- © 2004 Canadian Medical Association or its licensors
A recent CMAJ editorial about the outbreak of Clostridium difficile-associated diarrhea in certain Canadian hospitals1 describes the “stifling of concerned voices on the front lines of medicine” as the “worst news” in a bad-news story.
What causes silence in such situations? Health care “insiders” are frightened they might make the situation worse. They worry that disclosure of problems will be seen as unjustified criticism, not just of the current state of affairs in the health care system, but also of health care professionals — in some cases colleagues — who are already stretched to their limits, demoralized and working miracles in very difficult situations. There is a risk of being labelled as not being team players, as troublemakers, as self-serving in some way, or as “the enemy” — whistleblowers often are — and of suffering the consequences of such stigmatization. Those consequences can include loss of professional opportunities, promotion, prestige, a congenial work situation and even friendships.
Addressing these problems is complex, and it would be a grave mistake to think otherwise. But I would like to make a few suggestions as to where we might start. First, we must recognize that it can be seriously unethical to not speak out and to not change a culture that does not recognize the necessity of open disclosure. Furthermore, it is not only people who can be unethical; systems can also be unethical. Therefore, we must try to design ethical hospital systems. At the least that requires protecting those who try to prevent or correct breaches of ethics — for instance, whistleblowers — and ensuring that the organizational structure does not create or condone what Nuala Kenny calls “ethical distress.”2 A person experiences ethical distress when he or she knows that another is acting unethically but, because of lines of authority, is powerless to do anything about it or would suffer serious repercussions by doing so. In short, we need a comprehensive system of identified corrective mechanisms and remedies for such situations.
Finally, many ethical mistakes are made because an ethical problem is not recognized as such, but rather is wrongly identified as a public relations or communications problem. Instead of asking what ethics requires in the situation, those involved ask, “Will it make the minister, the hospital, etc., look bad, and if so, how can we avoid that?” The problem is spin-doctored, a process that often augments the ethical wrongs, as for example in deciding for public relations reasons not to tell the public about risks or tell patients about mistakes.
I once heard a PR person give the following advice: “Never say you don't know. Never say you were wrong. And never apologize.” How not to do ethics, in a nutshell.
Margaret Somerville Centre for Medicine, Ethics and Law McGill University Montréal, Que.
Reference
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