Review the case of Paradise Hills Medical Center, below. The CEO has asked you for a recommendation. What will you tell him?

PARADISE HILLS Medical Center is a 500-bed teaching hospital in a major metropolitan area of the South. It is known throughout a tri-state area for its comprehensive oncology program and serves as a regional referral center for thousands of patients suffering from various forms of malignant disease.

Paradise Hills is affiliated with a major university and has residency programs in internal medicine, surgery, pediatrics, obstetrics/gynecology, psychiatry, radiology, and pathology, all fully accredited by the Accrediting Commission for Graduate Medical Education. In addition, Paradise Hills also has an oncology an oncology fellowship program, a university-affiliated nursing program, as well as training programs for radiology technicians and medical technologists. All of these teaching programs are highly regarded and attract students from across the nation.

Paradise Hills enjoys an enviable reputation throughout the area. It is known for its high-quality care, its state-of-the-art technology, and its competent, caring staff. While Paradise Hills is located within a highly competitive healthcare community, it boasts a strong market share for its service area. Indeed, its oncology program enjoys a 75 percent market share and its patients provide significant referrals to the surgery, pediatrics, and radiology programs as well. Paradise Hills is a financially strong institution with equally strong leadership. Its past successes, in large part, can be attributed to its aggressive, visionary CEO and his exceptionally competent management staff.

But all is not as well as it seems to be at Paradise Hills. While the oncology program still enjoys a healthy market share, it has been slowly but steadily declining from its peak of 82 percent two years ago. In addition, the program's medical staff are aging and some of its highest admitting physicians are contemplating retirement. The oncology fellowship program was established a few years ago in anticipation of this, but unfortunately, thus far the graduates of this program have not elected to stay in the community. Of most concern to the CEO and his staff is the fact that the hospital's major competitor has recently recruited a highly credentialed oncology medical group practice from the Northeast and has committed enormous resources to strengthening its own struggling oncology program.

Last week the board of trustees for Paradise Hills had its monthly meeting with a fairly routine agenda. However, during review of a standard quality assurance report, one of the trustees asked for clarification of a portion of the report indicating that 22 oncology patients had received radiation therapy dosages in excess of what had been prescribed for them. The board was informed that the errors had occurred due to a flaw in the calibration of the equipment. The board was also informed that the medical physicist responsible for the errors had been asked to resign his position.

The question was then asked if the patients who were recipients of the excessive radiation had been told of the error. The CEO responded that it was the responsibility of the medical staff to address this issue and it was their decision that the patients not be informed of the errors. The board did not concur that the responsibility for informing the patients of the errors rested solely with the medical staff and requested that the administrative staff review the hospital's ethical responsibility to these patients, as well as its liability related to this incident, and report back to the board within two weeks.

The CEO and his management staff responsible for the radiology department and the oncology program met with the medical staff department chairmen for internal medicine and radiology, the program medical directors for oncology and radiation therapy, and the attending oncologists.

The CEO reported on the board discussion related to the incident and the board's request for a review of the actions taken, specifically the decision to not inform the affected patients. The physicians as a whole agreed that the adverse effects of the accidental radiation overdose on the patients were unknown. Therefore, they argued the patients should not be told of the incident. These are cancer patients and they don't want or need any more bad news, the oncologists argued.

"Let's face it, these patients are terminal." "Informing the patients of this error will only confuse them and destroy their faith and trust in their physicians and in the hospital," they added. Furthermore, they claimed, informing the patients of the errors may unnecessarily frighten them to the extent that they may refuse further treatment and that would be even more detrimental to them.

Besides, argued the physicians, advising the patients of potential ill effects just might induce these symptoms through suggestion or excessive worry. Every procedure has its risks, insisted the chairman for radiology, and these patients signed an informed consent. Physicians know what is best for their patients, the attending oncologists maintained, and they will monitor these patients for any ill effects.

The department chairman for internal medicine volunteered that, in his opinion, this incident is clearly a patient-physician relationship responsibility and not the business of the hospital. Besides, added the chairman of radiology, informing the patients would "just be asking for malpractice litigation."

The medical director for the oncology program then suggested that the board of trustees and the management staff "think long and hard" about the public relations effect of this incident on the oncology program. "Do you really think patients will want to come to Paradise Hills if they think we're incompetent?", he asked.

The CEO conceded that he supported the position of the medical staff in this matter and he, too, was especially concerned about preserving the image of the oncology program, but "his hands were tied" since the board clearly considered this an ethical issue and one that would be referred to the hospital's ethics committee for its opinion.

The physicians noted that if indeed it was the subsequent recommendation of the ethics committee that these patients be informed, then realistically, that responsibility would rest with the patient's primary care physician and not with any of them.