Medicine, Health Care and Philosophy

, Volume 20, Issue 1, pp 37–42 | Cite as

Simulation as an ethical imperative and epistemic responsibility for the implementation of medical guidelines in health care

Scientific Contribution


Guidelines orient best practices in medicine, yet, in health care, many real world constraints limit their optimal realization. Since guideline implementation problems are not systematically anticipated, they will be discovered only post facto, in a learning curve period, while the already implemented guideline is tweaked, debugged and adapted. This learning process comes with costs to human health and quality of life. Despite such predictable hazard, the study and modeling of medical guideline implementation is still seldom pursued. In this article we argue that to systematically identify, predict and prevent medical guideline implementation errors is both an epistemic responsibility and an ethical imperative in health care, in order to properly provide beneficence, minimize or avoid harm, show respect for persons, and administer justice. Furthermore, we suggest that implementation knowledge is best achieved technically by providing simulation modeling studies to anticipate the realization of medical guidelines, in multiple contexts, with system and scenario analysis, in its alignment with the emerging field of implementation science and in recognition of learning health systems. It follows from both claims that it is an ethical imperative and an epistemic responsibility to simulate medical guidelines in context to minimize (avoidable) harm in health care, before guideline implementation.


Medical guideline implementation Ethical imperative Epistemic responsibility Medical simulation Moral luck Learning health systems 


  1. Ash, J., et al. 2004. Some unintended consequences of information technology in health care: The nature of patient care information system-related errors. Journal of the American Medical Informatics Association 11: 104–112.CrossRefGoogle Scholar
  2. Banks, J. (ed.). 1998. Handbook of simulation: Principles, methodology, advances, applications, and practice. New York: John Wiley.Google Scholar
  3. Beauchamp, T., and J. Childress. 2008. Principles of biomedical ethics, 6th ed. Oxford: Oxford Univ. Press.Google Scholar
  4. Caro, J., A.H. Briggs, U. Siebert, and K. Kuntz. 2012. Modeling good research practices-overview: A report of the ISPOR-SMDM modeling good research practices task force–1. Value Health 15(6): 796–803.CrossRefGoogle Scholar
  5. Casalino, P. 1999. The unintended consequences of measuring quality on the quality of medical care. NEJM 341(15): 1147–1150.CrossRefGoogle Scholar
  6. Code, L. 1987. Epistemic responsibility. Hanover: University Press of New England and Brown Univ. Press.Google Scholar
  7. Eccles, M.P., J.M. Grimshaw, P. Shekelle, H.J. Schunemann, and S. Woolf. 2012. Developing clinical practice guidelines: Target audiences, identifying topics for guidelines, guideline group composition and functioning and conflicts of interest. Implementation Science 7: 60.CrossRefGoogle Scholar
  8. Field, M.J., and K. Lohr, eds.; Committee to Advise the Public Health Service on Clinical Practice Guidelines Institute of Medicine. 1990. Clinical practice guidelines: Directions for a new program. Washington, DC: National Academy Press.Google Scholar
  9. Gagliardi, A.R., and M.C. Borrowers. 2012. Integrating guideline development and implementation: analysis of guideline development manual instructions for generating implementation advice. Implementation Science 7: 67.CrossRefGoogle Scholar
  10. Garbayo, L. 2014. Epistemic considerations on expert disagreement, normative justification, and inconsistency regarding multi-criteria decision making. In Constraint programming and decision making: Studies in computational intelligence, Vol. 539, 35–45.Google Scholar
  11. Harrell, C., B. Ghosh, and R. Bowden. 2000. Simulation using ProModel. New York: McGraw Hill.Google Scholar
  12. Harrison, et al. 2013. Guideline adaptation and implementation planning: a prospective observational study. Implementation Science 8: 49. doi:10.1186/1748-5908-8-49.
  13. IOM (Institute of Medicine) and NAE (National Academy of Engineering). 2011. Engineering a learning healthcare system a look at the future: Workshop summary, Learning health system series. Washington, DC: National Academies Press.Google Scholar
  14. Karnon, J., J. Stahl, A. Brennan, J.J. Caro, J. Mar, and J. Moller. 2012. Modeling using discrete event simulation: A report of the ISPOR-SMDM modeling good research practices task force–4. Value Health 15(6): 821–827.CrossRefGoogle Scholar
  15. Kitson, A.L., J. Rycroft-Malone, G. Harvey, B. McCormack, K. Seers, and A. Titchen. 2008. Evaluating the successful implementation of evidence into practice using the PARiHS framework: Theoretical and practical challenges. Implementation Science 3: 1. doi:10.1186/1748-5908-3-1.CrossRefGoogle Scholar
  16. Kuntz, K., F. Sainfort, M. Butler, B. Taylor, S. Kulasingam, S. Gregory, et al. 2013. Decision and simulation modeling in systematic reviews. Rockville, MD: Agency for Healthcare Research and Quality (US); 2013 Feb. Report No.: 11(13)-EHC037-EF.Google Scholar
  17. Madon, T., K. Hofman, L. Kupfer, and R. Glass. 2007. Implementation science. Science 318(5857): 1728–1729.CrossRefGoogle Scholar
  18. Merton, R. 1936. The unanticipated consequences of purposive social action. American Sociological Review 1(6): 894–904.CrossRefGoogle Scholar
  19. Nagel, T. 1993. Moral luck. In Moral luck. SUNY series in ethical theory, ed. D. Statman. Albany: SUNY Press.Google Scholar
  20. NINDS, and NIH. 1996. In Proceedings of a National Symposium on Rapid Identification and Treatment of Acute Stroke. Bethesda, MD.Google Scholar
  21. Pitman, R., D. Fisman, G.S. Zaric, M. Postma, M. Kretzschmar, J. Edmunds, and M. Brisson. 2012. Dynamic transmission modeling: A report of the ISPOR-SMDM modeling good research practices task force–5. Value Health 15(6): 828–834.CrossRefGoogle Scholar
  22. Roberts, M., L.B. Russell, A.D. Paltiel, M. Chambers, P. McEwan, and M. Krahn. 2012. Conceptualizing a model: A report of the ISPOR-SMDM modeling good research practices task force–2. Value Health 15(6): 804–811.CrossRefGoogle Scholar
  23. Shekelle, P., S. Woolf, J.M. Grimshaw, H.J. Schunemann, and M.P. Eccles. 2012. Developing clinical practice guidelines: Reviewing, reporting, and publishing guidelines; updating guidelines; and the emerging issues of enhancing guideline implementability and accounting for comorbid conditions in guideline development. Implementation Science 7: 62.CrossRefGoogle Scholar
  24. Siebert, U., O. Alagoz, A. Bayoumi, B. Jahn, D. Owens, D. Cohen, and K. Kuntz. 2012. State-transition modeling: A report of the ISPOR-SMDM modeling good research practices task force–3. Value Health 15(6): 812–820.CrossRefGoogle Scholar
  25. Solomon, M. 2010. The ethical urgency of advancing implementation science. American Journal of Bioethics 10(8): 31–32.CrossRefGoogle Scholar
  26. Solomon, M., and A. Bonham, eds. 2013. Ethical oversight of learning health care systems. Hastings Center Special Report 43(1): S1–S44.Google Scholar
  27. Stahl, J.E., K.L. Furie, S. Gleason, and G.S. Gazelle. 2003. Stroke: Effect of implementing an evaluation and treatment protocol compliant with NINDS recommendations. Radiology 228(3): 659–668.CrossRefGoogle Scholar
  28. US Preventive Services Task Force. 2009. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine 151(10): 716–726.CrossRefGoogle Scholar
  29. Woolf, S., H.J. Schunemann, M.P. Eccles, J.M. Grimshaw, and P. Shekelle. 2012. Developing clinical practice guidelines: Types of evidence and outcomes; values and economics, synthesis, grading, and presentation and deriving recommendations. Implementation Science 7: 61.CrossRefGoogle Scholar
  30. Zagzebski, L. 2001. Recovering understanding. In Knowledge truth, and duty: Essays on epistemic justification, responsibility, and virtue, ed. Matthias Steup. Oxford: Oxford Univ. Press.Google Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2016

Authors and Affiliations

  1. 1.Departments of Philosophy (College of Arts and Humanities) and Medical Education (College of Medicine)University of Central FloridaOrlandoUSA
  2. 2.Geisel School of MedicineDartmouth CollegeHanoverUSA
  3. 3.Institute of Technology Assessment, Massachusetts General HospitalBostonUSA

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