very human enterprise.

            The medical establishment has been glacially slow in facing up to its fallibility. In 1984, Dr. David Hilfiker, then a family practitioner in rural Minnesota, published a remarkable article in the New England Journal of Medicine, entitled “Facing Our Mistakes.” In this paper, he spoke openly about some of his own errors and near-misses and called for a more open and humane approach to physician error.[5] His proposal lay dormant for 16 years until the IOM’s report in 2000. This seems to have been the bombshell that awakened the medical establishment. Since its publication, there has been considerable movement in the field, but resistance persists among physicians.

            If doctors have been slow on this issue, Christian theologians and ethicists have been stone dead. There is virtually nothing written from an explicitly Christian perspective on the theology and ethics of medical fallibility and error. David Hilfiker’s writings contain Christian ideas, but he never explicitly identified himself or his writing as Christian. I have searched numerous books on Christian bioethics, as well as the literature, and turned up nothing. Taylor and Dell’Oro offer as the purpose of their recent book, published six years after the IOM report, “the retrieval of vulnerability in ethics” through reflection on “the phenomenological meaning of specific realms of human moral experience hitherto neglected.” They wish to go “from dignity and integrity to vulnerability and relationality.”[6] I read the book with anticipation, but was disappointed to find their otherwise fine book does not address medical error nor human fallibility as components of their paradigm of human vulnerability and relationality. In a paper on vulnerability, Hoffmaster, who also ignores medical error, claims that vulnerability is missing from moral philosophy because moral philosophy ignores the body. “Western moral philosophy is grounded in reason – the purer the better.”[7] He seems to be saying that Western philosophers (and, I suggest, theologians too) are, in effect, Cartesians. They are disembodied minds thinking about abstract principles and theories ignoring the fact that their minds are really their bodies of flesh and blood, made of the dust of the earth, subject to all the messiness of earth-bound existence. The Christian tradition and the gospel of Jesus Christ should, I would think have a lot to say to this issue. But have Christian theologians and ethicists been silent?[8]

            Our current approach to physician error is embedded in modern culture with all its myths and assumptions about power, efficiency, progress, individual autonomy, and human perfectibility. M. Therese Lysaught writes: “Weakness, dependence, and imperfection are not part of the story our culture tells us about itself; these realities are deeply at odds with contemporary values of efficience, productivity, physical beauty, and perfection. . . . We who have been so deeply formed by the myth that we are autonomous beings do not want to be reminded of the radical contingency of our control over nature, over our lives, over our destinies. . . . Illness reminds us that we are in fact embodied, hardly the Cartesian selves, the disincarnate minds that we prefer to think we are.”[9] Doctors and, perhaps, theologians and ethicists, are deeply influenced by these modern myths.

            The medical tort system is currently the principal means of addressing errors in healthcare, but it does a poor job if it. It is an arbitrary and coercive system based on fear and it exacerbates the spiritual and emotional trauma of errors for both the physician and the patient-victim. The tort system offers neither deterrence nor timely and fair compensation and is fundamentally unjust to the patient, the physician, and to society.^[10] Where is an ethical critique of the tort system based on Christian theology, and where are alternatives based on Christian theological ideas? Here again, Christians have had little to say except to talk about caring for the wounds and needs of doctors when they are sued. As a doctor who was sued twice myself, I do not demean the pain that suits bring, but don’t we have more to say? While Christians have remained silent, the secular medical establishment is developing interesting new alternatives such as “fair-compensation” being implemented by the Veterans Affairs Hospital in Lexington, Kentucky and Catholic Healthcare West.

            Medical error, with its potentially dire consequences suffered by the one whom the doctor intended to help, offers an array of theological, epistemological, and ethical questions. As a physician, I have had experiences where, faced with a difficult clinical problem, I prayed earnestly to God for guidance only to find myself forgetting something, making a poor judgment, or committing a blunder that hurt the patient. I have, on such occasions, asked God why he did not answer my prayer or why he answered it in this way—allowing me to make a hurtful mistake. In a universe that is subject to varying degrees of random, chaotic, and unruly behavior (including the brains of doctors), and when the consequences of one’s error are visited on others, how do we explain the grace, providence, and justice of God? Theodicy is an essential component of an adequate Christian treatment of physician error.

            Medical errors can only occur in a world of realism. When we don’t know something or we get something wrong, and it results in injury, was it due to the inherent uncertainty of earthly existence or was it my fault? Where is the line between the intrinsic imperfection of human beings and moral failure? If earthly existence is inherently uncertain, and errors are inevitable, does this mean that doctors do not bear responsibility? Does “ought” imply “can”?[11] What is a Christian response to this question?

            And what do Christians have to say to the problem of disclosure? The consensus today is that all harmful errors should be disclosed to the patient and/or family. But if I make a serious mistake that does not harm the patient, what is my moral responsibility then? Do I disclose it or not? Is apology required?

            Many doctors experience guilt when they make a mistake. Can guilt be objective in this case, and if so, when? How should it be dealt with? When is forgiveness required and how does it work? How does a doctor forgive herself? It would seem that with the gospel of Christ as a resource, Christian theology would have a lot to say about guilt and forgiveness.

            I will close this little paper by offering one principle that might form the basis of a Christian ethic of medical error. Doctors, like all of us, are self-centered. Historically, when addressing the problem of medical error, they have focused overwhelmingly on themselves. Their trauma and stress over malpractice suits dominates their thinking and their conversations. I propose that from a Christian perspective this is misguided. The essence of the medical profession is love—seeking to help another human in need.[12]            When a doctor’s error harms a patient, this does not change. Jesus said, “Whoever wants to save their life will lose it, but whoever loses their life for me will save it” (Lk. 9:24)

            I suggest that Jesus was offering a general principle here, a paradox of life. The physician whose error has harmed a patient will find her own healing, not by trying to protect and save herself, but by continuing to love the patient—by giving of herself for the sake of the one whom she has injured, even if it is costly to herself. The focus should be on the patient. This is not to diminish the pain for the doctor or the trauma of being sued, nor to deny the injustice of the tort system. But if we have made a mistake, whether we are sued or not, owning up to it, disclosing it to the patient, seeing to the patient’s welfare, and seeking to prevent further errors should be our primary concern, and are, it seems to me, what Christ calls Christian doctors to do. Christians, it seems to me, ought to be advocating for a more compassionate, cooperative, reconciling, and healing approach to the management of medical error.

            Medical error is a nexus of ethics and spirituality, of power and weakness. It is where fragile, vulnerable humans encounter the destructive power of the modern technology they hold in their hands. Medical error combines the moral and the emotional, the technical and the spiritual, the transcendent and mundane. The physician who has made a harmful mistake is faced with the terrible reality of her power and weakness. It is a direct challenge to her sense of self and her worldview. Medical error can be a wrenching, twisting, disorienting event for the doctor as well as the patient and family. Christian theologians and ethicists can offer a great deal. It is time for them to step up to the plate.