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The Emperor’s Speech: Catastrophe and Complexity in Japan

Runners visiting Tokyo know that the place to go is the Imperial Palace. The sidewalk loop around the palace grounds, in the heart of the city, gets you a 5K without any cross streets, and with the green rise of the grounds on one side balancing the traffic on the other side. I assumed my daily slog during visits to Tokyo was the closest I would ever get to Japan’s first family – until Emperor Akihito made a vodcast, which appeared on Japanese television this week.

Journalists have discussed the Emperor’s first-ever public broadcast in the context not only of the rituals of state, but of cultural norms concerning breaking bad news, such as cancer diagnoses. These norms are now under pressure from multiple sources of information, analysis, speculation, and myth concerning the scale of the still-unfolding devastation in Japan following the earthquake, tsunami, and damage to nuclear reactors.

Research into patient safety as a complex system in which safety is continuously created or diminished through countless technical activities has long been informed by research in other industries, notably aviation and energy. “Handoffs” – the transfer of information that occurs during shift changes – are one sort of technical work that hospitals and nursing homes have in common with air traffic control centers and with nuclear power stations. These organizations also share a tendency to look backward in the aftermath of catastrophe: it is easier to see a safety breach once you – or someone – has already experienced it, and much harder to imagine the different places that could give way in the future, under different types of pressure.

Richard Cook, a University of Chicago-based anesthesiologist who studies “cognitive technologies” – checklists and other methods by which workers manage information, and their own interactions, when aiming to achieve a safety goal, has written his own checklist of what predictably happens after complex systems fail. As Cook writes, the “interesting” systems – hospitals, nuclear reactors – are “inherently and unavoidably hazardous.” It makes no sense to imagine that these environments can ever be free of danger or the potential for catastrophe. Workers in these systems know that “error-free” or “accident-free” is a temporary, even illusory, state even as they work to prevent mistakes and contain breaches of safety systems.

Cook also warns against the cognitive error that those inside and outside of complex systems tend to make whenever catastrophic events occur: we search for that telltale pattern of lower-level mistakes and violations that we’re sure must be there, and that will help us to draw an unbreachable line between safety and harm in the – in particular, in our – future.

In the aftermath of tragedy, the ancient ritual of hindsight bias is one that both comforts and blinds. If the Emperor of Japan can try something new, the rest of us can try to learn what “Fukushima” means, in all its complexity, as its story unfolds.

Nancy Berlinger is a research scholar at The Hastings Center and author of After Harm: Medical Error and the Ethics of Forgiveness.


Published on: March 17, 2011
Published in: Public Health

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