On higher ground: ethical reasoning and its relationship with error disclosure

There is broad consensus that disclosure of harmful medical errors is vital to improve safety and is ethically required. Although most physicians-in-training are taught ethics, there have been no empirical studies on whether ethical reasoning is related to disclosure. We examined whether scores on a test of ethical reasoning were associated with greater willingness to disclose errors.

We conducted a cross-sectional survey of house officers in internal medicine at Johns Hopkins Hospital. Ethical reasoning was assessed using the Defining Issues Test, V.2 (DIT-2). Higher DIT-2 scores are associated with more sophisticated ethical reasoning, and scores tend to improve after formal ethical training. Respondents were then given a medical error scenario with multiple scripted disclosure options. Ethical reasoning scores were compared for different levels of disclosure.

A total of 29 out of 127 medicine residents completed the survey (response rate=22.8%). The 41% of residents who would explicitly tell a patient that, 'an error happened' had significantly higher DIT-2 scores than those who would not (51.1 vs 31.6, p<0.01). Higher DIT-2 scores were found in the 62% of residents who would give the most detail about the error (44.8 vs 31.2, p=0.04) and in the 71% of residents who would take personal responsibility (43.5 vs 27.9, p=0.03).

Ethical reasoning scores were associated with acknowledging an error, providing more detailed explanations and taking personal responsibility. The low response rate may limit generalisability. Nevertheless, taken together with prior studies showing that ethical reasoning can be taught and measured, our findings suggest that ethical training may help to improve disclosure of medical errors.