Patient safety has been a priority at least since the U.S. Institute of Medicine (IOM)'s landmark report To Err is Human: Building a Safer Health System, which defined medical error as "[f]ailure of a planned action to be completed as intended or use of a wrong plan to achieve an aim" (Kohn, Corrigan, and Donaldson 2000, 210). The report inspired checklists and other protocols to reduce medical error that have since become standard. Nevertheless, the incidence of medical error is still high for a number of reasons, including the systemic nature of medical error, the complexity of healthcare systems, persistent communication problems, weak regulations, and other factors. Medical error, in fact, is the third leading cause of death in the United States, according to a 2016 Johns Hopkins study (Makary and Daniel).
Although scholarship and grant activity have increased since the IOM report (Stelfox et al. 2006), relatively little attention has been given to the ethical dimensions of medical error. This special issue brings together a collection of essays addressing this deficit.
Fritz Allhoff, the other guest co-editor for this issue, provides a substantive introduction to ethics and medical error in "Medical Error and Moral Luck." His conceptual and normative analysis takes the IOM report as its starting point, particularly the definition of medical error itself. Allhoff probes the role of "adverse events" in ascertaining the seriousness of medical errors. To the degree that our ethical assessment varies in proportion to patient injury, we might say that it depends on moral luck. And that raises a host of other issues that need to be resolved.
The remaining articles all deal with the fact that adverse events resulting from medical errors disproportionately affect vulnerable populations. The authors argue that personal, structural and historical biases distort the medical diagnosis and treatment of marginalized groups. These lapses in judgment, in turn, result in unjust healthcare disparities and loss of trust in the patient-provider relationship. [End Page vii]
In "The Harm of Ableism: Medical Error and Epistemic Injustice," David Peña-Guzmán and Joel Michael Reynolds argue for a specific kind of knowledge-based medical error originating in ableism. They characterize ableism as an epistemic schema that contributes to insidious schematic error. The issue is not only what providers know, but how they know within the dominant epistemology of medicine, which falsely assumes that impairment necessarily constitutes hardship. To help remedy the resulting contributory injustice, the authors argue that providers should learn about alternative ways of knowing that challenge their ignorance. For example, learning about disability from the perspective of disability communities themselves may contribute to better communication between providers and patients and, indirectly, to better care.
Rasmus Rosenberg Larsen likewise challenges the conventional wisdom of the medical establishment in "Psychopathy Treatment and the Stigma of Yesterday's Research." Specifically, he argues that psychopathy assessments are subject to continuing medical error due to a history of flawed research indicating that psychopathy cannot be successfully treated. The consequences of this error are grave, as forensic psychiatrists make these assessments in the context of legal and correctional decisions that may unfairly deprive patients of treatment and hurt their chances of rehabilitation.
Finally, Luke Golemon argues, in "Medical Overtesting and Racial Mistrust," that common strategies for reducing medical overtesting tend to result in race-specific harms to patients and communities of color. While allowing that certain nuanced solutions to overtesting may adequately address such harms, he suggests that, for the time being at least, racial minorities in the United States would be better off with medical overtesting as a rule. This would offset medical errors resulting from the influence of entrenched racist medical mythology and increase the trust that racial minorities have in the healthcare system.
This special issue of the Kennedy Institute of Ethics Journal was inspired by a 2018 Association for Practical and Professional Ethics (APPE) mini-conference co-sponsored by Western Michigan University's Center for the Study of Ethics in Society and the Western Michigan University Homer Stryker M.D. School of Medicine. The topic of medical error was no accident; it was the passion of the Ethics Center's associate director Shirley Bach, a trailblazer in biomedical ethics. We have dedicated Ethics and Error in Medicine, a forthcoming edited volume to be published by Routledge, to our colleague's memory. The book will feature the articles [End Page viii] in this issue, as well as other previously unpublished articles that venture further into the territory only glimpsed here.
We are thankful to Michael Barnes, the KIEJ's managing editor, for his expert supervision of the review process for this special issue, as well as Rebecca Kukla, the journal's editor-in-chief, for her willingness to highlight medical error in the KIEJ. We also are grateful to the reviewers who helped the authors sharpen their arguments and to the authors, of course, for their contributions; we think the results were well worth the effort. Although these articles can hardly be expected to provide a full picture of all the different ethical issues pertaining to medical error, we think they provide useful guideposts for continuing efforts to grapple with this important topic. [End Page ix]
Sandra L. Borden, PhD, directs the Center for the Study of Ethics in Society at Western Michigan University, where she is a professor of communication. She has published articles in some of the top journals in her discipline, including the Journal of Media Ethics, Communication Monographs, and Communication Theory. Her books include the award-winning Journalism as Practice: MacIntyre, Virtue Ethics and the Press (2007). She serves on the executive committee of the Society for Ethics Across the Curriculum.