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.