Doing the right thingBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5288 (Published 20 October 2015) Cite this as: BMJ 2015;351:h5288
There are times when health professionals endanger life and limb to care for their patients. Nearly 900 medical staff have contracted Ebola virus disease in Sierra Leone, Liberia, and Guinea, with 512 deaths, since the start of the current outbreak.1
Army medical personnel have also risked all to treat injured soldiers on the battlefield, under the threat of snipers, ambushes, and roadside bombs. So too have the thousands of humanitarian health workers who have been victims of violence, or threats of violence, in conflict zones.
While physical courage is lauded by all, lesser known is the moral variant of courage. Moral courage is when you act on the conviction that something is morally right even though you believe that something of personal value may be lost. It need not be heroic in the grand, traditional sense. A doctor breaking bad news may show moral courage by avoiding the temptation to dodge the difficult issues. She will tackle head on the question about, say, whether the patient will ever walk again.
Awards for moral courage
Since 2010, Washington Hospital Center in Washington, DC, has given moral courage awards to clinicians who have “exemplified the virtue of courage and acted against difficult and ethically challenging circumstances.” A past winner of the award was a nurse, Crystal, who called a dying patient’s family. The relatives were several hours away and the patient only minutes from death. Anticipating the inevitable, the medical team left the patient, but Crystal stayed behind. For several minutes she held the patient’s hand and uttered comforting words. “No one should ever die alone,” she told the colleague who eventually nominated her for the award. The colleague wrote, “We convince ourselves that we tried our best, so we move on to the next room while a patient dies in solitude. It is difficult to stand in a room and face what feels like defeat. So patients die alone because of our own cowardice and false sense that there must be somewhere more important for us to be at that moment.”
In another act of moral courage a doctor may speak out against an ethical violation when all others are silent. At a morbidity and mortality meeting, the consultant orthopaedic surgeon describes how the operation was conducted on the wrong level of the spine. Another procedure, at the correct level, is needed. No one asks whether the patient has been informed, until a trainee surgeon raises his hand: “Has the patient been told about this?” In a hierarchical department where consultants are emperors, asking that simple question could require tremendous courage.
Duty of candour
Under England’s new duty of candour a health service body such as an NHS trust has a statutory obligation to notify patients of a safety incident that has resulted, or has the potential to result, in moderate or severe harm.2 3 Failure to do so is a criminal offence. As the organisation’s representatives, doctors are responsible for discharging the duty. If your trust has not provided you with training or information on the duty of candour, ask for it.
And yet, even with the duty of candour and the GMC’s guidance that doctors must be open and honest with patients, a culture of secrecy still lingers in many departments. In those places, a doctor who strives to act morally and legally will need moral courage.
At times, matters should be raised with those higher up the chain of command. Few doctors seem aware of paragraph 25 of the GMC’s guidance on consent, which states, “If you think that limits on your ability to give patients the time or information they need is seriously compromising their ability to make an informed decision, you should raise your concerns with your employing or contracting authority.”4 If there is no time to obtain proper consent, whether through lack of staff or some other systemic reason, you should tell the managers and include paragraph 25 in your letter.
Neither should long term gaps in the rota be tolerated, which can push staff to the brink, violate the law on safe working times, and put patients at risk. The GMC states, “All doctors have a duty to raise concerns where they believe that patient safety or care is being compromised by the systems, policies and procedures in the organisations in which they work.”5 Many doctors know that these practices are unsafe and probably illegal, but they do nothing. As Theodore Roosevelt said, knowing what’s right doesn’t mean much unless you do what’s right.
Few doctors work in splendid isolation. Most form part of an organisation. The solution is to create an organisational culture where doing the right thing no longer requires moral courage. It should be expected, even encouraged. And if no award currently exists for “moral courage shown by a clinician” in the United Kingdom, someone should create it.
Cite this as: BMJ 2015;351:h5288
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.