When I first picked up Charles Bosk's Forgive and Remember, I thought that it would be a straightforward book about mistakes made in the medical field and how they are dealt with. However, I think that the biggest thing that I've taken away from this book so far is that what exactly constitutes a mistake is a highly contested and complex idea that depends on many factors. In fact, Bosk argues that residency training is primarily "a moral education, the purpose of which is to teach young doctors the standards of practice" (xvi). In other words, before doctors can truly be held accountable for determining what is right and what is wrong in medical practice, they must go through a grueling several years of preparation.
This seems counterintuitive because in many other aspects of life people seem to have an innate sense of what is right and what is wrong. Why should surgery be any different? I think that Bosk's answer to this lies in the complex and technical nature of surgery, as well as in the inherent uncertainty present in any form of medical practice. Unlike other aspects of life where right and wrong may be as clear as black and white, there is a huge gray area in medicine and especially surgery that makes it very difficult to tell when an unforgivable error has occurred. It might seem obvious to an outsider that if a patient dies than a mistake has occurred on the part of the surgeons, but sometimes doctors can do everything right and a patient still dies. Similarly, sometimes doctors can get away with making a lot of mistakes as long as they still have a positive patient outcome. This is a very pressing problem because it is impossible to learn from your mistakes if you don't even know that they occurred.
Bosk tries to tackle the problem that doctor's face of determining when a mistake has occurred by classifying mistakes into 4 categories: technical, judgmental, normative and quasi-normative. Technical and judgmental mistakes are thought to be inevitable and occur because the resident is inexperienced and doesn't know any better yet. Normative mistakes on the other hand, "involve the violation of universal rules that hold across surgical services" (xx-xxi). Similarly, Bosk defines quasi-normative mistakes as "involv[ing] rules specific to individual attendings and their services" (xxi). Both normative and quasi-normative mistakes are "treated as breaches by a morally accountable agent and as occasion for corrective remedies" (xix). On the surface this seems straightforward enough, but as Bosk goes on to explain, whether a mistake is classified as technical, judgmental, normative, or quasi-normative depends on a dizzying array of factors including "who the attending was, who the resident was, how smoothly things were going on the service when the mistake surfaced, how a request for information was managed, what time of year it was when the mistake occurred", etc. (xx).
To me, this highlights the central problem of this book: if judging mistakes is so arbitrary, how can we really know when something unforgivable has occurred versus when an innocent and unavoidable mishap has occurred? And how does this uncertainty effect patients and doctors alike?
I like cece's post in that her last questions are very thought provoking. How can we, normal citizens blame our doctors for the mistakes they made and likewise forgive our doctors for those unavoidable mishaps? Are we to trust the universal moral code that every citizen follows for the limited and expansive code that every surgeon follows. I believe that while doctors have very difficult and circumstantial work, they are citizens of our world nonetheless and should follow the codes, rules and morals that every citizen follows. If a patient dies shouldn't the doctor be to blame if a different doctor had the resources and knowledge to save that patient? regardless of the fact that many doctors might support the one who made the mistake, I believe it isn't up to doctors to tell us what is okay and what isn't. Thats our job as patients.
ReplyDeleteThis post got to the core of what Bosk's book is about, the complexities of surgical mistakes and how it effects the career of a surgeon. However, a critique I had of the analysis by Bosk, while I find it's holistic approach very useful in describing surgical mistakes, is that in our litigious society, there is no distinction made by a slighted patient between a normative and a technical error. Forgivable or not, a patient will still sue and will still be in contempt of the surgeon who made the mistake on them. That being said, I appreciated Cece's thoughtful observation that the world of surgery is governed by a set of morals and values that are outside of the moral universe of the world outside the operating table.
ReplyDeleteI agree with Neil and William that Cece’s post really cuts to the heart of many of the important aspects of Bosk’s book. Reading Cece’s questions at the end I was reminded of something I read in the book that I found pertinent. Bosk writes, “It is nevertheless important to remember that the costs of technical failure never shrink to zero, and it is the patient who always pays” (39). This is one of the problems with viewing failure as a blameless crime, because it is most certainly lot a victimless one.
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