Ask the expert - speaking up about ethical behaviour

Dr Marika Davies, a medicolegal adviser, solves your dilemma around speaking up about unethical behaviour.

Question

I recently assisted another junior doctor who was inserting a chest drain into an older patient. The doctor experienced some difficulty doing the procedure, which took a few attempts. The patient repeatedly experienced pain and asked the doctor to stop, but she continued regardless and ignored the nurse’s offers to bring more local anaesthetic. I held the patient’s hand and didn’t say anything at the time, but now I regret that I did not. What should I have done?

Marika replies

You may often find it difficult to speak up, especially as a junior member of the team in a situation where you are uncertain, and when you are understandably keen to have a good relationship with your seniors. Sometimes it is only on further reflection after an event that its importance becomes apparent, leading to worry that you should have done something differently at the time.

The patient will have been comforted by your presence, but you have good reason to feel concerned about what happened. Firstly, with regard to the issue of patient consent: this is an essential requirement for any procedure, and can be withdrawn by the patient at any time. When the patient asked the doctor to stop, they should have respected this and stopped as soon as it was safe to do so. They should then have had a discussion with the patient and explored the option of further pain relief, before seeking the patient’s agreement to proceed. Although, ideally, you would not want to appear to disagree with a senior colleague in front of a patient, it would have been reasonable to politely but firmly draw the doctor’s attention to the fact that the patient was in pain. If they ignored this, you might have fetched more senior assistance or asked the nurse to do so.

The incident also raises a question about whether the junior doctor was competent to do the procedure without supervision, or whether they should have sought senior support when they ran into difficulties. GMC guidance says doctors must recognise and work within the limits of their competence.¹

The GMC also expects you to “raise any concerns you have about patient safety, dignity or comfort promptly.”² Junior doctors often think that they cannot speak up about unethical behaviour, or believe that speaking up will be ineffective.³ Healthcare organisations need to nurture a culture that supports health professionals raising concerns; however, in reality taking a stand is difficult and takes courage.⁴

Developing the confidence to recognise unacceptable behaviour and to speak up about it is something that should be an essential part of medical education.

References

1. General Medical Council. Good Medical Practice.
2. GMC guidance, Raising and acting on concerns about patient safety
3. BMA Survey: Speaking up for patients May 2009
4. Kong WM. What is good medical ethics? A clinicians perspective. J Med Ethics 2015; 41:79-82.

A version of this recently appeared in Medical Student. Student BMJ 2016;24:i3544

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