The Australian Federal Health Minister Nicola Roxon has announced plans for a national health database. According to a report in The Australian today, the current version of these plans includes enabling patients to look up mortality rates for surgeons as well as rates of hospital-acquired infections and readmission rates. This development is seen by many as a response to a series of recent medical scandals in Australia, most notably the ‘Dr Death’ scandal at Bundaberg Base Hospital in Queensland. Predictably the Australian Medical Association is opposing these changes. Their reaction has been slammed by the Australian nurses union who have accused medical staff of ‘closing ranks over rogue surgeons’, according to Samantha Maiden, writing in The Australian.
The current Australian Government proposal is far reaching but it is far from groundbreaking. It follows in the footsteps of similar proposals that have been implemented in the United Kingdom, over the past ten years, as well as some American precedents. Comparative cardiac surgeon’s performance data has been published on the internet by the United Kingdom Healthcare Commission since 2006. Visitors to http://heartsurgery.healthcarecommission.org.uk/ can discover survival rates for coronary artery bypass grafts, aortic valve replacement surgery, and for all forms of heart surgery, for individual surgeons working at surgical units across the United Kingdom.
The ethics of publicising surgeons’ performance information is examined from a variety of different angles in a volume I co-edited, with Justin Oakley in 2007 entitled Informed Consent and Clinical Accountability: The Ethics of Report Cards on Surgeon Performance. See http://www.cambridge.org/catalogue/catalogue.asp?isbn=9780521687782
In the introduction to the edited volume we identify three ethical arguments in favour of publicising surgeons’ performance information. The first of these is the argument that the reporting of such information has the potential to enable patients to make better-informed decisions regarding surgery – thereby upholding the value of autonomy, which is a widely accepted ethical demand, particularly in health care.
The second argument is that by publishing such information, the surgical profession helps to fulfil its duty to be accountable to the community. The Australian Medical Association argues against the national database on the grounds that it would undermine their independence from government regarding standard setting. However, we argue that the government grants the surgical profession a monopoly on provision of surgical procedures, and in exchange for monopoly control the surgical profession has a reciprocal obligation to demonstrate to the community that its services are of an acceptable standard.
The third argument is that publicising surgeons’ performance information improves the quality and safety of surgical care. This is a consequentialist ethical argument, which has it that the consequences of introducing a system of publicising surgeons’ performance information will be beneficial for the general public, all things considered. The evidence for this third argument is not conclusive, however, studies of New York State, the area where cardiac surgeons’ performance information has been publicised for the longest (since the early 1990s) generally indicate that the quality and safety of cardiac surgery has improved as a result of the publicising of surgeons’ performance information.
Opponents of the publicising of surgeons’ performance information, including Rosanna Capolingua, the president of the Australian Medical Association, are often heard to complain that publicising surgeons’ performance information will lead to surgeons practicing ‘defensive surgery’, avoiding difficult cases. Two of the contributors to our edited volume have examined this issue and neither find the case for defensive surgery to be compelling.
Rosanna Capolingua is reported in The Australian as having claimed that the plan to publish surgeons’ mortality rates carries a risk of triggering an exodus of doctors from the public hospital system. But there is no evidence of any such effect having taken place in either the United Kingdon or in the parts of the United States where surgeons’ performance information has been publicised.