Bioethics Discussion Blog: Second-Guessing in Medicine: Is It Ethical?

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Wednesday, February 01, 2006

Second-Guessing in Medicine: Is It Ethical?

There has been a bunch of second-guessing going on about Katrina and also around the time that Ariel Sharon, Prime Minister of Israel, started bleeding in his brain. I felt it might be worth while to start a little discussion about the value and ethics of second-guessing. As for the definition, I guess there is two ways of defining it: 1) to criticize a decision or a process after the outcome is known and 2) to predict or anticipate an outcome. As examples one could question the events which man could control in Katrina and wonder whether they could have been better managed with the outcome being less disastrous. Some ask did Ariel Sharon receive improperly managed anti-coagulant therapy for his initial thrombotic stroke and was it unnecessary to perform the multiple brain surgeries with the cerebral hemorrhage? And there might be some who could answer “yes” to both examples.. but, of course, they would be “second-guessing”. What could make second-guessing improper and perhaps unethical? One factor is lack of knowledge of all the facts. Another is if it doesn't contribute to a good.

What is the role of second-guessing in medicine? Does the public, the families and the patients do it? Do the doctors do it with respect to their colleagues or do they do it with respect to themselves? I think they all do it. It is all related to trying to understand, rationalize and perhaps be able to improve on an unhappy, unacceptable and negative outcome. I think if we don’t attempt to second-guess and accept the outcome as inevitable, we will fail to find elements in the system or the person which could be improved upon. In second-guessing’s predictive sense, we are looking at the facts and anticipating something different than someone else’s predictions. Expressing this second-guessing might influence a change in the direction toward the final result. In both there approaches, second-guessing can provide a good, a benefit for this and future activities and events.

What makes second-guessing a poor behavior? When the guessing is based on belief but not on the facts. Belief can be speculation without an knowledge of details. Second-guessing without facts can lead to unfortunate and even at times damaging conclusions and actions. Accusing a doctor of malpractice simply on the basis of an unwanted outcome could be an example of second-guessing which is wrong. Calling in the President and Congress to write a law to prevent removing an unwanted tube feeding as in Schiavo is poor second-guessing.

I think that most second-guessing in medicine which in the end is valuable and good, is the second-guessing most physicians perform on themselves as they analyze their patient’s outcomes. I think physicians who don’t re-evaluate their own performance in view of the outcome of the patient’s illness have a pathologic self-confidence. That may sound rather strong. Self-confidence is great up to a point. You don’t want, as an example, a surgeon’s personal lack of self-confidence to cause a technical error because of hesitancy. On the other hand, you would want a surgeon to, in face of an unexpected bad outcome, to look at what has been done and try to find what could have been done to lead to a more successful outcome. The difference between a physician second-guessing him/herself and someone else doing the second-guessing on the outcome is that it is the physician him/herself who should know all the facts that need to be known to make an analysis. Again, second-guessing without knowing the facts is poor guessing.

Is second-guessing an issue ethical? Sure it is, if it contributes to an improvement or benefit to its various stakeholders. It is not, if it is done without factual knowledge of an issue and is aimed to be maleficent and not contribute to a good. Anyway, that is my opinion. ..Maurice.

4 Comments:

At Wednesday, February 08, 2006 10:46:00 AM, Blogger Kevin T. Keith said...

It's an important question, and increasingly timely as this sort of frenzied media attention attends every vaguely medical aspect of any vaguely public issue.

I think there are two ethical questions regarding "second-guessing": one having to do with patient privacy, and the other with the various professional/clinical implications of long-distance diagnosis.

In the first case, "second-guessers" very often issue opinions or supposed diagnoses and prognoses that would be grave breaches of confidentiality if they were based on first-hand knowledge. (Oddly, the worse your grounds for speaking out, the more ethical it appears to be.) This cannot be literally a breach of confidentiality, because there is no agreement of confidentiality in the absence of a provider-patient relationship, but it is certainly a breach of privacy. I regard these breaches as being similarly unethical to actual violations of confidentiality, but for a different reason: they are not breaches of the patient-provider agreement, but they are uses of professional expertise to deduce and then reveal information about patients to the public. I believe professionals have an obligation not only to hold privileged information confidential, but to use their professional knowledge circumspectly and with respect for those it touches upon.

The other issue is the possible practical implications of public second-guessing, which can take many forms: uninformed criticism of a patient's diagnosis or treatment may unfairly slander fellow professionals; it may cause unfounded concern or loss of confidence in the treating team on the part of the patient; it may cause pain or concern on the part of family members who have been given a more-hopeful prognosis by the patient or treatment team; it may influence public support for certain forms of healthcare (such as "alternative" treatments in lieu of scientific ones that have been publicly condemned); it may influence public events involving the patient (especially in the case of political leaders and other influential figures, who are stripped of their right to control their public image by unprivileged third-party statements about the patient's prognosis or mental status); perhaps others. These are all consequences that outside agents are not authorized to dabble in, but may recklessly influence with loose talk.

You can make an argument for "freedom of speech" in this regard (clinicians are just citizens who read the newspapers like anyone else, so they should be free to comment on what they read there as long as they're not violating an explicit obligation of confidentiality), but I think clinical professionals are expected to act circumspectly and with restraint in all cases, not just those where they have an overt contractual arrangement with a patient. I think third-party commentary from a position of ignorance is both a violation of that obligation of professional decorum and likely to cause trouble, and ought to be avoided for those reasons.

 
At Wednesday, February 08, 2006 11:35:00 AM, Blogger Maurice Bernstein, M.D. said...

Kevin, I will not second-guess your comments. I will simply agree with them! ..Maurice.

 
At Friday, February 10, 2006 11:27:00 PM, Blogger Bernard W. Freedman, JD, MPH said...

Hello Maurice: The phrase “second guessing” is itself a problem in its implication that the purpose is to look over the shoulder of another for the purpose of disparaging their conduct. As it is with so many ethical analyses, the intent and purpose of the action governs its morality. I do not think that most of us would not say that having the NTSB investigate a plane crash as second guessing. It is, rather, a professional unbiased look at the cause of a disaster. Do we run the risk of undermining the confidence of other pilots by such and investigation? Perhaps, yet, for a worthy purpose, namely our understanding and need to avoid duplication of the tragedy. The aviation analogy is, I think, a good one because each involves the application of sound educated judgment and the safety and preservation of life.


Similarly, the conduct of peer review in medicine is intended to evaluate, educate and avoid repeating mistakes. Hello Maurice: The purpose of a medical negligence case is to uncover clear errors, or breaches in recognized good medical practice and to compensate the victims of those errors.

It is the intent of ascribing blame for the purpose of undermining a physician, for who the application of prudent judgment is required, that is without merit and is, indeed, unethical.

All the best, Bernard

 
At Saturday, February 11, 2006 4:51:00 PM, Blogger Maurice Bernstein, M.D. said...

Bernard, as you can see from my last statement in the posting ("Is second-guessing an issue ethical? Sure it is, if it contributes to an improvement or benefit to its various stakeholders. It is not, if it is done without factual knowledge of an issue and is aimed to be maleficent and not contribute to a good."), I fully agree with you. Specifically, I also agree that the expression "second-guessing" is often used in a derogatory effect in the sense that "I could have done it better than you." ..Maurice.

 

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