Moral Maginot Lines

Gawande and Williams

Moral Maginot Lines

Gawande and Williams

Moral Maginot Lines
An email conversation about the news of the day.
March 16 1999 1:48 PM

Gawande and Williams

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Dear Marjorie,

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I don't know about yours, but my kids (3, 2, and 3 months) are adorable when they're sick. They cling like little koalas and sniffle and just in general need you. Sick spouses, on the other hand, are crabby, refuse to take advice, and try to boss you around. The combo must be chaos for you, but I hope still a cute one. As for medical advice, this may be somewhat technical, but if anyone barfs up blood or passes out on you or starts writhing in pain, you should probably get some help, no?

Now, regarding the Alpine gondola accident, maybe I'll soften up over time about the videotape the crew spirited away. But part of my firm reaction comes from a distinction we make in medicine between "judgment" errors and "normative" errors. On my first day of surgical residency, one of the senior surgeons sat me and the other new residents down and spelled out a very clear Maginot line for behavior. We could, indeed we would, make mistakes of ignorance, fatigue, faulty memory, inattention, stupidity, and so on. We should try our best and always work to reduce such errors of judgment, but they are human mistakes. To some irreducible extent, they cannot be avoided. But, he said, lying about patient care--especially something even remotely related to a mistake--would not be tolerated. It is a normative error, a violation of essential norms of professional behavior, norms that allow people to be trusted and teams to work safely. Even after I've seen a fellow resident get fired after years of training for just such a violation, I still think this distinction is right. It seems like we have a tendency to assume that terrible consequences (e.g., 20 dead skiers) must be the result of a commensurately monstrous behavior. But often it's the small, seemingly innocuous actions (stealing a possibly irrelevant videotape) that are the most troubling.

Here's where it gets hard: Most areas of life are not like doing surgery or piloting airplanes. Lying is sometimes OK, even essential, as the philosopher Sissela Bok has pointed out in her book about lying. Certainly, maintaining unambiguous lines for acceptable sexual behavior (unlike professional behavior) is either impossible or self-defeating. If one of the cardiac surgeons at my hospital were having an affair with a young surgical intern, it would be disturbing, and his wife might have something to say about it. Perhaps the affair, like many things, even distracts him from providing the best patient care. But I still don't think that would be any of the hospital's business, and I certainly don't think he should be fired. In the medical context, it just wouldn't constitute a high crime or misdemeanor. And if your editor were ... ?

Atul

Atul Gawande has written about medicine for The New Yorker and Slate, is a surgical resident in Boston, and is a fellow at the Harvard School of Public Health. Marjorie Williams is a contributing editor at Vanity Fair.