Pharris Livingston

Professor Emerson

IDMD 101

26 October 2023

Unnecessary Medical Intervention and Treatment Errors

The topic was introduced to the class through three sources. The first was “When Evidence Says No, But Doctors Say Yes” by David Epstein. In this paper, Epstein describes the extremely prevalent yet relatively unknown issue of physicians performing medical interventions or prescribing drugs that have been proven to be harmful, ineffective, or inferior to other treatments.

The second source was “Medical Error, Malpractice And Complications: A Moral Geography” by David M. Zientek. This passage explains how recent research has shown that medicine has put a major emphasis on preventing system errors but not so much on actual human error. This could pose an unintended negative consequence of shifting attention from individual moral agency in untoward incidents. The third source was not referenced in the class discussion, and, for this reason, I see no utility in summarizing it.

I kicked off the discussion with a current healthcare conundrum that was introduced by Epstein. The question was as follows, “What do you believe is the correct balance between strict FDA Drug approval that ensures drug efficacy and safety and more casual FDA approval that allows patients to receive drugs sooner?” This question was met with a notable silence that I take as a good representation of the difficult decision that this question poses. The first comment made explained that it was difficult to hold any other view except supporting strict FDA approval because Epstein was so against loose FDA regulations. The class concluded that it came back to an argument about personal freedom. The individuals that supported loose FDA regulation did so on the grounds that if a patient decided that they were willing to bear the responsibility of any negative side effects of a drug, then they had the right to receive the drug. This argument was opposed three different ways. The first argued that because we would not fully understand the long-term side effects of drugs that are not well tested, they could have negative side effects that outweigh the benefit. I can agree with this point but not because the future negative side effects could outweigh the benefits. I can agree because this would mean that the patients would be incapable of providing informed consent as being informed of possible long-term effects would be impossible. This would mean that patients would be incapable of accurately deciding if they were willing to bear the responsibility of the negative side effects of experimental drugs when there is no way to know the severity of those side effects. The second was that loose regulations could jeopardize physician credibility because they would be the ones to prescribe treatments and, therefore, could share in the culpability of future complications. This point was quickly dismissed by the idea that physicians would not be held responsible, the patients would. I agree with this rebuttal. The last point argued that doctors are a beacon of authority and experts in their discipline; therefore, patients could not just receive a drug if they were willing to take a risk. The overall response to this point was that this denies patients the autonomy to make decisions about their own health. This was the end of this exchange as the issue came back to the core discussion, and everyone made their own conclusions based on what they valued more: personal autonomy or physician expertise.

My next question was asked as follows, “In the 2nd article by Zientek, it is stated that a healthy hospital environment encourages its physicians to speak up regarding their own mistakes so that further mistakes can be avoided. How do you believe that hospitals can foster this environment considering physicians are incentivized to keep their mistakes to themselves?” The class’ first reaction to this question was the suggestion that a hospital environment was largely dictated by respected authority figures; therefore, if they accepted accountability for their actions, then the whole hospital would. This argument was strongly supported by a student who admitted that there was a moment when working at a pharmacy where he or she thought they might have made a mistake, but because they respected their manager, was entirely open to discussing the error. After some investigating, it turned out that they were not at fault and the problem was fixed. I fully agree with the class regarding this discussion. Leading by example is an important aspect of any authority position, so if a certain environment is desired in hospitals, it is the responsibility of the hospital leaders to establish norms.

As this discussion reached a consensus I asked my third question based on a hypothetical described by Zientek. The question went as follows, “Zientek describes an anecdote in which a nurse accidentally hangs the wrong IV bag, but as a result of being overworked and bags not being clearly labeled. How much of the blame of this error do you believe lies with the nurse versus the system that perpetuated the error?” The first few points basically placed the entirety of the blame on the hospital system, which was supported by the fact that the bags were not labeled well. Initially, I did not subscribe to this idea. Even though the system definitely shares in the blame, the nurse did make a mistake. He or she should be checking the labels to IV bags carefully enough to avoid any kind of error; therefore, the nurse also shares culpability. I maintain this belief, but I fully agree with the idea that healthcare workers are people too. So, hospitals are obligated to help minimize mistakes. Poorly labeled IV bags are unacceptable. The class then began to discuss the reason that the nurse was overworked: a shortage of healthcare workers. The reasons the class listed for this shortage was the mistreatment of healthcare workers, the cost of education, and a lack of medical school and residency opportunities. This led Dr. Emerson to ask, “If overworked nurses are a systematic error, how do you fix systemic issues?” One student explained that if the entire staff of hospitals maintained accountability, then preventable action could be taken against systematic errors. This would be more effective than increased funding because these issues could not be solved by financial means. I do agree that money would not solve most medical systematic errors, but I also do not believe that money was ever even considered for a solution considering that hospitals have the money to solve problems if it is deemed necessary.

I had many takeaways from this discussion. The first was the idea that when deciding between strict and loose FDA drug regulations, the discussion comes down to one’s beliefs regarding the importance of personal autonomy or physician expertise. When debating this in the future, these two values should be the focus of the discussion. My second takeaway was that in order to foster an environment of accountability in medicine, it is the responsibility of authority figures to encourage accountability through example. My final takeaway was that hospitals are obligated to maintain systems that minimize gross error in the treatment of their patients, and if systematic error is involved in a mistake, the blame lies entirely with the system.

Works Cited

Epstein, David. “When Evidence Says No, but Doctors Say Yes.” ProPublica, Feb. 2017, www.propublica.org/article/when-evidence-says-no-but-doctors-say-yes. Accessed 10 October 2023.

Zientek, David M. “Medical Error, Malpractice and Complications: A Moral Geography.” HEC Forum, vol. 22, no. 2, 18 May 2010, pp. 145–157, https://doi.org/10.1007/s10730-010-9130-9. Accessed 10 October 2023.

Pharris Livingston

Physician Assisted Death

Physician assisted death is the practice of a physician giving a terminally ill patient the means to end his or her life. Physician assisted death has been a controversial medical topic for many years. The opposing sides of the debate are a fantastic representation of the long standing medical dilemma of balancing patient autonomy with a physician’s paternalism and traditional role as a healer. An article by Charlotte Huff discusses the history of this debate and outlines each side of the argument. Huff begins her article by describing some statistics originating from the state of Washington, who had just legalized physician assisted death just over a year before the article was published. She explains that this makes Washington the 2nd U.S. state to legalize physician assisted death as Oregon legalized it as early as 1994. Huff transitions this description of what was the current political state of physician assisted death to the more general aspects of the moral dilemma. She explains how the physicians opposed to physician assisted death generally hold the view that it violates the physician’s core responsibility to heal and comfort. On the other hand, supporters argue that patients have a right to decide how they will die, especially considering that these patients are already terminally ill.

The statistics that Huff includes from Washington were that, in total, 63 people requested and obtained the lethal medication. Of these 63, 47 died, but only 36 did so as a result of taking the medication. Huff explains that “in expressing their end-of-life concerns, all reported fearing loss of autonomy. Other common concerns were loss of dignity, reported by 82%, and loss of the ability to participate in enjoyable activities, reported by 91%” (Huff). Similarly, of the 460 people who underwent physician assisted death in Oregon from 1998 to 2009, 91% stated that “loss of autonomy was the leading concern” (Huff). Inadequate pain control and financial implications of treatment were also points of inquiry, but, when compared to loss of autonomy, they were significantly less prevalent. The main takeaway from this data is that autonomy is of utmost importance to patients when considering physician assisted death.

The Stanford Encyclopedia of Philosophy defines paternalism as “the interference of a state or an individual with another person, against their will, and defended or motivated by a claim that the person interfered with will be better off or protected from harm” (Dworkin). Paternalism is relevant to physician assisted suicide because withholding the option of physician assisted death from patients is a paternalistic act that does not respect patient autonomy, so the question as to the justification of this paternalistic act is what the debate on physician assisted death largely hinges on. The articles “Medical Paternalism – Part 1” and “Medical Paternalism – Part 2” by Daniel Groll discuss the moral validity of medical paternalism. Groll finds that two accounts of paternalism hold the most moral weight: the authority account and the beneficence account. Groll explains that the authority account is when “a clinician acts paternalistically when, for her patient’s good, she usurps his decision-making authority,” and the beneficence account is when “a clinician acts paternalistically when, for her patient’s good, she acts only or overridingly out of concern for his good” (Groll 1). The main difference between these accounts is that the beneficence account characterizes a physician’s act as paternalistic because the choice to disregard a patient’s autonomy is based on the physician’s belief that the act is for the patient’s own good. This is different from the authority account because the authority account does not take the physician’s motivation to act for the patient’s own good into account. Groll argues “for a conception of paternalism according to which a person acts paternalistically to the extent that she acts in a way that is only or overridingly motivated by concern for another person’s good. In the context of medicine, this is often appropriate since for many patients – i.e. those that are not competent to make their own decisions – the only (or at least primary) consideration that is relevant for the surrogate decision maker is the patient’s good” (Groll 8). With this definition of paternalism established, Groll recognizes that the well-being of the patient is not the only factor that must be taken into account as the patient’s right to dictate his or her own treatment is also important. The conflict arises when what the physician views as preferable for the patient’s health contradicts what the patient desires (Groll 8). Groll concludes that because the authority account trumps the beneficence account, “acting paternalistically (at least when it comes to competent patients) is presumptively impermissible” (Groll 1). 

When placing the issue of physician assisted death in the context of this conclusion, it appears that restricting patient access to physician assisted death is not justifiable as it is a paternalistic action that does not allocate patient’s with the freedom to choose if they want physician assistance in their death. One counterclaim that could be made against this conclusion is the idea that patient’s who are not mentally fit to make decisions about their treatment could request physician assisted death. In this scenario, Groll explains that it is morally permissible to make decisions for a patient that is unfit to make his or her own decisions: a belief that is well established across medicine (Groll 8).

When reading the article by Huff regarding the history and ongoing debate of physician assisted death, I believe that the side of the argument that a reader would take would be largely based on the reader’s own perceived preferences for his or her own death and the likelihood that he or she would be open to utilizing physician assisted death if the possibility presented itself. I would assume that the readers that fear a loss of autonomy, being a burden, or suffering greatly in their final moments are generally more likely to support the legalization of physician assisted death because they would actually consider using it. Conversely, readers that would not consider physician assisted death are more likely to support the restriction of it. Another factor that would likely affect how readers perceive the issue would be how strictly they believe doctors must abide by their traditional role as a healer. Readers who believe that doctors must stay extremely loyal to their obligation to heal patients are more likely to be against physician assisted death while readers who do not feel that this traditional role is binding or should have any tangible authority over real world issues are more likely to support physician assisted death.

Works Cited

Dworkin, Gerald. “Paternalism (Stanford Encyclopedia of Philosophy).” Stanford.edu, 2020, plato.stanford.edu/entries/paternalism/.

Groll, Daniel. “Medical Paternalism – Part 1.” Philpapers.org, 2014, philpapers.org/rec/GROMPP. Accessed 10 Oct. 2023.

Groll, Daniel. “Medical Paternalism – Part 2.” Philpapers.org, 2014, philpapers.org/rec/GROMPP. Accessed 10 Oct. 2023.

Huff, Charlotte. “Doctors Debate the Ethics of Assisted Suicide.” ACP Internist, 1 July 2010, acpinternist.org/archives/2010/07/suicide.htm.