Many argue that moral character, or “being good,” leads to moral action, or “doing the right thing.” This is particularly true among surgeons. However, it is possible to do the right thing for a bad reason, and vice versa. Rather, the motive for taking a specific action speaks more to character, or virtue, than the action itself. Doing “what is right” may not be easy or widely supported. This is especially true when the “right thing” for the patient may bring about a negative consequence for the surgeon or institution. Surgeons may be deterred by a particularly difficult conversation with a patient or family member about surgical error, or the fear that an admitting to an error will lead to litigation. Reluctance to face these situations is understandable. Such cases are likely to trigger the instinct for self-preservation; however, when this instinct arises, virtuous motives and good moral character reinforce the decision to act in a way that is consistent with moral norms.

Some virtues serve surgeons particularly well in matters of patient safety. A small sample of noteworthy examples includes trustworthiness, truthfulness, respectfulness, discernment, courage, conscientiousness and humility (Table 29.2). However, just as “the road to hell is paved with good intentions”; virtuous motives are often not enough. This is especially the case when faced with complex moral dilemmas in which there is no satisfactory solution, let alone a clear right or wrong. When these cases arise, it may be preferable to use a defined framework to help evaluate the various options and come to a decision. For this, the field of medical ethics often employs a framework that has come to be known as principlism.

Moral norms, specifically principles, are commonly employed to inform moral conduct. In their book, Principles of Biomedical Ethics, bioethicists Tom Beauchamp and James Childress, present an ethical framework for medical decision-making based in common morality theory, or principlism [10]. This framework is known today as the four principle approach to biomedical ethics, and is a common normative tool to “identify and reflect on moral problems” in biomedical ethics. The four principles—respect for autonomy, beneficence, nonmaleficence, and justice—and their general implications for patient safety in surgery are briefly introduced in this section [10]. The ethical application of these principles to patient safety in surgery is expanded upon later in this chapter. The relationship between theory, principle, and practice as it relates here is illustrated in Fig. 29.1.

Respect for autonomy recognizes the patient as the decision maker and facilitates action in accordance with patient choice [10]. This places the onus on the surgeon to provide patients with sufficient knowledge to enable reasonably informed medical decisions. As such, “while the surgeon is the authority, the patient has the authority” [8]. Respect for autonomy acknowledges the fact that patient decisions are informed by personal values, opinions, beliefs, and experiences. As a result, objective assessments of a “medical benefit” may not align with the patient’s subjective benefit assessment [11]. The classic example is that of the exsanguinating patient who requires urgent transfusion in order to survive. An objective assessment of medical benefit points clearly towards administering blood to the patient in order to preserve life. However, if the patient is a Jehovah’s Witness who adheres to the belief that it is not permissible to accept blood products, regardless of the possibility of death [8]. For the patient, receiving blood products may lead to excommunication from their community and fear of eternal damnation. From this patient’s perspective, benefit is not a question of the physical outcome, but the spiritual one. In patient safety, both prospective informed consent and full disclosure of all medical errors are obligatory to respect for autonomy. A decision to withhold information based on what the surgeon thinks the patient should do, or not to disclose information about the cause of an error, is paternalistic and violates patient trust.

Derived from the principle of nonmaleficence, the maxim to “Do no harm,” is inextricably linked to patient safety. The principle of nonmaleficence denotes an obligation not to impose harm or the risk of harm [10]. Nonmaleficence relates closely to the principle of beneficence, the ethical obligation to maximize benefits and minimize risks and costs. In this context, harms are defined as adverse outcomes that occur as a direct or indirect result of medical error. Nonmaleficence refers primarily to errors of commission [2], such as surgical slips or wrong site surgeries; however, its application is both active and preventative. Conscientiousness is a particularly valuable virtue in surgeons as both meticulousness and thoroughness are traits that lend themselves to prevention of surgical harms.

In patient safety, beneficence presumes an obligation to avoid errors of omission [2], such as incorrect diagnosis, failure to perform a necessary surgery, or failure to utilize evidence based practices. To maximize benefits, the surgeon and members of a patient’s care team have an obligation to execute procedures and provide quality post-op treatment to ensure the best possible outcome from surgery. To minimize risks and costs, there is an obligation to minimize the potential adverse consequences of error. This applies to psychological, financial and physical harms. Should an error of any scale occur, a timely, carefully executed apology and description of plans for follow up or future prevention will often minimize the harms experienced by victims after the event. Further, doing so allows individuals and organizations to learn from errors in order to prevent future harms. The ability to learn from adverse incidents when they occur is a function of both beneficence and nonmaleficence.

Justice asserts that equals ought to be treated equally, and “unequals” should be treated unequally. In healthcare, the principle of justice insists on fair distribution as well as fair, equitable, and appropriate treatment in light of what is due or owed to individuals and groups [10]. Justice-based obligations related to patient safety in surgery are closely connected to the principles of nonmaleficence and beneficence.

First, there is an obligation to provide an appropriate (i.e. adequate) standard of surgical care to patients. Similar to beneficence, surgeons who believe they are putting patients at undue risk of surgical harm must address the problem [12, 13]. Further, all members of the surgical team have a duty to take action if he or she recognizes a problem in a colleague that may introduce undue risk. If a team member notices a pattern of carelessness or error, or believes a colleague may be impaired and says nothing, then he or she is morally complicit to subsequent harms. When faced with the obligation to approach a colleague or superior to report suspected negligence, moral virtues such as truthfulness, courage serve surgeons and other personnel well. Second, there is an obligation to ensure that surgical resources are distributed fairly among all patients who need them [14]. Efficiency is implicit to the concept of fair distribution. Efficient care is care that both meets patient needs and is not wasteful. Preventable adverse events that result in harm to the patient do not meet either standard. Nor do unnecessary surgeries. Finally, patients or their loved ones ought to be able to seek compensation for harms when they do occur [2, 12].

According to Beauchamp and Childress, these principles present a “prima facia” obligation that “must be fulfilled unless it conflicts on a particular occasion with an equal or stronger obligation.” An obligation related to the four principles is always binding unless it conflict with another obligation of equal weight. When this happens, the optimal solution is that which finds the greatest balance between the two in the specific circumstances [10].

A simple example is the conflict between autonomy and nonmaleficence in cases involving disclosure of near miss medical errors. On one hand, there is a duty to disclose based in autonomy and the patient’s right to know. On the other, there is the concern that telling a patient about the near miss error will do more harm than good. There is also the possibility that not disclosing may do equal or worse damage if the patient finds out. Given the fact that the patient’s response to disclosure can be affected positively by employing communication skills that help with disclosure, it is possible to respect autonomy and do so without inflicting additional harms. If the surgeon decides not to disclose, then autonomy is not respected in any regard. Therefore, the option that provides the greatest balance between the autonomy and nonmaleficence is well-executed disclosure (Fig. 29.2).

Public health ethics is the systematic analysis of moral problems that arise in public health and preventive medicine. The ethical act in public health is one that aims to improve or preserve the health of the public. Thus, there are different principles that emerge as paramount to decision making and policy development. Besides the principles associated with “do no harm,” utility and fairness (or social justice) are central to the systems approach to patient safety.

One view of public health ethics involves the balance of individual liberties with the advancement of good health outcomes for the population, or autonomy with utility [14]. The principle of utility promotes maximal balance of benefit over harm or other costs [10], and is a concept that is paramount to public health ethics. In this context, utility asserts a duty to promote action that will do the most good for the most people as opposed to what is in the best interest of an individual patient. The principle of utility is apparent throughout current patient safety policy recommendations as both a justification for action and a consideration in weighing options for specific policy. The principal measure of utility in this context is health, but economic utility is also a significant motivator. In other words, money will motivate when nothing else will. However, if financial concern is the primary motivation, then significant conflicts arise when doing the right thing for safety are actually costs more to implement than to allow errors to continue.

Fairness is also integral to understanding the public health approach to patient safety. The principle of fairness technically falls under the principle of justice; however, as with “do no harm,” it applies slightly differently in this context. Fairness not only encompasses fair distribution of resources, but also calls for policies of action that preserve human dignity and show equal respect for the interests of all members of the community [15].

While informed consent is discussed in depth in a previous chapter, it is important to stress that the informed consent process is principally an ethical tool for respecting persons, rather than a legal formality. The informed consent process, as a function of respect for autonomy, is founded in the patient’s right to be adequately informed about the risks and benefits of his or her treatment, and his or her right to decide whether to accept treatment under given conditions. Respect for autonomy is especially crucial in surgery due to the invasiveness, short term harm, and “temporary unconscious state of the patient” [12]. With respect to patient safety, the informed consent process should include an honest discussion of the potential complications of a proposed surgery.

Surgeons must recognize and avoid personal bias, and must not allow personal opinion about what “should” be done to impact the content or quality of the information that is provided to the patient during the consent process. The surgeon is charged with disclosing all information pertinent to the patient’s participation in the fiduciary relationship. The extent of the disclosure ought to depend on severity of the potential complication, the likelihood of occurrence, and the patient’s preferences to be informed [12]. This is also referred to as the “reasonable person standard”; the surgeon should provide the amount of information that a reasonable person in the patient’s circumstances would want to know.

What a reasonable person would want to know in order to make a decision is not the same as deciding what a reasonable person would decide. If misinterpreted this way, the surgeon may not provide information tailored to the specific patient. The patient will influence the extent and content of disclosure. Information about patients, such as activity level, profession and other interests, may help surgeons better assess what information he or she should include during the consent process.

After errors occur, patients want incidents to be acknowledged, information about what happened, an apology, a plan for prevention of future errors [16, 17], and access to financial reparations and legal action [17]. Virtues that aid disclosure include courage to do the right thing, humility to admit to making an error, and truthfulness.

Any argument against full and transparent disclosure of surgical errors lacks ethical standing. Patients have a right to be informed about their medical care. To withhold knowledge of a near miss event denies the patient the right to make medical decisions given all of the potentially relevant information, and violates trust. In addition, failing to report knowledge of a near miss or other type of error committed by a colleague violates beneficence, by impeding the ability to learn from near miss incidents.

There is discrepancy between the number of practicing physicians who agree that all medical errors should be disclosed to patients, and those that actually practice full disclosure [16–18]. Some of the reasons doctors do not disclose include: the belief that harm is trivial or that patient will not find out; the belief that the patient would not want to know or would not understand; personal psychological reasons, such as self-preservation or denial; and fear of litigation [16, 19]. Not surprisingly, those who believed that litigation may be reduced by disclosure, were more likely to disclose. The research shows that surgeons are less likely to explicitly disclose medical errors than other medical specialists [16].

Disclosure alone is an insufficient tool for minimizing the harms that occur as a result of medical error. It is evident that the simple act of saying “sorry” does not meet the needs of patients or family members. Without proper training and execution, apologies may be perceived as disingenuous and may cause additional harm. Patients want apologies to include an assumption of responsibility [20]. An apology should include: (1) information about what happened and what will happen in response; (2) sincerity; and (3) appreciation for those involved and how they will be impacted not only financially but emotionally [16, 20, 21]. Communications researchers have also indicated that the non-verbal cues play an important role [20]. In western cultures, well executed apology is associated with positive response and reduced likelihood that a patient will change physicians [21]. In response to concerns about liability, apology laws have been enacted by two thirds of the states, some of which disallow use of statements made during an apology to be used in future litigation. However, the structure of these laws has been criticized for impeding full apology.