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all things twice, first tragedy then farce lessons from a transplant error charles l. bosk In a recent book on capital punishment, Scott Turow reversed his long-standing support for the practice. While the reasons to oppose capital punishment are numerous, there was one in Turow’s brief that I found particularly intriguing. Celebrated cases, those that attract the public’s attention because the crimes in question stand out as particularly loathsome instances of a hanging o√ense, those cases that most cry out for a guilty verdict and punishment by the death penalty as part of a collective stampede for retributive justice, are precisely those cases where errors occur most frequently . Fueled by public outrage and extensive media coverage, a network of actors, connected only by their shared desire to make certain that justice is neither delayed nor denied, collude, albeit unwittingly, to reach a hasty, foregone conclusion. Police investigators discount evidence that points to other suspects or that exculpates the defendant. Prosecutors suppress evidence that they are required to share with the defendant’s attorneys, suborn perjury, or otherwise overlook procedural rules that would normally be followed as a matter of course. Judges ignore past precedents in overcoming objections to the introduction or suppression of evidence or in providing instructions to jurors. Members of the jury, having witnessed a constricted adversarial contest, have little di≈culty determining guilt and then settling upon the death penalty. Turow argues that public attention creates pressures that encourage mistaken judgments in those circumstances where their consequences are the gravest, least reversible, and most likely to undermine public faith in legal institutions once they come to light. Celebrated cases of error in medicine are much like celebrated capital cases in law. There is a premature rush to judgment about what happened and why. As a consequence, as many of the contributors to this volume point 98 charles l. bosk out, our ability to learn from such events is limited by a number of factors: (1) our major source of data is repetitive media coverage of dubious accuracy and of uncertain relevance; (2) critical data from o≈cial inquiries is often ‘‘con- fidential’’; results, presented in summary form, form the basis for new policies and procedures. However, without the ability to inspect the data, we are unable either to challenge the wisdom of ‘‘o≈cial’’ conclusions, to fashion alternatives to conventional wisdom explaining the case, or to determine which new vulnerabilities the newly adopted measures create; (3) the rush to restore public confidence and to provide reassurance in the face of what looks to be at first glance breathtaking incompetence or negligence stifles any e√orts to acknowledge obdurately irreducible vulnerabilities, uncertainties, and limitations that are embedded in the provision of technologically complex care to desperately sick, brittle patients with multiple-system problems in a resource-constrained environment; and (4) multiple stakeholders have an interest in celebrated cases of medical error; they are not shy about using these cases to promote those agendas, however tangential they may be to the central issues raised by the case. The Duke transplant error—‘‘the case of Jesica Santillan’’—illustrates how creative stakeholders are at transforming celebrated cases into vehicles for delivering issues to a mass audience. For example, stakeholders have used the transplant error as a dramatic example of the seriousness of and the need to control medical error; of anxieties about immigration; of the increasing coarseness of a market-driven, global economy that views body parts as just one more commodity to be bought and sold; of the disparities and inequalities within our chaotic health care system, both nationally and internationally ; of the need for tort reform; of the di≈culty distinguishing experimental from therapeutic interventions; and of the barriers to achieving a genuine informed consent when the patient is an adolescent. The coarse opportunism of a crowded field of stakeholders makes it a certainty that celebrated cases of error provoke discussion in public arenas; but whether that discussion is productive is another question, one that is considerably more di≈cult to evaluate. The question of how to measure the e≈cacy of policies formulated in the wake of celebrated, spectacular errors in medicine is a vexing problem, its di≈culty indexed, in part, by the general inattention paid to it. If we grant three propositions, the di≈culties of assessment are more easily apprehended and appreciated. First, one of the things that makes a case celebrated is that it is a rare event...

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