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C H A P T E R 9 God, Science, and History: The Cultural Origins of Medical Error K E N N E T H D E V I L L E Introduction Many Americans appear to believe that we are currently experiencing a plague of medical errors. A decade ago, the Harvard Medical Practice Study reported that 4 percent of hospital patients suffered iatrogenic injuries, two-thirds of which were due to medical error (Leape et al. 1991; Leape 1993). These and other error studies reported high rates of missed diagnoses, mistaken treatments , medication errors, and a wide range of other mistakes in patient care (Leape 1994; Bedell et al. 1991; Shimmel 1964). More recently, of course, the Institute of Medicine (IOM) report To Err Is Human: Building a Safer Health Care System estimated that medical error was responsible for 44,000 to 98,000 inpatient deaths a year (Kohn, Corrigan, and Donaldson 2000). The IOM study received much attention from governmental bodies, regulatory agencies, and the mainstream media. For example, the New York Times compared the IOM rate of error in U.S. hospitals to three jumbo jets crashing every two days. “If the airlines killed that many people annually,” the writer observed, “public outrage would close them over night” (Weinstein 1998). As a healthy and laudable consequence of these reports and observations, the public, the government, health care administrators, health regulators, the medical profession, and a plethora of multidisciplinary groups are taking a long, hard look at medical error, its origins, and its prevention. Much has been made of the statistical limitations of the IOM study, and it should be. But I want to focus on another curiosity, the seemingly prevalent notion that medicine has suddenly become more dangerous and error-prone. The relatively recent reports of widespread error and mistake in medicine have led observers in some quarters to suggest that health care workers are careless or reckless. Richer explanations, however, have demonstrated that this evident plague of error is just as likely to have arisen from faulty systems designs that conceal “error 143 c09 sharpe pp143-158 08/05/2004 16:56 Page 143 traps,” or that require health care professionals to work too hard or too long or press their cognitive abilities beyond that which is safe for patients (Reason 1990; Perrow 1999; Leape et al. 1995). Systems analyses have been applied to error in other contexts—the airline industry, for example—to great benefit and will likely play an important role in preventing and mitigating human harm in the medical context. For practical reasons, it is important to focus on the prevention of both individual and systems error in response to the current groundswell of concern regarding medical error. But despite the usefulness of a systems approach (or other approaches), there is much that is left unexplained. Such approaches, for example, do not fully explain why medical error has increased, or has seemed to increase, at a time when medical professionals have almost certainly become better educated, more skillful, and more careful than their historic counterparts. In addition, there is no definitive agreement or even working definition of what constitutes error or culpable error (Hofer, Kerr, and Hayward 2000). Charles Bosk has explained that the definition of error is, and is likely to remain, “contested .” It is contested in part because a society’s view of what incidents to construe as error and culpable error is highly dependant on cultural conventions and historical context (Bosk 2000). The origins of medical error are multifactoral , relating both to the individual health care practitioner and to organizational deficiencies. But medical error, like disease, is an amalgam of physiological explanation and social definition (Rosenberg 1962). In this chapter, I argue that the apparent rise in medical error in the U.S. must be seen not merely as a product of human action or inaction, or of flawed systems , but as a product of our culture and history. I attempt to connect the way that Americans explain medical misfortune to three discrete but related changes that have occurred in American culture over the past several centuries. First, the weakening of providential views of the world has led Americans to explain misfortune as the result of actions or inactions on the part of human actors, rather than as the work of God. In Anglo-American culture, the gradual transformation of society’s view of God’s role on earth has gradually allowed and encouraged society to search for human...


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