Introduction
The instant ethical review case reviews involve a malpractice suit regarding the treatment of a patient by a surgeon. All material events involved in the case took place in the early parts of the 21 st century, between 2001 and 2003. The main parties involved are Estate of Arturo Iturralde, the deceased patient; , Hilo Medical Center, a hospital; , Hawai‘i Health Systems Corporation, a not-for-profit medical equipment provider; from the government of the State of Hawaii; , Medtronic Sofamor Danek which is , a manufacturer of medical equipment,; and finally, Robert Ricketson, a surgeon. The deceased patient, Arturo Iturralde, had an operation under the care of Robert Ricketson. The operation took place at Hilo Medical Center using equipment manufactured by Medtronic Sofamor Danek and supplied by Hawai‘i Health Systems Corporation.
At the operation table, the surgeon realized that the supplied equipment did not include two titanium rods that the surgeon was to fix into the patient's spine. The surgeon elected to improvise and used a stainless- steel piece of metal that he cut off from a bolt. However, this information was never shared with the patient. Afterward, the improvised steel bolt raptured, leading to injury and the need for several surgeries to rectify complications that arose specifically due to the surgeon's improvisation. Due to the complications and the need for frequent hospitalization, the patient gradually deteriorated and finally died in 2003. The patient's Estate sued the parties listed above, and subsequent appeals involving the liability of third parties such as Medtronic caused the case to reach the Intermediate Court of Appeals of Hawaii eventually. The said court found in favor of the deceased patient Arturo Iturralde and remanded the case for further proceedings at the lower court.
Delegate your assignment to our experts and they will do the rest.
Medical Malpractice Component
Key Legal Components
The malpractice component, in this case, involves the primary professional, the surgeon. Surgeons, as licensed professionals, are bound by the law and professional ethics to provide the utmost care to their patients in good faith. Among the requirements of utmost care involve adhering to set down rules of procedure (Weiss, 2017). In the instant case, the surgeon was supposed to ensure that each instrument and equipment necessary for the surgery was in place before commencing with the procedure. The doctor was informed that there was no inventory for the required equipment before commencing the surgery but elected to proceed. Such conduct in itself amounted to misconduct.
Standard of Care
The standard of care for the scenario in the care as set down by law and rules of procedure is that doctors cannot use medical equipment that is not tested and licensed for use in specific procedures. In the instant case, the doctor used a piece of stainless steel that he created in the operating room, on the spinal cord of the patient. Such use amounts to malpractice and illegality. Finally, the law and rules of clinical practice provide for patient autonomy, and clinicians should seek patient consent in making critical decisions. In the instant case, the surgeon did not consult the patient or the patient's loved ones before or after improvising. The patient did not know that there was a problem with the surgery until complications arose. The cover-up was a major breach of both the law and professional ethics (Weiss, 2017).
Malpractice Policies
As outlined in the court ruling, there a set policy in place for the reporting and investigation of medical malpractice. Normally, the investigation begins with a report by a professional who witnessed potential malpractice. Alternatively, the patient who has been the victim of malpractice can also make a report. The report will lead to a professional investigation in which the professional accused of malpractice will have an opportunity to elucidate the issue (Thiels et al., 2018). If there is potential for malpractice, the administration of the hospital may involve the professional body which has licensed the practitioner. In the case where the act of malpractice also involves a crime, law enforcement will also be involved in the investigation.
The Culture Perspective
Further, although the culture of a patient is a common bearing factor in medical malpractice cases, in the instant case, culture did not play an active role. It is important to note that according to the facts of the case, the cover-up was successful save for a whistleblower. After the surgery, a nursing officer reported the surgeon's error and its aftermath, but the report was ignored. After complications led to several secondary surgeries on the patient, the same nursing officer once again made a report, but the hospital's administration again ignored the report even after the patient died. The parties involved in the malpractice were only held to account after the nursing officer leaked information about the error to a lawyer and the family of the deceased patient. The level of success of the cover-up reveals a broken accountability system.
Accountability Process
From the perspective of accountability, it is telling that the clinician involved and hospital administration almost successfully covered-up the mistake and its aftermath. In the instant case, the surgeon elected to create an unlicensed stainless steel part and use it on a patient without informing the patient as it would have uncovered a mistake. The cover-up created a cascade of complications that ended up with the death of a patient. It took the courage of a whistleblower to reveal the events and thwart the cover-up process. As reflected in the malpractice segment above, there are systems in place for the investigation of medical malpractice. However, such systems fail when professionals do not adhere to them. The accountability process in the healthcare system is thus in need of review.
Ethical Component
Ethical Issues Involved in the Case.
The fundamental principle of bioethics is pPrimum non nocere , meaning, first, do no harm, which is a nNon-maleficence fundamental rule (Weiss, 2017). In the Hippocratic Oath, doctors bind themselves to treat all patients with a view never to injure or undertake wrongdoing. Protecting patients is the fundamental ethical principle that the surgeon in the instant case undertook. By not following the laws, rules, and regulations as outlined above, the surgeon intentionally exposed the patient to potential harm and injury. This mistake is the initial ethical breach. The second ethical breach relates to cover-up. From an ethical perspective, the practice of medicine is supposed to follow deontology. Under deontology, a decision is right if it is lawful and in adherence to the duties of the decision-maker (Mandal, Ponnambath & Parija, 2016).
Applicable Ethical Theory in the Case
In the instant case, the doctor and the hospital's administration were supposed to own up to the error and investigate how it happened. However, the surgeon and the hospital elected to adhere to another theory of ethics, utilitarianism. Under utilitarianism, an action is right if it brings pleasure to the majority while visiting limited displeasure to the minority (Mandal, Ponnambath & Parija et al., 2016). Admitting the error may have affected the surgeon and the hospital, thus harming other patients who rely on them. On the other hand, if the administration admitted the mistake, the admission would have allowed for another surgery to correct the mistake. The cover-up amounted to electing utilitarianism instead of deontology, which cost a patient's life.
Patient Shared Decision-making Model
The suitable Shared decision making (SDM) for such cases, would require the involvement of the patient in every critical decision relating to the surgery. In the case where the patient is unconscious, the surgeon can consult a designated member of the family who is supposed to determine the best interest of the patient (Carlisle, Shinkunas & Kaldjian, 2018). Important decisions should include consulting the patient or the patient's loved ones. In the case of emergencies in the operating room, consultation should be at the earliest after averting the emergency.
Proposed Ethical Guidelines and Its Defense
From an ethical perspective, I would propose that the hospital embraces a deontological approach to ethics, not a utilitarian one. The laws, rules, and regulations that govern the practice of medicine have taken centuries to develop, through an approach of gradual betterment. It would be pretentious and erroneous for a single practitioner or the administration of a hospital to attempt to override set down rules. Under deontology ethics, the decision-maker does not evaluate whether the rules are right or wrong but seeks to apply them as they are. Such an approach would have prevented both the incident in the operating room and the resultant cover-up. Further, an approach that embraces full adherence to the law in the investigation of malpractice will ensure a higher level of care in the healthcare profession, which will, in turn, reduce cases of malpractice. There is a need for trust between healthcare professionals, their patients and the general public. Strict adherence to the law can enable healthcare professionals ear and maintain the necessary level of trust with the said external stakeholders.
Recommendations and Conclusion
The instant case arose due to the combination of an error and a cover-up. The recommendations outlined herein canvass both the error and the cover-up.
Clinicians should operate under the principle of "trust and verify" when dealing with suppliers of medical equipment.
An active verification process should take place before any surgery involving material supplied by third parties.
Clinicians should operate under a deontological approach, not a utilitarian one when dealing with patients. The life and health of every patient are sacred.
Shared decision making (SDM) is fundamental for every patient. Clinicians should not make any significant decisions without consulting the patient or the patient's designated guardian.
There should be a proper reporting mechanism for malpractice in hospitals. The hospital's administration should report each case of malpractice thoroughly and transparently, including the application of SDM.
Arturo Iturralde passed away in 2003, whereas the Intermediate Court of Appeals of Hawaii determined this case in 2012. The determination included sending the case back for a retrial which would take several more years. The legal costs alone for the hospital would be astronomical, so would the loss of time in preparing for the suit and attending court proceedings. Eventually, the hospital would still incur heavy losses in terms of damages and negative publicity. Therefore, seeking to cover up errors and malpractice costs hospitals more than adhering to set laws and rules of procedure. Cover-ups are not in the best interest of the practice of medicine or the running of hospitals, a fact that vindicates the recommendations made herein.
References
Carlisle, E. M., Shinkunas, L. A., & Kaldjian, L. C. (2018). Do surgeons and patients/parents value shared decision-making in pediatric surgery? A systematic review. Journal of surgical research , 231 , 49-53.
Mandal, J., Ponnambath, D. K., & Parija, S. C. (2016). Utilitarian and deontological ethics in medicine. Tropical Parasitology , 6 (1), 5.
Thiels, C. A., Choudhry, A. J., Ray-Zack, M. D., Lindor, R. A., Bergquist, J. R., Habermann, E. B., & Zielinski, M. D. (2018). Medical malpractice lawsuits involving surgical residents. JAMA surgery , 153 (1), 8-13.
Weiss, D. (2017). Primum Non Nocere: Medicine's Culture of Dealing with and Denial of the Occurrence of Medical Harm (Master's thesis). Linköping University, Linköping .
