Mandatory training for rare anaesthetic events – a philosophical view

Abstract

Murphy's letter opposing the call for mandatory training for rare anaesthetic events [1] challenges issues inferred, but not contained, in the editorial by Nathanson et al. [2]. For example, Nathanson et al. did not suggest that training would make individual humans less error prone. They proposed that we should be training staff to work in multidisciplinary teams, as teamwork can help us identify and correct the inevitable errors of our colleagues and can help them identify and correct ours. While the concepts of teamwork can, and should, be learned through lectures and reading existing literature, developing and refining the non-technical skills required for good teamwork requires training and deliberate practice, with targeted positive feedback. Simulation is the ideal learning environment for this, allowing non-technical skills to be observed, practised and improved. Murphy also seemed particularly concerned about the possibility of sanctions for failing to meet standards, but sanctions do not have a role in simulation training, and they were not mentioned by Nathanson et al.

In response to Murphy's philosophical position that we should view this issue through a utilitarian lens, we believe that a Kantian perspective would be much more appropriate. Utilitarianism can be summarised as the greatest good for the greatest number of people; it is important to recognise that this is based on consequentialism, meaning that, when we act, we are trying to predict how much good the act will produce, as opposed to whether the act is good [3]. The Kantian approach is deontological in nature. This means our actions are judged as objectively good or bad based on ethical values and principles, rather than predicted consequences [4]. According to Kant, what matters is the ethical or moral value of an action. While outcomes are important, it is vital to recognise that, instead of trying to anticipate the optimal outcomes for all parties involved, we have a duty to act in the most ethically correct way for our patients. This includes supporting all measures to ensure that we, as doctors, are appropriately trained to deal with serious rare events that we know cause death and disability. This, therefore, includes supporting the call by Nathanson et al. for mandatory training [2].

The second relevant element of Kantian ethics is found within his categorical imperative, which boils down to the principle of universalisation [5]: “if I act in a certain way, I should be content with everyone else also acting in this way”. This mirrors the question posed by Nathanson et al.: “would we be happy if a member of our family were under the care of an anaesthetist who was unable to demonstrate they could safely manage inadvertent oesophageal intubation or acute anaphylaxis to a neuromuscular blocking drug?” [2]. We believe anaesthetists would answer this question with a resounding ‘no’, supporting the argument that mandatory training is necessary.

Finally, although we do agree with Murphy's assertion that learning from success is valuable, we need to recognise that success rarely comes from exceptional individual human performance but from good teamwork, the very same thing that will help when rare serious complications occur.

From moral, ethical, scientific and philosophical perspectives, it is evident that the time has come to implement mandatory career-long training for rare anaesthetic events. This training should emphasise multidisciplinary crisis management and human factors to enhance patient safety.