PERSPECTIVE MAKING DECISIONS FOR PATIENTS WITHOUT SURROGATES l. Pope TM. Legal fundamentals of surrogate cision maker: who decides? Ann Intern Med 5. white DB, Jonsen A, Lo B. Ethical cha decision making. Chest2012141:107481.2007;147:3440 T Legal briefing: the un. 4. Caring for Georgia s unbefriended elders: unrepresented patients. Am J Crit Care 2012: befriended- making healthcare decisions views from the probate bench on the 2010 21: 202-7 2012;23(1):8496,23(2)17792 onset Statute. Atlanta: Georgia Appleseed, DOl: 10. 1056/NEJMp1308197 3.Whitedb,CurtisJr,WolfLe,etal.Life2013(http://www.gaappleseed.org/docs/Copyright@2013massachusetts support for patients without a surrogate de- caring- for-elders. pdf) - HISTORY。 F MEDICINE Railways, Industry, and Surgery -The Introduction of Risk Management Thomas schlich. MD rains sometimes derail, planes larly vulnerable to being blamed ever, at the end of the day, al crash, factories collapse for bad outcomes, since the link these strategies had their limita- yet we take trains and planes and between an operation and the tions. The power of hidden factors keep building factories. We have death of a patient is normally ob- and pure chance was too strong learned to live with risk. The no- vious and hard to deny. PirogovPirogov explicitly rejected the tion of risk is so common that it assumed that the reason why idea of using statistical calcula has been described as a defining surgeons had always had to cope tions to deal with this uncertainty feature of modern societies. Mod- with this problem was that out- because, he explained, the chance ern risk management has made comes in surgery were essentially element in probability calcula risk calculable and to some ex- beyond the practitioner's control. tions made them inapplicable to tent controllable. It is also a cen- Surgeons needed a certain"prac- the surgeon's day-to-day work. tral feature of medical interven- tical tact, "explained Pirogov, to In 1881 the German surgeon tion, most notably in surgery. judge whether or not to operate Richard von Volkmann suggested But when risk management was in a situation in which the odds that the traditional surgeon re- initially introduced into surgery, could neither be completely known sembled a farmer who could only in the 1870s, it was not only be- nor influenced. Such decisions cultivate his land and wait to see cause of developments in medi- had to take into account a whole how his harvest turned out, where cine(such as antisepsis) but also economy of risk, involving the as the modern surgeon, with anti- because of precedents in the rail- influences of both medical and sepsis at his disposal, resembled road and manufacturing arenas. nonmedical factors. Surgeons in- a manufacturer from whom the This new attitude toward risk led curred particularly high risk to public expected consistently high to great surgical interven- their reputations and future work, quality products. 1 Volkmann had tions and, I would argue, was at for example, when operating on adopted Joseph Lister's antisepsis least as important as antisepsis a patient of high social standing. a decade earlier and had become for the development of the field. Some patients, Pirogov advised, Germany,'s most influential pro- Before the late 19th century, should therefore be referred to ponent of the antiseptic method, surgeons had engaged in what colleagues. Others should be dis- an innovation that had engen- might be called the "management suaded from undergoing surgery dered an unprecedented expansion of chance. "A particularly instruc- altogether. Involving several doc- of surgery Operations whose per- tive example of this approach is tors in a given case could dis- formance would have been con- encapsulated in an 1854 essay by perse responsibility. One could sidered insane or criminal just 15 the Russian surgeon Nikolay also try to perform as many safe years earlier were now performed Pirogov, aptly titled"On Luck in operations as possible so that the routinely. The decisive advantage Surgery. "As Pirogov knew, sur- occasional failure would not spoil of antisepsis, however, was the geons had always been particu- one's mortality statistics. How- predictability of good results so 1978 N ENGL J MED 369: 21 NEJM. ORG NOVEMBER 21, 2013PERSPECTIVE 1978 n engl j med 369;21 nejm.org november 21, 2013 1. Pope TM. Legal fundamentals of surrogate decision making. Chest 2012;141:1074-81. 2. Pope TM, Sellers T. Legal briefing: the un￾befriended — making healthcare decisions for patients without proxies. J Clin Ethics 2012;23(1):84-96, 23(2):177-92. 3. White DB, Curtis JR, Wolf LE, et al. Life support for patients without a surrogate de￾cision maker: who decides? Ann Intern Med 2007;147:34-40. 4. Caring for Georgia’s unbefriended elders: views from the probate bench on the 2010 amendments to the Surgical and Medical Consent Statute. Atlanta: Georgia Appleseed, 2013 (http://www.gaappleseed.org/docs/ caring-for-elders.pdf). 5. White DB, Jonsen A, Lo B. Ethical chal￾lenge: when clinicians act as surrogates for unrepresented patients. Am J Crit Care 2012; 21:202-7. DOI: 10.1056/NEJMp1308197 Copyright © 2013 Massachusetts Medical Society. Making Decisions for Patients without Surrogates HISTORY OF MEDICINE Railways, Industry, and Surgery — The Introduction of Risk Management Thomas Schlich, M.D. Trains sometimes derail, planes crash, factories collapse — yet we take trains and planes and keep building factories. We have learned to live with risk. The no￾tion of risk is so common that it has been described as a defining feature of modern societies. Mod￾ern risk management has made risk calculable and to some ex￾tent controllable. It is also a cen￾tral feature of medical interven￾tion, most notably in surgery. But when risk management was initially introduced into surgery, in the 1870s, it was not only be￾cause of developments in medi￾cine (such as antisepsis) but also because of precedents in the rail￾road and manufacturing arenas. This new attitude toward risk led to greater use of surgical interven￾tions and, I would argue, was at least as important as antisepsis for the development of the field. Before the late 19th century, surgeons had engaged in what might be called the “management of chance.” A particularly instruc￾tive example of this approach is encapsulated in an 1854 essay by the Russian surgeon Nikolay Pirogov, aptly titled “On Luck in Surgery.” As Pirogov knew, sur￾geons had always been particu￾larly vulnerable to being blamed for bad outcomes, since the link between an operation and the death of a patient is normally ob￾vious and hard to deny. Pirogov assumed that the reason why surgeons had always had to cope with this problem was that out￾comes in surgery were essentially beyond the practitioner’s control. Surgeons needed a certain “prac￾tical tact,” explained Pirogov, to judge whether or not to operate in a situation in which the odds could neither be completely known nor influenced. Such decisions had to take into account a whole economy of risk, involving the influences of both medical and nonmedical factors. Surgeons in￾curred particularly high risk to their reputations and future work, for example, when operating on a patient of high social standing. Some patients, Pirogov advised, should therefore be referred to colleagues. Others should be dis￾suaded from undergoing surgery altogether. Involving several doc￾tors in a given case could dis￾perse responsibility. One could also try to perform as many safe operations as possible so that the occasional failure would not spoil one’s mortality statistics. How￾ever, at the end of the day, all these strategies had their limita￾tions. The power of hidden factors and pure chance was too strong. Pirogov explicitly rejected the idea of using statistical calcula￾tions to deal with this uncertainty because, he explained, the chance element in probability calcula￾tions made them inapplicable to the surgeon’s day-to-day work. In 1881 the German surgeon Richard von Volkmann suggested that the traditional surgeon re￾sembled a farmer who could only cultivate his land and wait to see how his harvest turned out, where￾as the modern surgeon, with anti￾sepsis at his disposal, resembled a manufacturer from whom the public expected consistently high￾quality products.1 Volkmann had adopted Joseph Lister’s antisepsis a decade earlier and had become Germany’s most influential pro￾ponent of the antiseptic method, an innovation that had engen￾dered an unprecedented expansion of surgery. Operations whose per￾formance would have been con￾sidered insane or criminal just 15 years earlier were now performed routinely. The decisive advantage of antisepsis, however, was the predictability of good results so