Habitual dependence…can lead to atrophy of the brain. Incredible as it seems…during a recent power failure…some people complained of getting stuck for hours on escalators. — Sam Levenson

Not long ago, the pilots of Swiss Air Flight 111 were sharply at odds about how to handle an emergency. Protocol required they go through a lengthy checklist. The captain insisted on going by the book while the copilot wanted to scrap the rules and land quickly. Smoke was filling the airplane and seeping into the cockpit. They could have headed directly to the nearest airport and executed an emergency landing. The co-pilot repeatedly suggested steps that would have led to a rapid landing, but the captain repeatedly rejected them while focusing on the checklist. Only a few minutes before the plane plunged into the ocean, the captain made it clear he was in the middle of a checklist and didn’t want to be interrupted again. He wasn’t; soon, he and the 229 others aboard were dead.

This situation raises an issue of great concern in health care—especially since safety experts such as Lucian Leape, MD, have identified overreliance on checklists as the cause of many errors. With increasing emphasis on best practices and evidence-based practice, which apply most of the time, we may be in danger of demonstrating Levenson’s “atrophy of the brain.” While empirical evidence supports practice guidelines, I have this nagging doubt: Is it possible people will turn off their judgment and go by the book when it’s the wrong thing to do? This has happened in every other area of human concern. Why not health care?

Clearly, a discussion of the nature and place of rules, intuition, and judgment is in order. Rules—or at any rate, practice guidelines, checklists, and best practices—have been developed by some of the best brains in the world. Intuition is an amalgam of knowledge, experience, and common sense. Common sense is that decidedly uncommon quality—sound, practical understanding.

Judgment (as in good judgment) puts all three together. It comes together so quickly we’re unaware of the logic behind it, so we call it “going from the gut.” There’s no substitute for judgment, whether it applies to pilots or healthcare personnel. In fact, professional autonomy was invented to protect judgment.

And there’s a price you pay if your judgment is wrong. Relatively speaking, you’re “safe” if you go by the book. That’s why so many professionals take that route even when it’s wrong or just plain dumb—and that’s why I’m worried. I’m not proposing we scrap evidence-based practice, best practices, and the like. But I worry about excessive reliance on them. If we go by rote, never making professional judgments, we lose the most valuable contribution a professional can make—professional judgment. And everyone will be the poorer for it.

In his book Nichomachean Ethics, Aristotle wrote, “What creates the problem is that the judgment is right, not according to the rule…but a correction of the rule. The reason is that all rules are universal [at least within the confines of their intended application] and about some things it is not possible to make a universal statement which shall be correct in all situations.”

We cannot allow practice guidelines and the like to become substituted judgments, but should use them as guidelines. Otherwise, we’ll reach a time and a place where common sense and going by gut instinct are indefensible even when they’re right. Without in any way diminishing the wise counsel of experts (as articulated in practice guidelines, etc.), we must retrieve judgment from the dust heap of nonuse and return it to a vigorous role in professional life.

Leah Curtin, RN, ScD(h), FAAN
Executive Editor, Professional Outreach
American Nurse Today

Selected references

Aristotle’s Nicomachean Ethics (Philosophical Library Series). Sachs J. (translation). Focus Publishing/R. Pullins Company; 2002.

Dr. Leah Curtin, RN, ScD (h), FAAN, is Executive Editor, Professional Outreach, American Nurse Today. An internationally recognized nurse leader, ethicist, speaker, and consultant, she is a strong advocate for both the nursing profession and high-quality patient care. Currently she is Clinical Professor of Nursing at the University of Cincinnati College of Nursing and Health. For over 20 years, she was the Editor-in-Chief of Nursing Management. In 2007, she was appointed to the Standards and Appeals Board of DNV Healthcare, a new Medicare accrediting authority. Dr. Curtin can be reached at LCurtin@healthcommedia.com.

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