April 1981 II/8


Recently, two articles evaluating the performance of health care professionals appeared in the New England Journal of Medicine. One article reported "a one year prospective survey to identify adverse outcomes due to error during care in the field of general surgery." The other article studied "iatrogenic illness on a general medical service at a university hospital." Because the topic of error is significant for everyone associated with healthcare, especially patients, I would like to reflect upon these articles from an ethical point of view. The article evaluating error in patient care in general surgery reported that the approximate incidence of complicated cases amounted to about one percent. There were 56 important errors in all, and in 11 cases the patients died with surgical mistakes as a contributing factor. The origins of error were identified as misplaced optimism, unwarranted urgency, urge for perfection, and vogue therapy. "The predominant example of fallibility appears to have been insufficient restraint and deliberation. Excessive haste, impatience, overconfidence and inadequate peer group consultation were important influences in this regard." However, all the errors seem to be due to error of judgment rather than error of negligence.

The article concerned with medical service defines iatrogenic illness as "any illness that resulted from a diagnostic procedure or from any form of therapy, or harmful occurrences that were not natural consequences of a patient's disease." This study reports on 815 patients; of these, 290 (36 percent) had one or more iatrogenic illnesses, with a total of 497 such occurrences. A total of 76 patients (nine percent of all those admitted) had major complications. In 15 cases, the iatrogenic illness was believed to have contributed to the death of the patient. The three causes of most iatrogenic events were drugs, cardiac catherizations, and falls. Of all patients with complications, 53 percent had at least one problem related to drug exposure.

Ethical Observations

1. The hospital trustees, administrators, and medical personnel responsible for these studies are to be commended for the thorough evaluation of their work. Thorough evaluation of one's efforts in order to improve effectiveness is an ethical responsibility, especially when the effort in question is concerned with important human values such as health and life. Through surveys of this nature, even though they may be painful, health care professionals should be able to determine the prevalence of avoidable errors and establish surveillance and educational procedures which will minimize them. Something similar to these studies should be instituted in each reputable health care facility so that greater proficiency and accountability result.

2. There are two sources of error and iatrogenic illness, namely mistaken judgment and negligence. In every way possible, negligence must be guarded against by physicians and other health care professionals. Methods and procedures must be instituted to control and, if possible, eliminate negligence. But these studies show that even when negligence is minimized or eliminated the potential for error and complication still remains due to mistaken judgment. Thus the fact that medicine is not an exact science is demonstrated vividly once again. In both surgery and medicine, there are many things, especially the reaction of patients to particular drugs or procedures, which cannot be predicted in advance. Though good physicians are careful, if they were to act only when they were absolutely certain, they would not act very often. This is the nature of the service that they offer people. Most people in health care realize the potential fallibility of their judgments, but it would seem that the general public should be educated in this regard as well. Many patients have unrealistic expectations of health care professionals. Often they are frustrated and angry when these expectations are not fulfilled. Thus, better relationships between health care professionals and patients would exist if the nature of medicine were clearly understood by all concerned.

3. As the authors of the medical study indicate, the risk incurred during hospitalization is not trivial. Thus serious considerations should be given to new methods of monitoring untoward occurrences in hospitalized patients, especially as the result of drugs. Some might respond that most hospitals already have committees that should attend to the incidence of iatrogenic complications. One can legitimately wonder, however, whether the processes utilized in most hospitals to evaluate quality care are as thorough as those indicated in these articles. Moreover, one questions whether such studies are ever made public. A recognized expert In hospital administration states that few hospitals would have good enough records to allow quality assurance studies of this nature. Though the Joint Committee on Accreditation (JCAH) does make some effort to have hospitals evaluate their services, the methods utilized depend upon the local health care facility. Thus the objectivity and openness needed to produce effective quality care studies is not often present. Tn a profession, in order to ensure competent service and personal satisfaction, there should be peer evaluation and peer discipline. Are these two characteristics fully operative at the present time in the profession of health care?

4. The surgical study emphasizes that complications arising from physicians' errors contribute to the high cost 05 medical care. No one can deny that complications in surgery and medicine will increase the cost of health care. But is this the major reason why health care professionals should be concerned about preventing surgical errors and iatrogenic illness? Should not they be more concerned about the effect these errors and complications have upon the patient, the physician and other health care professionals? Not one word is offered about patient suffering or family sorrow due to errors by physicians or hospital personnel, Nor is there any mention of the anguish, sorrow and self-doubt caused in the lives of people offering health care. There is a degrading and dangerous tendency--degrading to the health care professional and dangerous to the patient-to make cost and economics the principal standard by which medicine and health care are evaluated. This tendency is most obvious when people speak about the "health care industry." Health care is not an industry; it is a profession. As such, its first standard of evaluation for its efforts is patient well-being and human welfare. Though monetary factors must be considered, they should not dominate or control the evaluation of health care.

Kevin O'Rourke, OP


1. NEJM; Mar. 12, 1981; Vol. 304, n.11; p.634-641.

© Kevin O'Rourke, O.P.