Instructor's Guide: Truthfulness

Case Summary

A 9-month-old boy, Andre, comes to the clinic with his mother for his well-child visit. His mother specifically wants to address his immunization status and make sure he is up to date. She hands you his state immunization record. You see that he hasn't received his third Haemophilus influenzaetype B (Hib) or inactivated poliovirus (IPV) immunization yet.

Because his mother is in a hurry to get to her own doctor's appointment, you help expedite Andre's catch-up shots by asking your medical assistant (MA) to give them as you leave the patient's room.

Ten minutes later, as you begin to write a note in Andre's chart, you notice a note written three months earlier, when Andre saw one of your partners. The note states that Andre received Hib#3 and IPV#3 as part of that visit. It occurs to you that the immunization card was probably not completed after Andre's last visit. You run to see if you can stop the MA from administering the shots, but it's too late: you meet her coming out of Andre's room just having given them.

• Does the accidental administration of an extra dose of a recommended vaccine qualify as a medical error? How would you define medical error?
• Can a physician commit an error without it being negligent?
• Do you feel an obligation to disclose the situation to the mother? In general, do healthcare providers have an obligation to disclose errors?
• Would your feeling about disclosing this situation to the mother change if you had just caught the MA before she went in the room to give the shots - i.e., if it had been a near miss?
• If you decide to disclose this situation to the mother, how will you go about it?
• What are your concerns about having this conversation with the mother?

Alternative Cases

Excerpted from Hobgood (2005)

• A 6-year-old female child is evaluated for fever and body aches. She is diagnosed with a virus and discharged. Two hours later, she comes back with a higher fever, rash and headache. More testing is done and meningitis is diagnosed. She is admitted to the intensive care unit for a month. She recovers but has a permanent hearing loss (failure to diagnose, lifelong disability).
• A 5-year-old male child complains of a sore throat. His doctor examines him but does not order tests or prescribe medicines. The boy continues to experience a sore throat and fever. Three days later he returns to the doctor and is diagnosed with strep throat. He is treated with an antibiotic and within a week he is completely well (failure to diagnose, minor clinical effects).
• A 7-year-old receiving chemotherapy for cancer is given twice the dose of one of her chemotherapy medicines. She becomes critically ill and requires a three-month stay in the hospital. Because of her critical illness, her kidneys fail and she becomes dependent on dialysis three times a week for life (medication error, lifelong disability).

Learning Objectives

After participating in this module, the student should be able to:

1. Formulate a definition for medical error, recognize the variability in this process and understand that the definition is not dependent on harm to the patient
2. Understand the moral and ethical obligations surrounding disclosure
3. Understand patient expectations with respect to disclosure of medical errors
4. Identify important components of an appropriate conversation with a patient or patient's family regarding the disclosure of a medical error
5. Recognize the barriers to acknowledging physician fallibility in the medical profession

Suggested Reading for Instructor

Bok, S. Lying: Moral Choice in Public and Private Life. New York: Random House (Vintage Books); 1978.

Bok, S. Secrets: On the Ethics of Concealment and Revelation.New York: Random House (Vintage Books); 1983.

Crigger NJ. Always having to say you're sorry: an ethical response to making mistakes in professional practice. Nurs Ethics. 2004;11 (6):568-576.

Crook ED, Stellini M, Levine D, Wiese W, Douglas S. Medical errors and the trainee: ethical concerns. Am J Med Sci. 2004;327 (1):33-37.

Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients' and physicians' attitudes regarding the disclosure of medical errors. JAMA. 2003;289 (8):1001-1007.

Gawande A. When doctors make mistakes. The New Yorker. 1999; (Feb 1): 40-55.

Hilfiker D. Facing our mistakes. NEJM. 1984;310:118-122.

Hobgood et al. Parental preferences for error disclosure, reporting, and legal action after medical error in the care of their children. Pediatrics. 2005;116 (6):1276-1286.

Leape L. Error in medicine. JAMA. 1994;272:1851-1857.

Matlow A, Stevens P, Harrison C, Laxer RM. Disclosure of medical errors. Pediatr Clin N Am. 2006;53:1091-1104.

Sheldon M. Truth-telling in medicine. JAMA. 1982;247:651-654.

Truthfulness in the Physician-Patient Relationship

1. Instructor's Guide 2. Student's Guide 3. Case Discussion

This instructor's guide was developed by Douglas J. Opel, MD, senior fellow, Clinical Bioethics, and Douglas S. Diekema, MD, MPH, director of education, Treuman Katz Center for Pediatric Bioethics and Palliative Care, Seattle Children's Hospital.

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