Toward a Theory of Medical Fallibility

Dated Jan 1, 1976; last modified on Thu, 02 Sep 2021

Medical care is like the opposite of moving fast and breaking things. If it’s so taboo to admit error, then that could make errors more common because fewer people are learning from past errors.

Norms for Scientific Activity and the Sources of Error

“Science” is taken to mean “Natural Science”.

Internal norms derive from a cognitive pursuit of science. They are:

  • Focus on the central rather than the peripheral problems of the science in in question.
  • Craftsmanship standards in the design of experiments and hypothesis testing.
  • Distinguished theorizing is elegant and simple.
  • Searching for a theory that is closer to the truth than the currently accepted theory.

External norms govern motives for participating in and using the results of scientific activity, e.g.

  • Care in acknowledging contributions of others, and the priority of publication.
  • Reasons for a particular scientist doing this rather than that sort of science.

Given that these norms influence scientists, all scientific error arises from either:

  • The limitations of the present state of natural science, i.e. ignorance.
  • Or, the willfulness of negligence of the natural scientist, i.e. ineptitude.

Pure vs. Applied Sciences

Applied sciences differ from pure sciences in that they are defined with essential reference to some practical aim, and in terms of subject matter which is identified in pre-scientific terms.

Just as the pure scientist can only err from ignorance or ineptitude, so can the applied scientist, e.g. a physician prescribes a drug with unfortunate side effects, then, barring willful intent, either the limits of pharmaceutical and physiological knowledge are to blame, or the physician was negligent.

Reinterpreting Natural Science

Natural science claimed to discard Aristotelianism, but it actually retained an inability to give a plausible knowledge of particulars. The scientist looks for law-like relationships between properties, and the particulars are merely bearers of the properties under consideration.

While some particulars, e.g. ice cubes, can be understood as the sum-total of the physical and chemical mechanisms that operate on them, others cannot, e.g. salt marshes, hurricanes, higher primates, etc.

To predict any outcome, a scientist needs:

  • Accurate formulations of the relevant laws.
  • Knowledge of the initial conditions and boundary conditions.
  • A controlled and limited environment, where state transitions are detached from historical antecedents and interventions of environmental circumstance.

Reminds me of Markov Chains in ORF 309.

1 in 1,200 experience dangerous (and sometimes fatal) effects as a reaction to the smallpox vaccine. While there must be reasons why those individuals succumb, we do not know all the relevant laws and the victim’s conditions and the victim’s interaction with the environment subsequent to vaccination. So our predictive ability is constrained.

Principles of crystal formation are inferred from the observable characteristics of diverse particular crystals. The differences between crystals are not the point - it is their similarities that support generalization.

In contrast, in medicine, how a particular patient differs from another is as important as the characteristics shared with the general population.

Therefore, the current definition of natural science that is concerned exclusively with knowledge of universals blinds us to the existence of particulars as proper objects of knowledge.

A Science of Particulars

Some consider science to be amoral. It is the scientist’s duty to pursue empirical truth, but qua scientist, they have no further concern with the social effect of the discoveries or the ethical status of the process of inquiry that led to the discoveries.

Eyes on you, Wernher Von Braun

However, if science is to be properly concerned with particulars as well as universals, then other values, like the fluorishing of the particulars, are as internal to science as truth-seeking and problem-solving.

Necessary Fallibility

Empirical, inductively founded “characteristically-and-for-the-most-part” generalizations may be the best instruments of prediction about particulars. However, as the evolving environment interacts with the particular, it may lead to unavoidable predictive failure.

Without full and systematic records of medical errors, it is impossible to provide the empirical basis necessary for an adequate theory of the limitations upon the predictive powers of physicians.

The physician-patient relationship should be redefined as one in which necessarily mistakes will be made, sometimes culpably and other times inevitably. The public also needs to understand that treatment is part of medical science and not a mere application of it.

Knowledge about the individual patient is not merely essential, but it is always and necessarily potentially inadequate to the extent that an intervention from an “Olympian physician” may still lead to damaging error. It then follows that injury is not proof of culpability.

Malpractice and Compensation Policy

A medical action should be considered malpractice based on whether it was performed justifiably, and not whether there were iatrogenic injuries.

The specification of the canons of good medical practice needs an accurat understanding of what has previously worked, and of the degree to which autonomy of judgment in clinical circumstances tend to a good medical result.

Therefore, the primary burden for discovering malpractice, bringing charges and imposing sanctions falls not on the individual injured patient, but on those concerned with the integrity of the medical profession, including perhaps most prominently the practitioners of medicine themselves.

Given the necessary fallibility and barring culpability of medical practitioners, possible alternative policies are:

  • Given a population to which a treatment will be applied, estimate the cost of iatrogenic injuries and absorb them into the general overhead of medical care. For the victim, compensation would only depend on the fact of injury.
  • Iatrogenic costs should be borne like any other natural disaster where relief is provided by private insurance and if large-scale enough, by government intervention.

References

  1. Toward a Theory of Medical Fallibility. Samuel Gorovitz; Alasdair MacIntyre. The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine, Volume 1, Issue 1, January 1976, Pages 51–71. https://doi.org/10.1093/jmp/1.1.51 . Jan 1, 1976.