The fourth episode of the PBS sensation “Downton Abbey” provided a clinical examination of how bias of all kinds can rule the most important decisions in our lives, and how moral luck so frequently determines our conclusions about whether those decisions were right, wrong, or really, really wrong. It also shed some light on the  current policy conundrum of how best to consider medical malpractice suits—as a fair and necessary means of rewarding the victims of professional errors, or as a decidedly unfair device that distorts the practice of medicine and inflates its costs without improving treatment.

For those who have not caught the trans-Atlantic mania of following the saga of the Earl of Grantham and his extended family as they try to maintain their life of luxury as members of the landed aristocracy post-World War I, here are the relevant plot points of the most recent episode (in the U.S.; Great Britain is a season ahead of us):

Sybil, the much loved but rebellious daughter of the Earl is staying at the family estate (all right, castle) as she prepares for childbirth. (She and her Irish revolutionary husband Tom are on the lam from British authorities, but never mind that). The Earl naturally wants the best medical care for his daughter, and rejects the long-time family physician, Dr. Clarkson, for the task, because he has made some faulty diagnoses of late that led to all kinds of sorrow in last season’s drama. So the Earl calls in a renowned surgeon to the upper crust who is upper crust himself, Sir Philip Tapsell. (He appears to be an arrogant, pompous jerk, but the show’s writers show him giving sage and well-worded advice to the Earl’s non-Irish revolutionary son-in-law on the delicate matter of his sperm count, so we know he’s not a fraud as well.)

The Earl’s American but far too deferential wife Cora (in case you wondered whatever happened to the cute Elizabeth McGovern from “Ordinary People,” the answer is, “This!”) seeks to rescue Dr. Clarkson from a stinging snub by insisting that he come to Downton Abbey and be present for the childbirth as what we would call a consulting physician to Sir Philip, who doesn’t want one. Two head-strong doctors and hostile doctors looking after the same patient—yes, this will work out well.

Sure enough, Sybil’s pregnancy takes an ominous turn. Her ankles are swollen (“Perhaps she has thick ankles!” huffs Sir Philip, pooh-poohing the symptom. “She does not!” replies loyal Dr. Clarkson), her mental state is confused, and there is protein in her blood. Clarkson concludes that Sybil is toxemic and believes she could suffer eclampsia if she isn’t taken to the hospital immediately for a Caesarian section. Sir Philip dismisses him as a hysteric hack, and insists that Sybil’s pregnancy is normal and fine. Since Caesarians were risky in the 1920’s, often resulting in the deaths of the mother, the baby, or both, he believes Dr. Clarkson is giving irresponsible advice. As critical minutes tick away, Lord Grantham asks Clarkson if he can guarantee that Sybil will survive the ordeal of a Caesarian. “There are no guarantees,” he replies, correctly. Not hearing what he wanted to hear, the worried father turns to Sir Phillip and asks how certain the blue-blood doc is that the operation is unnecessary. “Completely certain,” is the ridiculous reply.

Announcing that certainty is a better bet than equivocation, Lord Grantham decrees that Sybil will remain at the castle to have her child, which she promptly does. All seems to be well, too, with a healthy baby, a beaming mother, a relieved family, and a smugly gloating Sir Phillip. But then Sybil goes into the violent seizures characteristic of eclampsia, and it is too late to save her. She dies. Dr. Clarkson’s diagnosis was correct. The family is devastated; Sir Philip is stunned, Cora is furious at both him and her husband, and the Earl of Grantham is feeling guilty.

Got that?

Cora’s anger, the Earl’s guilt and the vindication of Dr. Clarkson are all the result of a bad-tasting recipe of hindsight bias and moral luck. Sybil might have not gone into convulsions. She might not have survived the Caesarian, in which case Dr. Clarkson would be the one looking incompetent, Sir Phillip would say “I told you so,” and Cora would be furious at a different doctor but the same decision-maker, her husband, who would still be sleeping in the guest room. Continue reading →