John Banja, from the Center for Ethics at Emory University, has written a book about the psychological reactions of physicians to causing harm to patients, and why disclosure of harmful errors to patients is so difficult. His book is called Medical Errors and Medical Narcissism, and I highly recommend reading this book to gain a perspective on why physicians have such a difficult time honestly talking with patients about errors. In this post I summarize Chapter 2, in which Dr. Banja describes two models for rationalizing the concealment of medical errors. These rationalizations provide a way for the physician to feel satisfied with giving a less-than-truthful explanation (or no explanation) to the patient.
The first model is based on a physician’s need to resolve their cognitive dissonance. This cognitive dissonance arises from three things: the need to maintain their identity as a moral and competent professional, the realization that they have made an error causing harm, and the knowledge that the ethical action is to disclose the error to the patient (but this would be an unpleasant experience). The purpose of rationalization is to convince themselves that concealing the error is the right thing to do, and therefore concealing the error is consistent with their identity as a moral individual. Rationalization proceeds by reinterpreting the situation. Some of these strategies for reinterpreting (drawn from the work of psychologist Jo-Ann Tsang and explained on pages 33—34) are:
- Euphemistic language: Choosing words and phrases to conceal harm, such as calling the outcome of an error a “complication”.
- Advantageous comparison: Comparing the concealment to something worse, such as believing that telling the patient will only make the patient feel worse.
- Distorting the consequences of an action: Reinterpreting the consequences in a positive light, such as saying that a lethal error was a “blessing in disguise” or a learning experience.
- Displacing responsibility: For example, blaming the malpractice insurance carrier of a hospital policy for not allowing disclosure.
- Diffusion of responsibility: Transferring responsibility to an entire group of people. There is some validity in placing responsibility on a group when the error resulted from a system failure (such as a chain of events that led to a medication error). However, this form of reinterpretation is dangerous when it is used to dismiss responsibility rather than acknowledging responsibility of the team or organization.
- Attribution of blame: Blaming another individual, such as the patient, for an error.
- Fragmentation: Diverting attention from the “bad” self to the “good“ self by emphasizing examples of life-saving work as a physician.
The second model of rationalization is based on a bioevolutionary model by psychologist Daniel Goleman. This model is based on characteristics of neurological activity that occur in response to a threat to survival. As Dr. Banja writes, “…the brain’s first response of pain alerts an individual to the danger, while the brain’s second response diminishes the pain he or she might feel from it. Bioevolutionists speculate that the reason for this neuromodulatory two-step is to alert the organism, first, that it is in very serious trouble but then to diminish the way physical pain might compromise the organism’s survival opportunities through immobilizing fear or panic.” (p. 35) The organism’s attention is then selectively directed toward action to escape the threat or pain. Banja extends this to moral situations by postulating, “…if the factual and/or moral reality of the event is too painful, the event can be reconstructed through rationalization so that a person’s sense of moral salience (i.e. what ought to be done or how to understand what is happening) is redefined.” (p. 37)
This pattern of selection-and-reinterpretation can lead to justification for concealment of errors. One form of this pattern of thinking is to recognize that an error occurred, but to focus on events before or after the error. For example…
- This was caused by the inexperience of the nurse, which was not his/her fault.
- The possibility of this type of outcome was mentioned in the consent form.
- We cannot say for sure that the error caused this outcome.
Selection-and-reinterpretation can also act on perceptions of the outcome of an error:
- The patient would have eventually died anyway.
Alternatively, selection-and-reinterpretation can be used to rationalize that an error did not occur:
- Not all experts agree on what the definition of an error is.
- This was simply the result of under-staffing.
So how can these theories inform efforts to educate healthcare professionals on the responsibility to disclose errors? Individuals who understand these mechanisms of rationalization are more likely to overcome it. As Dr. Banga explains, “…the more the individual evinces a struggle between his or her self-serving impulses that encourage error rationalization versus consideration about what the patient is owed, as articulated in section 8.12 of the AMA code, the more conscientious and attentive he or she will be of various competing motives and reasons to rationalize. If this individual has neural representations that are strongly supported by ‘moral emotions’ that incline him or her to ethical other-regarding behavior despite the pain he or she may nevertheless experience by owning the error, he or she will be said to be morally courageous.” (p. 41)