When Doctors Are Wrong, and Patients Are Right

Medical Mistakes

Doctors are not infallible.

They often make diagnostic errors. Though the incidence of such errors can be hard to measure, autopsy studies provide one metric that is hard to dispute: “major diagnostic discrepancies” were identified in 10–20% of cases (Graber 2013). Other types of studies find similar results (see Graber 2013).

In some cases, doctors are systematically mistaken about important medical facts. In one study, gynecologists were asked about the likelihood that a woman who has tested positive on a mammogram actually has breast cancer. They were presented with four alternative answers, one of which was correct, and they were given the statistical facts needed to calculate their way to the correct answer, so the task should have been easy.

Only 21% chose the correct answer, which means that the doctors did slightly worse than we would expect them to do if they chose the answer at random (Gigerenzer et al. 2008).

Should We Be Worried?

These facts are troubling. When doctors are wrong, the consequences may be severe. It is tempting, therefore, to react with a scathing criticism of doctors and medical education.

In part, this is warranted. The human tendency to crash and burn when faced with problems that require Bayesian reasoning, which is what foiled the gynecologists in the study above, can be corrected with proper teaching (Gigerenzer et al. 2008). Diagnostic errors that result from cognitive biases could be removed using formalized procedures such as checklists (Ely et al. 2011).

However, as long as doctors remain human, errors will occur. Moreover, since medicine is a field characterized by risk and uncertainty, focusing on individual blame for mistakes runs the risk of focusing on outcomes rather than the procedure leading to those outcomes.

Malpractice

Malpractice suits, which are the legal manifestation of such a focus on individual blame, are more likely to be filed when outcomes are bad, such as when someone dies because of a delayed diagnosis of cancer. The likelihood of the filing (in the case of diagnostic errors) increases with the severity of the outcome (Tehrani 2013). But a bad outcome does not automatically entail any error of medical judgment.

Any positive diagnosis involves a risk of overdiagnosing a healthy patient. Any negative diagnosis involves a risk of underdiagnosing a patient with a serious ailment. As both overdiagnosis and underdiagnosis can lead to serious harm, the trick is to balance the risks according to their costs and benefits, but there is no way to completely avoid the risk.

The Costs of Blame

One serious cost of blaming doctors for mistakes is the phenomenon known as defensive medicine. The harms resulting from underdiagnosis and undertreatment are usually much more spectacular and easy to understand than the harms resulting from overdiagnosis and overtreatment. This means that doctors can minimize the risk of being sued for malpractice by erring on the side of the latter. According to one estimate, defensive medicine costs the US between $650 billion and $850 billion annually (jacksonhealthcare.com).

Another significant cost of the focus on blame is the harm that befalls doctors. Being a physician is stressful. Depression and burnout are common, and the suicide rate among doctors is frighteningly high—41% higher than average for men and 127% higher than average for women (Schernhammer 2004). A likely contributor to this is the blame and guilt associated with making mistakes, or even with making completely justified decisions that, because they involve risk, happen to result in bad outcomes.

Less obviously, focusing too much on the responsibility of the physician obscures the fact that the institution of modern medicine tends to marginalize and overlook a significant healthcare resource: the patient.

The Doctor as Authority

Modern healthcare is still very much an authoritarian institution, where patients come in and are told what to do by the Olympians in white coats. Even title of “patient”, which you automatically gain once you enter the system, denotes passivity, someone “to which something is done” (oed.com). Doctors have access to a special set of skills and knowledge, which is demarcated by high social status and pay and often romanticized in popular culture. To a patient, the doctor is an unapproachable expert, one to which you listen, sometimes literally, on pain of death.

It is no wonder, then, that most of us are afflicted by what Wegwarth and Gigerenzer call the trust-your-doctor heuristic, which is the decision-making rule most of us follow in matters regarding our medical needs: consult your doctor and simply follow her commands (2013).

Because the gap in relevant knowledge between physician and patient is assumed to be astronomical, the responsibility for arriving at the right conclusions is placed squarely on the shoulders of the physician. Though the 20th century has given us the doctrine of informed consent, an institution intended to protect patient autonomy; the underlying picture is still that of a commanding doctor and consenting patient. By being bound by this framework, we risk losing out on the resources patients could bring to bear on solving their own medical problems.

Bridging The Gap With Google

As Andreas Eriksen discussed in his excellent post a couple of months ago, the advent of the internet and Google has increased the information easily available to the average person by several orders of magnitude. This means that the knowledge-gap between doctor and patient is less absolute.

No doubt it’s true that a doctor with Google is better suited to diagnose and propose treatments than most patients with Google. However, it is also true that most patients spend a lot more time thinking about their medical condition, their symptoms and how it affects their life than their doctors do. A doctor can’t spend hours researching on Google every consultation, and they cannot routinely monitor their patients as they go about their daily lives.

Every patient should be considered an expert on her circumstances of life. More and more, the medical knowledge they can muster through the use of Google and other resources should be taken seriously. When combined, these two insights make a good argument that a healthcare model based on the idea that responsibility and authority in medical matters should belong solely to the physician is obsolete.

Taking The Patient Seriously

The involvement of patients in medical decisions should not be regarded merely as matters concerning the protection of their autonomy but as an important part of improving the medical decisions themselves. Through the last couple of centuries, medicine has seen a gradual shift towards a focus on the patient in several ways, through informed consent and, more recently, the ideal of shared decision-making. This is a trend that should continue.

Doctors are sometimes wrong. Patients are sometimes right. On an authoritarian model, the instances where these situations overlap will result in doctors overriding their patients’ correct judgments with their own mistaken ones. In an ideal situation, a patient’s correct judgment should correct the doctor’s mistake. Taking the patient’s resources to make medical decisions seriously should be a step towards achieving this ideal.

Litterature

Ely, John W., Graber, Mark L. & Croskerry, Pat. 2011. “Checklists to Reduce Diagnostic Errors”. Academic Medicine. 86 (3).

Gigerenzer, Gerd, Gaissmaier, Wolfgang, Kurz-Milcke, Elke, Schwartz, Lisa M. & Woloshin, Steven. 2008. “Helping Doctors and Patients Make Sense of Health Statistics”. Psychological Science in the Public Interest. 8 (2). 53–96.

Graber, Mark L. 2013. “The incidence of diagnostic error in medicine”. BMJ Quality & Safety. Online First.

Schernhammer, Eva S. & Colditz, Graham A. 2004. “Suicide Rates Among Physicians: A Quantitative and Gender Assessment (Meta-Analysis)”. The American Journal of Psychiatry. 161. 2295–2302.

Tehrani, Ali S. Saber, Lee, Hee Won, Mathews, Simon C. Shore, Andrew, Makary, Martin A., Pronovost, Peter J. & Newman-Toker, David E. 2013 “25-year summary of US malpractice claims for diagnostic errors 1986–2010: An analysis from the National Practitioner Data Bank.” BMJ Quality & Safety. 22. 672–680.

Wegwarth, Odette & Gigerenzer, Gerd. 2013. “Trust Your Doctor: A Simple Heuristic in Need of a Proper Social Environment”. In Simple Heuristics in the Social World. Hertwig, Ralph, Hoffrage, Ulrich & The ABC Research Group. Oxford University Press.

Authors comment: This post was written after binging a season of “Doctors vs. Google” (originally: “Hva feiler det deg”) the Norwegian TV series that pits a team of people without medical education, but with access to google, against a team of doctors without google. The task: to correctly guess the diagnosis of people based on a brief anamnesis and some rounds of questioning. Andreas mentions the show in his post, which is where I found out about it, and it is worth watching, as it’s both entertaining and a fair showcase of the potential (and the limits) of what patients can achieve with the help of google. Though the doctors often come out on top, this is probably in part because in the weightiest task point-wise, a time constraint means that there is almost no time to use google.

Ainar Miyata-Sturm is a PhD student at the Centre for the Study of Professions (SPS), and part of the project Autonomy and Manipulation: Enhancing Consent in the Health Care Context. He is also the editor of Professional Ethics.

Photo: Sonja Balci

Edmund Henden

Should We Improve Informed Consent Through Non-Rational Intervention?

Why Informed Consent?

A wide swath of human activities require informed consent (shorthand for informed, voluntary, and decisionally-capacitated consent), including employment, medical care, medical research, professional relationships, and so forth.

Respect for autonomy and the value placed in liberal societies in allowing the pursuit of rival conceptions of the good life is what underlies this requirement. As Kant famously put it, people should have “freedom to make public use of [their] reason in all matters […] for we are all equipped to reason our way to the good life” (Kant, I. “What is Enlightenment?” Political Writings. Cambridge University Press, 1991).

A central plank of liberal political philosophy is that infringements of autonomy for any reason, such as paternalistic intervention for the agent’s own good, are entirely unacceptable unless they prevent greater harm to others.

But how good are people at reasoning their way to what constitutes “the good life”, to identify the behaviours enabling them to achieve the ends at which they aim, and acting as they themselves believe they ought?

Evidence of Irrationality

In fact, psychology and behavioural economics have accumulated plentiful evidence that our judgement and decision-making are flawed and biased in predictable ways:

We are subject to cognitive biases that limit our ability to assess evidence. We are motivated by incentives but we have a stronger aversion to losses than we have an affinity for gains. Our acts are often powerfully shaped by emotional associations and influenced by subconscious cues. Hyperbolic discounting frequently interferes with our ability to effectively pursue the goals we are setting for ourselves (many believe it plays a role in substance addiction and also explains the obesity epidemic).

In short, the catalogue of cognitive distortions and volitional pathologies is vast and ever-growing. There can be no question of their significant welfare-reducing effects, not only on the lives of individuals, but also on society.

It is not surprising, therefore, that policymakers, employers, insurance companies, researchers, and health-care providers are increasingly interested in the application of various forms of interventions based on psychology and behavioural economics to affect people’s decision-making with respect to health-related behaviours, lifestyles and habits.

Correcting For Biases

Here is an interesting question for professional ethics: Should we also extend the application of such interventions to the informed consent process in order to enhance comprehension or convey information better than what would occur through standard communication?

Should, for example, researchers be allowed to use non-rational interventions to produce changes in the affective states of research subjects in order to manage inflated expectations of benefit (therapeutic overestimation) or conflation of trial participation with care (therapeutic misconception)? Should doctors be allowed to “nudge” their patients to make “better” choices, e.g., use deliberate framing to induce false beliefs in these patients in order to make them choose a medically needed treatment they otherwise would not have chosen?

Those who claim that they should not, argue that such interventions are manipulative rather than respectful of subjects’ autonomy; that they exploit people’s flawed methods of reasoning or decision heuristic; that they elicit irrational rather than rational decision-making, and that they break the bond of trust in the professional-client relationship.

Those who claim that they should be allowed, argue that, as long as they promote the welfare of the subjects and exert their influence without blocking choices or increasing the cost of any of the alternatives, they neither threaten autonomy nor rational decision-making.

Who is right?

A Third Solution?

One simple thought might be: neither. What might be needed is an account of which non-rational interventions do, and which do not, violate the obligation to give subjects a fair opportunity to give autonomous consent. A fundamental problem might be that the analysis of the basic notion of “undue influence” itself is impoverished.

In what way does such influences interfere with autonomous agency and voluntary decision-making? It is difficult to find any shared or well-developed model of such interferences in the ethics literature. What we need is an analysis of this notion that makes explicit its connections with non-autonomous decision-making. Only then can we hope to be able to determine what role, if any, “nudges” and other interventions can legitimately play in enhancing consent and decision-making in the health-care context.

 

Edmund Henden is a professor at the Centre for the Study of Professions (SPS), where he currently heads the project Autonomy and Manipulation: Enhancing Consent in the Health Care Context.

Photo: Ainar Miyata-Sturm

Andreas Eriksen, a philosopher who works on professional ethics and role morality.

Professional ethics in the age of AI: Upgrading to v3.0

Doctors versus Google

Can a team of laypeople armed with Google beat doctors at diagnostics? That is the premise of a Norwegian TV show that has won international acclaim. Doctors are seemingly happy to participate and defend the honor of their practice. But the very fact that this is a realistic challenge is symptomatic of a more general and fundamental shift in the traditional power base of the professions. Developments in the field of artificial intelligence and the proliferation of online services are making accessibility of knowledge less dependent on traditional modes of professional practice. I believe this calls for a new perspective in professional ethics that takes these shifts seriously. As I will explain, “professional ethics version 3.0” may be an appropriate term for this upgrade.

“Increasingly capable machines”

The developments that necessitate this new perspective in normative theorizing are vividly portrayed in Richard and Daniel Susskind’s book The Future of the Professions (2015). They argue that technology is dismantling the monopolies of the traditional professions—for the better. In what they call our current “technology-based Internet society,” new ways of sharing expertize are refashioning public expectations. The book presents telling numbers on how artificial intelligence and online services are outcompeting traditional practices of providing academic courses, medical information, tax preparation, legal advice and more. Tasks that have been performed by professionals are taken over by “increasingly capable machines” that allegedly deliver services cheaper, faster, and better.

Normative theorists need to consider what these findings and predictions imply with regard to standards of professional role morality. Given that we are facing complex and fundamental change due to the possibilities of artificial intelligence, theories of professional ethics need to address how this alters the ground for legitimate public expectations and the conditions of trust. In particular, how does technological change in practice affect the merits of professional decisions and actions?

Professional ethics before AI

The call for a “third version” of professional ethics may sound hyperbolical, but let me explain how it relates to two previous stages. Version one concerned individual professionals. The early professional ethics codes were highly aware of how the behavior and values of the single role holder reflected on the public standing of the profession as a whole. Although this aspect has never disappeared, we can speak of a second stage (version two) when organizations and their procedural regulations gained more attention. This has been called “the institutional turn” in professional ethics (cf. Thompson, 1999). While organizations have always shaped professional practice, the appreciation of their significance for professional responsibility was gradual. The question now is how the swift arrival of artificial intelligence and new modes of sharing expertize changes our moral relation to professionals.

Philosophers should work in tandem with sociologists here. In this regard, consider how a call for a transition from version one to version two was foreshadowed in sociological writing. Thirty years ago, Andrew Abbott noted in his cornerstone contribution to professional sociology—The System of Professions (1988)—that the public approval of professional jurisdictions rested on outdated archetypes of work. The professions want to appear as virtuous, but the public image of the virtuous professional did not really track institutional reality. Abbott drew attention to how the public continued to think of the professionals in the image of a romanticized past: “Today, for example, when the vast majority of professionals are in organizational practice, and indeed when only about 50 percent of even doctors and lawyers are in independent practice, the public continues to think of professional life in terms of solo, independent practice” (p. 61).

When machines become professionals

How is the third version special compared to the previous two? One important distinction is how the third version is gradually dispelling the social logic of ordinary morality, which arguably remained perceptibly intact even in the organizational setting. That is, the organizational aspect of professional practice does not by itself imply a radical break with the kind of interaction we are familiar with from the ordinary or non-institutional morality. There are still face-to-face interactions that enable immediate emotional responses.

Care, loyalty, and respect are key virtues of role holders in hospitals or classrooms. They are also concepts that most clearly apply to the relations between agents who encounter each other directly. To care about patients or pupils, for example, seems to involve being concerned about the condition of concrete individuals, as opposed to more abstract categories. Similarly, loyalty to clients often requires attentiveness to how needs and interests are expressed (how they matter to this client), not just mechanical subsumption under institutional rules. Moreover, respect for autonomous decisions requires that conditions are present for making a professional judgment about relevant agent capacities of the decision-maker (e.g., understanding, free deliberation).

A natural question, then, for those who have worked with ethical theories for traditional practice will be how the old concepts translate to the new scene. What happens to the values of professional practice that were grounded in genuine human engagement and direct emotional participation? Susskind and Susskind are not worried about this; they believe machines will become better than humans to engage with understanding and empathic emotions (2015, p. 280). But whatever the technological realism of this stance, there is reason to stop and consider the conceptual difficulties it faces. We appreciate sincere expressions of empathy precisely because they communicate genuine like-mindedness. Many of our emotional reactions are tied to ideas about human dignity, fellowship, and mutual respect. We might have to find a new moral base for our interaction with machines. My suggestion here is that the third version of professional ethics needs to explain how the traditional moral concepts change meaning and significance when professional work is being gradually decomposed into more specialized tasks where new technology takes over old tasks.

New standards for professional practice?

A professional ethics for the new age is not just about the substance of norms and emotions, but also about how the standards for this normative order are derived or constructed. That is, even the basic sources of legitimate professional standards may be changing. Professional associations have traditionally developed their codes through appeals to the “internal” or “intrinsic” values of their practice. Some may hold that radical change in this regard is called for by the opportunities of technology. Technology may not merely be a vehicle of diffusing information; it may entail a form of “democratization” of the legislative process for professional norms. For example, one could argue that what is needed, for the most part, are efficient systems for registering user contentment. Now that people are being serviced in greater numbers at greater distances, the argument goes, the important thing is getting tools for aggregating satisfaction and adjusting the systems accordingly.

I believe, to the contrary, the standards of professional ethics cannot be reduced to aggregating satisfaction. It is a mark of professional integrity to resist pandering, to aim to rectify self-serving beliefs, and to making decisions responsive to genuine professional values. While some choice-friendly aspects of the new systems can overcome pernicious forms of paternalism that were made possible by traditional practice, there is still a need to allow professional judgment to be a counterweight to mere user satisfaction.

What machines can’t do

One reason for emphasizing the need for professional judgment is the lack of collaborative ability in machines. There is no mutual agreement on the appropriate end to pursue; the machine cannot adequately make normative assessments of the cognitive processes of others and it cannot place goals within a larger space of meaning (a lifeworld). The machine basically aids us in achieving our ends as they are, with at most a weak ability to interpret our situation or make counter-suggestions. In short, machines do not understand us and do not engage with us to determine our goals. This is a point argued at length in Steven Sloman and Philip Fernbach’s The Knowledge Illusion (2017). These cognitive scientists are skeptical about the potential for automated services to replace professional judgment. One of their findings is that using services like WebMD has the effect of raising people’s confidence in their own level of knowledge, without raising the actual level of knowledge accordingly. People tend to have rather a blurred sense of the distinction between what they know and what knowledge is available.

What does this mean for professional ethics?

None of the above is an argument against letting technology change professional practice. It is rather a point about how a theory of professional ethics can highlight considerations to which the new system needs to respond. The professional practice of the “technology-based Internet society” should be reformed in light of the genuine virtues of professional ethics, not vice versa.  While it is important to understand the gains in efficiency derived from compartmentalization, standardization, and automatization, it is also necessary to operate with an adequate conception of what kind of efficiency we should strive for. This does not just require the participation of practitioners of good judgment in the development of the systems. It also requires that theorists of professional ethics help articulate public frameworks for identifying the new ethical challenges that arise.

References

Abbott, A. (1988). The System of Professions. Chicago: The University of Chicago Press.

Sloman, S., & Fernbach, P. (2017). The Knowledge Illusion. London: Macmillan.

Susskind, R., & Susskind, D. (2015). The Future of the Professions. Oxford: Oxford University Press.

Thompson, D. (1999). The institutional turn in professional ethics. Ethics and Behavior 9(2), 109-118.

 

Andreas Eriksen is a Postdoctoral Fellow at ARENA Centre for European Studies.

Photo: Private

Conference on the Theory and Practice of Informed Consent

Hi all,

Here comes some exciting news:

Next month (June 8th and 9th) there will be a conference on the Theory and Practice of Informed Consent at Oslo and Akershus University College of Applied Sciences.

Many international researchers will hold talks, and judging by the abstracts they have sent in it looks like we are set for a stimulating and perhaps provocative couple of days.

If you are impatient and want to see the whole program for the conference, full abstracts etc. you can click here. Otherwise, read on for a brief digest of what we have in store.

Medical ethics

The medical context is often central when talking about informed consent. Since this one of my main research interests, I am happy to say that this will be the case at the conference as well.

Louis Charland (University of Western Ontario) will talk about how the psychological disorder Anorexia Nervosa could show us how too much concern for autonomy could be dangerous to certain vulnerable subjects.

Then Hallvard Lillehammer (Birkbeck, University of London) will perhaps strike a similar note when he asks whether the legitimizing power of consent always should be traced back to respect for autonomy.

Approaching the topic from a legal perspective, Henriette Sindig Aasen (University of Bergen) will look at the challenging case of childrens’ right to participate in medical decisions.

Research ethics

The first area where informed consent became a formal standard is research ethics following the Nuremberg Code, which was established as part of the judgment in the trial of the Nazi doctors in 1948.

In this light, Steven Edwards (Swansea University) will talk about how a weak version of the Humanity Formula of Kant’s Categorical Imperative (roughly: “don’t use people merely as means, but always also as ends in themselves”) is useful for thinking about consent in research ethics.

From the home field, Edmund Henden (Oslo and Akershus University College) and Kristine Bærøe (University of Bergen) will talk about whether addicts can give valid informed consent to participating in trials were they will be offered the drugs they are addicted to.

Neil Manson (Lancaster University) considers the proposal that biobanks should offer participants the opportunity to chose their own consent frameworks, and promises to argue against a practice of such “meta-consent”.

Professions and proffesional codes

The conferencewill not only be about informed consent: the second day will focus more on professional ethics in general.

Tor Halvorsen (University of Bergen) will  give a talk on the new ethical Challenges facing professionals given the new set of goals set by the UN to end poverty, protect the planet and ensure prosperity for all within a sustainable development agenda.

Finally, there will be a number of parallell sessions arranged by Profesjonsetisk nettverk (Network for Professional Ethics). The topic for these sessions will be Profession, Professionalization and Codes of Ethics, and there is an open call for papers which you might be interested in responding to, thought the deadline for submitting an abstract is Wednesday next week.

What’s not to like?

The conference is a part of the research project Autonomy and Manipulation: Enhancing Consent in the Health Care Context at SPS and is arranged in cooperation with Profesjonsetisk Nettverk. Here is the link to the full program again. If you have any questions, feel free to send me an email.

Oh, and you can let us know you’re coming by clicking attend on the facebook event we have created.

Or not—you’re welcome anyway.

 

I hope to see you there!

Best,

Ainar

Welcome to Professional Ethics!

Welcome to Professional Ethics, a blog about just that: professional ethics. The blog will be dedicated to exploring  this relatively undeveloped  area of philosophy, and a long term goal is for the site to be a resource for professionals who want to know more about the ethical side of their craft. If you are interested in professional ethics, this is your site!

For now, the site is quite sparse, but rest assured—more is coming.  In the meantime you can check out our About page, the Guidelines or the Events calendar. If you would like to keep up to date with the blog, you can Subscribe (scroll to bottom of page) to never miss a post.

Our plan:

The aim of the site is to be a friendly and accessible place to present and discuss interesting philosophical problems and ideas within the topic of professional ethics. We want the bar for participation to be low so that ideas that are not yet fully developed can be discussed.

The main content of the blog  is intended to be short texts by philosophers, professionals and researchers from other disciplines working in the field of professional ethics.

Are you a philosopher, a researcher or a professional and would like to contribute to the blog? Check out the Write for Us! page and send me an email!

Who are we?

Professional Ethics is affiliated with the Centre for the Study of Professions (SPS) at Oslo and Akershus University College of Applied Sciences. SPS is a multidisciplinary research center where researchers from a wide variety of fields  study questions relating to the professions.

The site is edited by me, Ainar Petersen Miyata, a PhD Candidate at SPS and part of the research project Autonomy and Manipulation: Enhancing Consent in the Health Care Context. My main research interest is nudging and its relationship to autonomy and informed consent.

 

I hope you will find the blog both useful and enjoyable! If you have any sort of feedback, let me know.

All best,

Ainar

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