Question

Read the case, "Medical Errors: Paradise Hills Medical Center" beginning on page 19 of the Perry text. If this matter is to be considered by the ethics committee, what issues do you believe the committee must consider before issuing its decisions?

PARADISE HILLS MEDICAL CENTER is a 500-bed teaching hospital in a major metropolitan area of the South. It is known throughout a tri-state area for its comprehensive oncology program and serves as a regional referral center for thousands of patients suffering from various forms of malignant disease.

Paradise Hills is affiliated with a major university and has residency programs in internal medicine, surgery, pediatrics, obstetrics and gynecology, psychiatry, radiology, and pathology, all fully accredited by the Accreditation Council for Graduate Medical Education. In addition, Paradise Hills has an oncology fellowship program, a university-affiliated nursing program, and training programs for radiology technicians and medical technologists. All of these teaching programs are highly regarded and attract students from across the nation.

Paradise Hills enjoys an enviable reputation throughout the area. It is known for its high-quality care, its state-of-the-art technology, and its competent, caring staff. Although Paradise Hills is located in a highly competitive healthcare community, it boasts a strong market share for its service area. Its patients provide significant referrals to the surgery, pediatrics, and radiology programs as well.

Paradise Hills is a financially sound institution with equally strong leadership. Its past successes can be attributed in large part to its aggressive, visionary CEO and his exceptionally competent management staff.

But all is not as well as it seems at Paradise Hills. Although the oncology program still enjoys a healthy market share of 75 percent, it has been slowly and steadily declining from a peak of 82 percent two years ago. In addition, the program's medical staff is aging, and some of its highest admitting physicians are contemplating retirement. The oncology fellowship program was established a few years ago to address this situation, but unfortunately the graduates of this program have so far elected not to stay in the community. Of most concern to the Study CEO and his staff is the fact that the hospital's primary competitor has recently recruited a highly credentialed oncology medical group practice from the North­east and has committed enormous resources to strengthening its own struggling oncology program.

Last week Paradise Hills's board of trustees had its monthly meeting, with a fairly routine agenda. However, during review of a standard quality assurance report, one of the trustees inquired about a section of the report indicating that 22 oncology patients had received radiation therapy dosages in excess of what had been prescribed for them. It was explained that the errors had occurred as a result of a flaw in the calibration of the linear accelerator and that the medical physicist responsible for the errors had been asked to resign his position. Another trustee then asked if the patients who had received the excessive radiation had been told about the errors. The CEO responded that it was the responsibility of the' medical staff to address this issue, and they had decided not to inform the patients about the errors. The board did not agree that the medical staff were solely responsible for informing the patients about the errors and requested that the administrative staff review both the hospital's ethical responsibility to these patients and its liability related to this incident, and report back to the board within two weeks.

The CEO and his management staff responsible for the radiology department and the oncology program met with the medical staff department chairmen for internal medicine and radiology, the program medical directors for oncology and radiation therapy, and the attending oncologists. The CEO related the board's discussion about the errors and the board's request that the actions taken be reviewed, specifically the decision not to inform the affected patients.

All of the physicians agreed that the adverse effects of the accidental radiation overdose on the patients were unknown. The oncologists argued that the patients should not be told of the incident, asserting that the cancer patients did not want or need any more bad news. "Let's face it, these patients are terminal," they said. "Informing them about this error will only confuse them and destroy their faith and trust in their physicians and in the hospital." Furthermore, they claimed, informing the patients of the errors could unnecessarily frighten them to the extent that they might refuse further treatment, which would be even more detrimental to them. Besides, the physicians argued, advising the patients of potential ill effects just might induce those symptoms through suggestion or excessive worry. Every procedure has its risks, the radiology department chairman insisted, and these patients signed an informed consent.

Physicians know what is best for their patients, the attending oncologists maintained, and they would monitor the patients in question for any ill effects. The department chairman for internal medicine was of the opinion that the incident was clearly a patient-physician relationship responsibility and not the business of the hospital. Besides, the radiology chairman added, informing the patients would "just be asking for malpractice litigation."

The medical director for the oncology program then suggested that the board of trustees and the management staff "think long and hard" about the public relations effect this incident would have on the oncology program. "Do you really think patients will want to come to Paradise Hills if they think we're incompetent?" He asked.

The CEO conceded that he supported the position of the medical staff in this matter and that he, too, was concerned about preserving the image of the oncology program. But "his hands were tied" because the board clearly considered this an ethical issue that would have to be referred to the hospital's ethics committee for its opinion.

The physicians noted that if indeed the ethics committee subsequently recommended that the patients be informed, then realistically that responsibility would rest with the patients' primary care physicians and not with any of them.

Answer 1

The most important thing that needs to be looked in teh issue is the challenges which the hospital is facing. The committee should draft a report in which they need to keep a table of the issues faced in hospital on a daily basis to include, competition, recruitment for doctors for the department, market competition and the need to up skill themselves to the level of their competitors every day. They need to see how new doctors can be recruited to solve this issue and then think accordingly. They need to make the infrastructure to match up with the level of the other hospitals in the vicinity. They also need t evaluate the strengths of the current doctors in teh staff and seek their help in increasing the new hires.This can help to analyse the steps needed to improve the condition and become a reputed hospital.