058. Accidents

A discussion we weren’t meant to have.

Due to the pandemic, we will meet remotely on March 23 at 7 PM EST (Zoom link here)

Questions to ponder

  1. Who are you and why are you here?
  2. Diagnosis is a conclusion resulting from an observation of symptoms and a knowledge of human conditions during the practice of the medical arts and sciences. Error can manifest in the enterprise at just about any level – a mistake in observation, an omission of symptoms, an incomplete knowledge of human conditions – and cascade forward, affecting prognosis and treatment. As such an incorrect diagnosis is a singular form of “accidental” medical error. Under what circumstances is an individual practitioner at fault? Can the medical system itself be at fault? Are there times when neither is error and accidents just happen?
  3. Schubert et al. identify four aspects to a framework of identifying liability in medical error: intent (what was a practitioner trying to do), etiology (is there a causal connection between an action and an undesired result?), context (could others of skill in the art have identified/prevented the error readily?), and outcome (does the error result in harm?). Are these four facets sufficient? Is there any feature you would add/eliminate/(de)emphasize?
  4. How do we assign blame?
  5. A surgeon, working 12 hours straight on a difficult and complex open chest heart surgery in the final hour nicks a small vein. After completing the surgery, the patient awakens, spends a few days in recovery, is able to go home. A week after surgery, on the way to their check-in appointment, the patient suffers a cardiac event resulting from the small wound in the nicked vein. Could anything have been done to prevent this or is this “just the way that it goes”?
  6. There has been a trend in modern healthcare systems to shift away from blame and punishment of medical errors in order to facilitate disclosure of said errors. What’s more, self-blame – such as guilt, regret, and remorse – can lead to negative psychological effects on individual practitioner, possibly worsening their abilities. Tigard posits “those who take the blame are in the best position to offer apologies and show that mistakes are being taken seriously, thereby allowing harmed patients and families to move forward in the wake of medical error.” Should medical practitioners take on more active role in their errors (I made a mistake) or a more passive role (mistakes were made)?
  7. Do the “systems” of medicine preferentially/implicitly/necessarily induce accidents in people of color more often than others?
  8. “Medical error” has been identified as the third leading cause of death of the United States with studies putting the annual toll in the hundreds of thousands. Who or what is at fault for these massive casualties? Can the regularity of these deaths (on the order of one every other minute) be said to be accidental or systemic? 
  9. Tort law is ultimately intended to promote rectificatory justice, i.e., to pay for harms done. One study found the cost of the medical liability system to be approximately 2.4 percent of total healthcare spending in America (or about $91 billion last year). Is this too much, too little, or just about the right amount of money to be spending on medical errors? (Note, this does not account for the cost of the loss of life due to medical error, merely in the insurance and litigation of such errors.)
  10. “Moral luck” is the contingency of circumstance in moral actions. Consider the scenario in which two doctors are tasked with determining the presence of cancer in their patients, one in the habit of ordering a standard suite of tests intended to diagnosis a wide range of cancers (resulting in larger medical bills, but fewer misdiagnoses) and one who orders narrowly tailored tests based on the observation of symptoms, conditions, and second opinions (resulting in lower medical bills, but an increased possibility of a missed diagnosis). Is one practicing medicine more legitimately than the other? If a patient presents with a difficult case (uncommunicative patient, incomplete medical records, rare cancer), and one fails to diagnose the patient, are they “in error”? Would the patient’s demise in such a case be an accident?
  11. There will come a time when our condition(s) will be diagnosed by both an artificial intelligence and a human medical practitioner. Who ought to make the first diagnosis and who the confirmatory diagnosis?
  12. If a machine-learning algorithm used to aid diagnosis makes an “error” who is at fault?
  13. Fate and Fortune being as they are draw our souls into a world of circumstance and happenstance. Are/Were we meant to be here?
  14. Is it better to come (or go) “on accident” or “on purpose”? 

Readings to consider