Tuesday, May 20, 2008

Honesty and Forgiveness in Biomedical Ethics

About four weeks ago, my wife underwent surgery on her face for melanoma. What initially appeared to be a pimple on her left cheek had been identified as cancerous. The purpose of the surgery was to remove tissue from her cheek and from sentinel lymph nodes to which the cancer might have spread. We were happy when tests showed that there were no cancerous cells in this tissue. But she will have to undergo extensive tests every two months for years to look for any reappearance of the cancer. We were also happy with the surgical work of Dr. Tapas K. Das Gupta, the 76-year-old chairman of surgical oncology at the University of Illinois Medical Center at Chicago. We discovered that Dr. Das Gupta is a master cancer surgeon who was able to do the surgery so that the scars on my wife's face will eventually be hardly noticeable.

We were very interested, therefore, when we saw the front page article on Dr. Das Gupta in the Sunday New York Times (May 18). This article by Kevin Sack was entitled "Doctors Start to Say 'I'm Sorry' Long Before 'See You in Court'." The article opens with the story of Dr. Das Gupta making a serious surgical mistake two years ago. He was supposed to remove a sliver of tissue from a woman's ninth rib. But instead he removed the tissue from her eighth rib. When he discovered his mistake, he told the patient what he had done and apologized to her. He told her: "After all these years, I cannot give you any excuse whatsoever. It is just one of those things that occurred. I have to some extent harmed you."

This is not standard practice for doctors. Most medical malpractice lawyers would advise doctors and medical administrators never to admit their mistakes. Because it has been long assumed that to avoid expensive malpractice suits, medical personnel should refuse to acknowledge their mistakes.

But according to this article, a few hospitals have adopted a new policy of honesty and forgiveness. Patients are told about the medical mistakes that have harmed them, and they receive an apology from the doctors. And contrary to what the malpractice lawyers have assumed for years, there is evidence that this has reduced the number and expense of medical malpractice lawsuits in the hospitals adopting the new policy.

In Dr. Das Gupta's case, the patient decided not to sue, and accepted compensation of $74,000 from the hospital. Her lawyer said: "She told me that the doctor was completely candid, completely honest, and so frank that she and her husband--usually the husband wants to pound the guy--that all the anger was gone. His apology helped to get the case settled for a lower amount of money."

For many decades, doctors and hospitals have been receiving ethical advice from professional bioethicists. Why has it taken so long to recognize the moral benefits from honesty and forgiveness? They might have seen this sooner if they had followed the tradition of moral philosophy from Aristotle to Adam Smith and Charles Darwin that stresses the importance of moral emotions. Reasoning is important for moral judgment because we need to deliberate about our moral decisions. But some moral philosophers (like Immanuel Kant, for example) assume that morality requires a dispassionate, abstract rationality that suppresses the emotions. But in the Aristotelian tradition that includes Smith and Darwin, morality rests in a complex interaction of reason and emotion.

I saw this many years ago when I wrote my book on Aristotle's Rhetoric. I noticed that most scholars interested in Aristotle's moral and political philosophy ignored or disparaged Aristotle's Rhetoric, because it gave so much weight to persuading people through their emotions. But for me, this pointed to a fundamental insight running through all of Aristotle's moral and political writings--that "reason by itself moves nothing," and that reason moves us only insofar as it elicits some emotional motivation. This is particularly true in politics, because political debate always turns on emotional appeals. Adam Smith developed this same insight in his Theory of Moral Sentiments. Darwin deepened this tradition of thought by showing--in The Descent of Man--how the moral emotions could have arisen in the evolved human nature of the moral sense. Most recently, neuroscientists have uncovered the neural roots of the moral emotions in their complex interaction with cognitive reasoning. As I have argued in both Darwinian Natural Right and Darwinian Conservatism, this new research on the neurological basis of moral emotions and moral judgment confirms Aristotle's moral psychology.

For example, Aristotle in the Rhetoric analyzes the rhetorical psychology of anger. He defines anger as a desire for vengeance for an undeserved slight. Starting with this definition, he can then explain the various ways that anger is aroused or calmed. One way to calm people's anger is to apologize and ask for their forgiveness, because this removes the feeling of being slighted.

When medical patients think they have been harmed by medical mistakes, they become angry if they think the doctors are being dishonest in covering up their mistakes, because this insults the patients. If the doctors honestly admit their mistakes and ask for forgiveness, this act of humble confession of fallibility can calm the anger of the patients.

There is another lesson here. We often assume a conflict between morality and expediency, so that one's self-interest conflicts with one's moral duties. The Kantian tradition of moral philosophy makes that assumption about true morality as absolute selflessness. But the Aristotelian-Smithian-Darwinian tradition would question this assumption by suggesting that in the long run morality and expediency coincide. And so, in this case of medical malpractice, honesty really is the best policy, because honesty and forgiveness can calm the moral indignation of patients in ways that reduce the economic costs of malpractice lawsuits.

I can testify to this in a personal way, because in learning about how Dr. Das Gupta handled his surgical mistake two years ago, my wife and I found that we gained more respect for our doctor, with the knowledge that he was willing to honestly recognize his fallibility and ask for forgiveness.


Anonymous said...

Professor Arnhart:

I am sure that I am not alone among your readers in wishing your wife the best.

As way of preface: I have not made it competely through Darwinian Natural Right yet, but the main arguments are brilliant and very compelling (and obvious only in retrospect). Could I ask if you specifically chose to use the word "desire" (which you use in a very full sense) as a response to Strauss' challenge in the foreward to NRH that uses that same word?

With regard to this post: I am a physician and find the NYT article somewhat misleading in two ways. The first is that the only appropriate thing to do when you remove the wrong rib, etc. is to be open and honest. This is not a change. No one would ever have advocated pretending that the correct rib had been biopsied, removed, etc. The second issue is the suggestion that a new "openness" is a good defense against medical mal. plaintiffs attorneys. The tort reform which has worked so well in Texas (lower insurance premia, influx of subspecialists to formerly underserved areas, the emigration of trial lawyers, etc.) is the only real answer to that.

Anonymous said...

Just found your blog via google. Came to your name through research (your book is mentioned in Fukuyama's 'Our Posthuman Future') for a paper I'm writing for the human rights course I'm in. Interesting stuff you write about.

Anonymous said...

Thank you for sharing your and your wife's medical experience candidly. Restoring Humanity and Compasiion in Healthcare is not only the "right" thing to do but also, as you state, the most expeditious and cost-effective. It will take more physicicans and patients with courage to realize tort reform is not the only answer. And may not be the answer tey thinnk it is at all.
Mary Ellen, Founder, PULSE of PA, www.pulseofpa.org