Collective Cover-ups
When things go wrong, as they often do, the values and attitudes of both medicine and management can lead to the covering-up of serious failings in an attempt to preserve the reputations of both the medical professionals and management.
For example, there has been increasing public concern about the covering-up or non-disclosure (as it is often called) of medical errors. In the US, for example, the Institute of Medicine reports that there are perhaps over a million preventable adverse events each year. It suggests that of these “adverse events”, between 44,000 and 98,000 led to the deaths of patients. A note of caution should be recorded here, however, because the institute defines a medical error as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim” (Institute of Medicine 2000). But that is a counterintuitive definition of an error: if I plan to meet you at 8pm for dinner and I am prevented from getting to the intended restaurant because of a transport breakdown, I have not made an error. And it is not uncommon for most of us — and especially within the complex world of clinical medicine — to have rational evidence-based plans, which for unforeseeable reasons do not work. Sometimes, for example, the standard, evidence-based antibiotic might not clear the infection because an unknown strain of bacteria has appeared. These failures are hardly “errors”; nevertheless, there are areas of health care in which there are justifiable concerns about non-disclosure. These usually concern poor care, sometimes amounting to negligence. According to an article in YouGov: “One in six British adults knows of someone whose poor treatment by the NHS has been covered-up — and majorities support sacking, prosecuting, and removing the pensions of staff found to be involved” (Dahlgreen 2013). Even allowing for some populist exaggeration from the people questioned in this survey, there is no doubt that coverups are of public concern.There are several reasons why cases of poor treatment might be covered up. The first concerns the collective values of medicine, which encourage the closing of ranks. There is a smooth transition from the sharing of attitudes and a spirit of solidarity to a conspiracy of silence. The second is a legitimate desire not to upset the patient, especially when nothing can be done to put things right. The third, perhaps the most important, concerns fear of litigation. From the doctor’s point of view, there may be a fear of disciplinary action, which could extend to a loss of license to practice. But even from the management point of view, there may be incentives to cover up. For example, the phenomenon of the ambulance-chasing lawyer is common enough, and patients and their relatives can easily be persuaded that they have been badly treated and are therefore entitled to financial compensation. Indeed, in the UK even if the courts find in favor of the hospital and not the patient, costs are likely to be awarded against the hospital. Hence, hospitals may settle out of court because this is cheaper. Again, however, hospital management may not want the bad publicity that comes from admitting to failures in care. At the very least, this would weaken their hospital’s position in a competitive market. Hence, hospitals and their doctors — for different but understandable reasons — are inclined to play down significant adverse incidents. Collective attitudes here combine to work against good patient care. Once again, it may be a convenient fiction to speak of a collective cover-up and to attach moral blame to the hospital as corporate person, but the reality is that there has been a conspiracy of individual silences. Those who knew of the errors or poor treatment, and said or did nothing, are individually morally responsible.
Despite the understandable concerns of hospitals as corporate persons, however, the evidence seems to be that patients are less upset if there is disclosure of errors, provided that the disclosure is done in a compassionate way (Wu et al. 1997). Legal liability is another matter. Nevertheless, the American Medical Association’s Council on Ethical and Judicial Affairs states that “concern regarding legal liability which might result following truthful disclosure should not affect the doctor’s honesty with a patient” (American Medical Association 2007).
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