My book, “Medical Errors and Medical Narcissism,” has been in circulation now for about two years. It has received seven published reviews that I know about. Six of them ranged from respectable to extremely positive. One was largely negative. Six were written by nonphysician health professionals. One was written by a physician. I’ll leave it up to you to speculate on who wrote which ones.

I have received a respectable number of speaking invitations to discuss the topic of narcissism in relation to medical error disclosure. Some have even come from physician groups. Upon receiving these invitations, I’m always at pains to point out that by “narcissism,” I do not intend to characterize physicians as imperious, grandiose, out-sized egos who are singularly unempathic. While some certainly are, as are certain individuals in any professional group, my conception of “medical narcissism” is of a psychological defense whose function is to protect the professional from an assault on his or her sense of self. I based this construction on the large volume of psychological research, primarily deriving from cognitive dissonance, attribution, and “motivated reasoning” theory, indicating that when persons are confronted with evidence of their inadequacy or the inadequacy of beliefs or mental constructs that they hold dear, they will often distort that evidence in a manner that ultimately accommodates the self-image, conclusion or belief system they prefer. Of course, in the instance of medical error, one’s natural, self-protective inclination is to conceal or obfuscate the error for fear that its disclosure will eventuate in malpractice litigation. Furthermore, the very thought of disclosing the error is so fraught with embarrassment, anxiety, and humiliation, that it is easy to understand why health professionals might look for reasons to excuse their moral obligation to disclose it or will conduct the communication in a nonincriminating way.

From the very beginning, I believed (as all ethicists do) that disclosing a harmcausing error—when it was reasonably determined that such indeed happened—was ethically required. Consequently, it has been immensely gratifying to watch a decided trend develop in precisely that direction over the last few years. As I read the literature and travel about the country speaking on error disclosure, there is no question in my mind that hospitals are increasingly adopting a policy of frank, truthful, and comprehensive disclosure of error. In the preceding week of my composing this essay, for example, representatives from an Indiana hospital confessed to the national media that their hospital was responsible for medication errors that caused the deaths of three infants. A survey conducted earlier in the year of physician executives at hospitals showed a profound support for error disclosure.

While hospitals might be disclosing their errors more truthfully and honestly, I continue to suspect that physicians are more reluctant to do so. Indeed, recent research asking physicians, “What would you say?,” in the event of harm-causing error tends to confirm a reluctance among many physicians to come entirely clean about it. Unfortunately, though, there is little opportunity to do research in this area in the best way—that is, to actually observe error disclosure conversations between physicians and the persons who have been harmed. One reason is that doing so would probably breach the privileged nature of the communication and open such communications to public view. (So no hospital lawyer is likely to allow it.) The other is that such a research protocol would present a curious informed consent problem. That is, the protocol would bring into question how much information you should give the participant, i.e., the individual who will be informed about the error, prior to the conversation itself. As such, it is hard to believe that hospitals and their doctors would permit an observer, whose intent is to present his or her findings at public presentations or in publications, to observe error disclosure conversations.

In any event, I’ve come across no reason to abandon my “narcissistic” hypothesis; indeed, only materials to corroborate it. But we have to remember that not all narcissism is pathological. The challenge for health care facilities is to enable their professionals to preserve a healthy sense of self but also to do the right thing when harm-causing error rears its ugly head. We must also, I think, reach our medical and nursing students while they are still students and expose them to the ethical literature on medical errors. If we are to be ethical, we need to insist on the patient-centered justification for disclosure such that they realize the self-protective motivation for concealment.

Last, it would hardly surprise me to see significant reform in the arena of medical malpractice insurance—such as instituting no fault or enterprise liability models—that would make it somewhat less onerous for professionals to disclose error. Of course, the best approach is to make harm-causing errors more difficult to commit, by continually developing “goof-proof” systems. We will never see perfectly safe systems. As long as they are human, professionals will commit harm-causing errors and therefore need to remind themselves of their patient-centered obligations to disclose those errors when they occur.

John Banja’s book, Medical Errors and Medical Narcissism, was published by Jones and Bartlett in 2005. It can be ordered online.