Health and Medicine

Consequentialism, Bias, Moral Luck and Malpractice on PBS’s “Downton Abbey”

/ Jack Marshall / 16 Comments

downton_abbey

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 →

How Fake Statistics Become “True”: A Case Study From The Newtown Massacre Ethics Train Wreck

/ Jack Marshall / 23 Comments
As predicted, this ethics train wreck keep getting bigger.

As predicted, this ethics train wreck keep getting bigger.

There was a lot to wince about in Diane Sawyer’s “exclusive” interview two weeks ago with former Congresswoman Gabriella Giffords and her husband, Mark Kelly. The Arizona couple announced their intention to launch a non-profit organization dedicated to more effective anti-gun violence measures, concentrating, predictably, on the prominent features of the maniac’s rampage in Tucson that left Giffords with brain injuries that will impede her for a lifetime. Nothing to wince about regarding the effort, but Giffords’ diminished state—she can speak in only short burst of words, cannot see well out of one eye, and has difficulty walking—is tragic. It reminded me how unconscionable it was that she held her post in the Congress for more than a year when it should have been clear that her disabilities precluded her functioning as a Representative. The disturbing feeling also arose that Giffords, in her current pathetic condition, is now like the children President Obama used as window dressing for his gun-related Executive Orders announcement at the White House, an exploited figure of sentiment and public manipulation being used in the anti-gun wars. Her name was listed as the author of a first person op-ed in USA Today that contained sentences and perhaps thoughts that she cannot possibly compose. Diane Sawyer told us that she will be dragged into Congressional offices with her husband to seek support from her former colleagues, who will be forced, as Sawyer said, to say no “to her face.”

The most substantive wince, however, came from a statement of “fact” by Mark Kelly, who told Sawyer this:

“You know, how do we get to the point where 85 percent of the children in the world that are killed with guns are killed in the United States. That is a sobering statistic.”

Sobering, and obviously nonsense. Continue reading →

New Mexico Abortion Wars: Yes, It’s A Terrible Law, But Not A Terribly Unethical One

/ Jack Marshall / 50 Comments
Paving the road to hell? New Mexico lawmaker Cathrynn Brown

Paving the road to hell? New Mexico lawmaker Cathrynn Brown

My friend (and Ethics Alarms Ethics Blogger of the Year) Rick Jones went full-Django on New Mexico State Legislator  Cathrynn Brown for her proposed, now withdrawn, measure forbidding women who are pregnant as the result of incest or rape from getting an abortion on the theory that it constitutes “destruction of evidence.” The attempt launched Rick into rare form:

“Every once in a while someone mixes up a cocktail of such mind-melting stupidity, monumental inconsistency, and transcendent arrogance that there is little for the rest of us to do but drop everything and gaze in slack-jawed wonderment at the inanity before us. Behold, therefore, one Cathrynn Brown (right), a New Mexico legislator whose latest bill rockets off the scale, leaving “moronic” and “horrific” as feeble understatements of the idiocy involved.”

Whoa, Nelly!

Let’s calm ourselves and consider, shall we? Continue reading →

Ethics Mess In Kansas: The Lesbians and the Sperm Donor

/ Jack Marshall / 12 Comments
The parents in happier days

The parents in happier days

Auto mechanic William Marotta must rue the day he responded to a Craigslist ad placed by Angela Bauer and her life partner Jennifer Schreiner. They were seeking a sperm donor, for the obvious reasons, and he had sperm to donate. The trio then signed a contract in which all agreed that Marotta would have no rights to any child his sperm spawned, nor future responsibilities regarding the child’s care. Schreiner was artificially inseminated and conceived, making her the child’s mother, as Bauer stepped into the role of the child’s father. Exit Marotta forever, with thanks.

Or so he thought. Continue reading →

Comment of the Day: “Lisa Long’s Unethical, Despicable Bargain: Betrayal For A Blog Post”

/ Jack Marshall / 4 Comments

turn-the-tablesOffering a pointed response to Lisa Long’s blog post about her emotionally-ill son and the suffering Long has endured, is new commenter Fixitsurprise. When I first read the post, I actually thought that she might be Lisa Long’s daughter, so to those like me whose faculties are still addled from too much eggnog and viewings of “A Christmas Story,” remember that Long’s post was titled, “I am Adam Lanza’s Mother.” Fixitsurprise is table-turning.

Here is Fixitsurprise’s Comment of the Day on “Lisa Long’s Unethical, Despicable Bargain: Betrayal For A Blog Post”:

“I am Lisa Long’s Daughter.”

“My mother labeled me as mentally ill when I was 12 to avoid taking on any responsibility for my issues. I was sent to mental hospitals. I was sent to a behavior modification facility. Countless doctors and lots of meds with horrible side effects. I was forced to sign a contract admitting I was mentally ill and promising to be on medication the rest of my life to get out of reform school. She wouldn’t rest until I had a diagnosis that absolved her. I yelled and screamed and acted out. I did so because I had no voice, no respect, and was not allowed to make any boundaries whatsoever. She gave me poetry that spoke of how she was a victim of my illness. She was public about her struggles. How hard it was to have me. I burned it but the words still haunt me to this day. I am an adult now with the perspective of 18 years of parenting my own child. We do need to change the conversation about mental illness in this country, but what Long ironically, and unintentionally points out, is that a big part of the conversation needs to be about the family dynamic. That parents contribute, that society contributes, and that no psychiatric professional and no prescription can heal the child of a mother with a victim complex.”

______________________

Graphic: Cascadesmurf

Ethics Quote of the Month: Ken At Popehat

/ Jack Marshall / 12 Comments

“Evil exists. Good people should fight evil. But government is often the wrong instrument to fight evil. The people doing sick and contemptible things to children in the name of “curing” homosexuality very likely feel as strongly as I do, and might — if they got their way — use government to achieve their ends. People who love liberty must fight with their heads, not just their hearts.”

—– Ken, the First Amendment besotted lawyer/blogger/libertarian/wit who reigns at Popehat, writing about his doubts regarding California’s ban of so-called “conversion therapy.”

I recommend that you read the whole post, and everything Ken writes, basically.

I’m somewhat less conflicted than Ken in my opposition to this legislation, and wrote about the ban earlier this year, here, and here.

Untrustworthy NIH

/ Jack Marshall / 4 Comments

This is what the horror movie outbreak looked like. The real one? We don’t know.

In Barry Levinson’s (terrific, scary) eco-horror movie “The Bay,” slug-like sea creatures mutated by toxic waste eat their way through the faces and bodies of the residents of a Chesapeake Bay community, as medical authorities carefully keep the story under wraps from the rest of Maryland and the nation. At the National Institutes of Health Clinical Center in Bethesda last year, a different kind of monster bug was on the loose: the antibiotic-resistant bacteria known as Klebsiella pneumoniae.  For six months the bacteria spread, eventually infecting 17  NIH patients, killing at least six of them. Doctors took extraordinary precautions to keep the so-called “superbug” from getting out into the population, but such measures didn’t include telling the city, county or state what was happening, or informing non-physician staff, many of whom were at risk of infection, about the bacteria outbreak. The full story didn’t come to light until August of this year, when NIH researchers published a scientific paper describing the advanced genetic technology they used to trace the outbreak. Continue reading →

NOW You Tell Us? Rep. Scott DesJarlais (R-Tenn) Is Not What What He Appeared To Be

/ Jack Marshall / 16 Comments

Unconfirmed photo of Tennessee Rep. Scott DesJarlais caught out of his man suit.

In 2010, physician Scott DesJarnais ran to represent Tennessee’s Fourth Congressional District on a pro-life, anti-abortion platform, and won. He also ran as an honest, trustworthy, honorable individual, as all members of the U.S. House of Representatives ought to be.  He is an MD; integrity, intelligence and professional standards of conduct should be assumed. Little more than week after he was re-elected by Tennessee’s voters this year, however, the court records of his 2001 divorce were released. The Democratic Party in the state had fought to have them released before the election with the support of his ex-wife, but DesJarnais successfully persuaded a judge to wait—after all, why spoil a good surprise? When the transcripts were finally revealed, Tennesseans learned that their re-elected, pro-family Representative:

  • Supported his ex-wife’s two abortions before they were wed
  • Helped arrange abortions for a mistress and a patient he impregnated after they were married.
  • Had multiple sexual affairs with co-workers, subordinates and patients
  • Prescribed recreational pills for at least one of his sex partners
  • At one point, put a pistol barrel in his mouth for two hours and threatened suicide
  • Engaged in multiple actions that are violations of medical ethics, workplace ethics, and laws. Continue reading →

The Spectacularly Unethical Angela Buchanan, Making Life A Little Meaner For Us All

/ Jack Marshall / 12 Comments

According to court documents, Angela Buchanan, 30, of Lufkin, Texas, desperately wanted to be in a romantic relationship with a long-time female friend. She contacted the friend on Yahoo Messenger in March, explaining that she was diagnosed with breast cancer in 2008 and was now suffering from a pre-cancerous mass. She told her concerned friend that she was being treated by a local gynecologist. Then the gynecologist contacted the friend too, also on Yahoo Messenger.  The doctor confided to the friend that the pre-cancerous mass in Buchanan’s breast could possibly be delayed or even reduced and cured by an increase in hormone production, which, the doctor helpfully suggested, could be stimulated by sexual intercourse. The doctor recommended that the friend agree to participate in sexual activity with Buchanan in order to bolster this vital hormone production—if she really wanted to save her friend’s life, that is. Continue reading →

The Global Warming Debate Is The World Series of Confirmation Bias

/ Jack Marshall / 43 Comments

Confirmation bias is the dastardly human thought tendency that makes objectivity virtually impossible, and fair analysis nearly so. It is the human instinct to view external facts and events in such a way that they confirm preexisting beliefs, or, if they challenge these beliefs, to find reasons to distrust the facts or explain them away.

A line in a Washington Post book review caused me to realize that nothing  exemplifies confirmation bias at work better than the global warming controversy. It was a review by Post business editor Alan Sipress of “Spillover,”  a new book about how pandemics spread. He wrote:

“This year, a mild winter and an unusually hot summer — which look suspiciously like results of man-made climate change — yielded a bumper crop of virus-carrying mosquitoes. The result is an unprecedented outbreak that has sickened people in almost every state.”

Wait a minute: why does the past year’s mild winter and unusually hot summer “look suspiciously like results of man-made climate change”? Were there never mild winters with scorching summers before scientists developed climate change models? And why do those two factors, when paired, “look suspiciously” like man-made climate change? What about the winter and summer of 2012 screamed “man-made”? Continue reading →