Book Review

Margin of Error: The Ethics of Mistakes in the Practice of Medicine

N Engl J Med 2001; 344:389-390February 1, 2001

Article

Margin of Error: The Ethics of Mistakes in the Practice of Medicine
Edited by Susan B. Rubin and Laurie Zoloth. 374 pp. Hagerstown, Md., University Publishing, 2000. $29.95. ISBN: 1-55572-053-6

Recent widespread efforts to change how we identify and prevent errors in health care have generated only a limited literature on medical errors. Even more limited are discussions of error in the field of clinical bioethics consultation. This book thoughtfully explores these two related but quite distinct subjects. A range of perspectives from bioethics and the medical humanities provides the largely novel material, although several notable, previously published works are also included. Medical errors are discussed in parts 1 and 2 of the book; one analyzes concepts and definitions of errors, the other deals with physicians' involvement in errors. The third and final part of the book discusses medical errors as they relate to bioethics consultation. This material is intended for those working in bioethics and will prove to be seminal in this briskly evolving field. Others with an interest in clinical bioethics will also find the chapters in this part of the book illuminating.

In modern medical organizations, root-cause analyses and continuous quality-improvement programs uncover the systemic problems that underlie inevitable medical errors. Despite this enlightened approach, the pernicious notion persists that physicians are infallible. Some error is inherent in medicine, however; perfection in medical practice, while a laudable goal, remains forever unattainable.

The book pays considerable attention to how an action may be erroneously categorized as an error if the context in which the purported error occurs is improperly described. Medical errors also are discussed in their sociocultural and historical contexts, in two particularly interesting chapters; one surveys American attitudes toward health and medicine in the 18th and 19th centuries, and the other details the establishment of standards of practice and describes how errors were handled in the nascent field of neurosurgery around the turn of the 20th century.

One contributor calls for a more robust integration of humility into health care, to promote an environment in which errors and personal responsibility for errors may be more easily acknowledged. Another recounts his own errors in practice, laments the ever-present specter of miscalculation, and voices concern about the emotional health of physicians who constantly face potential tragedy.

These discussions will compel the reader to think critically and expansively about physicians' role in errors. Certainly, physicians should accept appropriate responsibility for their actions. However, a self-destructive arrogance underlies physicians' assumption that all errors are avoidable and blameworthy. Medicine is a humbling art and a complex team activity.

Part 3 of the book rigorously examines bioethics consultation and its practitioners. Although bioethics consultation is available in most hospitals, serious concern about the quality of this work persists, and the practice overall still requires critical assessment. Rubin and Zoloth lucidly frame the challenge of defining and managing error in clinical bioethics and note the lack of “readily definable, consensually agreed-upon standards according to which consultants are expected to function and against which they could be judged.” Furthermore, bioethicists unavoidably rely on inconsistent information when describing ethical problems and must assimilate changing assumptions, such as the acceptance of the concept of brain death and its subsequent critical reexamination.

Several contributors appropriately note that bioethics consultation defies standards for curricula, processes, and goals, and lacks measures of outcomes and efficacy. Competence is defined descriptively, but not definitively, in terms of skills or knowledge. One author observes that “ethics consultation is a skilled achievement that cannot be fully specified in rules.” As might be expected, there is no widely accepted accreditation process for clinical bioethicists. There is also concern that formal certification would limit the rich diversity of backgrounds represented among professionals in the field. Several contributors struggle to apply medical models of quality improvement and quality management to bioethics consultation. Bioethics consultation, simply stated, is clinically applied philosophy. To date, there are no precedents for legal liability for bioethicists. The author of one chapter considers potential liability and concludes that, although duty and some practice standards may be identifiable, liability is limited because causation and damages are difficult to prove.

The final chapter is a historical overview of ethics consultation and an analysis of Core Competencies for Health Care Ethics Consultation, recently published by the American Society for Bioethics and the Humanities. Included in this chapter are cogent critiques of actual bioethics consultations, an outline of the process and content of case consultation, and recommendations for institutional policy on bioethics consultation.

Margin of Error is a considerable and timely addition to the medical and bioethics literature. The book has great merit, despite an occasional unevenness of content. Rubin and Zoloth break new ground for inquiry into bioethicists' clinical activities, and their appeal for critical self-examination will help guide bioethics into its next phase of maturation. Margin of Error will further stimulate the discourse necessary to improve bioethics consultation and to enhance its legitimacy within health care.

Jeffrey T. Berger, M.D.
State University of New York at Stony Brook School of Medicine, Stony Brook, NY 11796