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

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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.

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Profs. Garbayo and Stahl wrote the bulk of this paper while collaborating doing research at the Massachusetts General Hospital - Institute for Technology Assessment 101 Merrimac St, 10th Floor Boston, MA 02114. The authors would like to acknowledge the helpful feedback of Prof. Dan Wickler (Harvard School of Public Health) on the discussion of moral responsibility and luck in health care, and of Prof. Mildred Solomon (Hastings Center/Harvard Medical School) on the overall ethics challenges pertaining to learning health systems. Prof. Garbayo was a visiting scholar at MGH-ITA, and at the Hastings Center, where this work was first presented and discussed. She received support from ITA/MGH, Hastings Center & UT El Paso Research Grant. She would like to thank ITA/MGH, Hastings Center and UT El Paso for their gracious support.

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Correspondence to Luciana Garbayo.

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Garbayo, L., Stahl, J. Simulation as an ethical imperative and epistemic responsibility for the implementation of medical guidelines in health care. Med Health Care and Philos 20, 37–42 (2017).

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