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Where life depends on protected judgment. From surgical teams to emergency medicine, medicine demonstrates how evaluation suppression, error-as-signal, and procedural authority function under ultimate stakes.
Why This Matters
Medicine demonstrates that judgment capacity requires architectural protection—pressure damages performance even when compliance is achieved. The checklist revolution proved that structure beats heroism.
Medical practice—particularly surgery and emergency medicine—provides evidence for RSA from a domain where the stakes could not be higher. Errors are visible, consequential, and often irreversible.
Traditional surgical culture emphasised individual heroism: the brilliant surgeon who never makes mistakes, never asks for help, never admits uncertainty. This culture cost lives.
The checklist revolution and crew resource management demonstrated that architectural interventions—not better training, not higher standards—reduced mortality more than any other intervention.
This is exactly RSA's claim: architecture protects what virtue cannot. Medicine proves this under conditions where the cost of being wrong is death.
High stakes under pressure
Life-or-death decisions with irreversible consequences
Time-sensitive judgment
Surgeons and emergency physicians work under extreme time constraints
Complex, non-optimisable
Every patient is unique; diagnosis cannot be reduced to algorithm
Clear counterfactuals
Well-documented outcomes of hierarchical vs. collaborative approaches
Long operational history
Millennia of practice with modern evidence since mid-20th century
Architecture over virtue
Checklists and protocols work independent of individual skill variance
Traditional surgical hierarchy silenced nurses and junior staff who saw problems. The shift to "sterile cockpit" protocols—where anyone can halt a procedure—demonstrates that evaluation suppression damages outcomes even when the silenced parties have correct information.
The morbidity and mortality conference tradition treats adverse outcomes as learning opportunities, not blame events. This maps directly to RSA's distinction between systems that use errors for improvement versus those that use errors for punishment.
Diagnostic medicine requires "time to think"—protected from administrative pressure, throughput metrics, and interruption. This is rate controlin its purest form: slowing the system to preserve judgment quality.
Checklists work because they give procedural authority to the checklist itself, not to any individual's judgment. The WHO Surgical Safety Checklist reduced mortality by 47%—not through better surgeons, but through better architecture.
Medicine is supporting evidence for specific RSA mechanisms, but it does not demonstrate:
Medical hierarchy is relatively clear; authority flows from expertise and credentialing. Medicine therefore tells us little about how to architect systems where authority is contested, plural, or emergent—the harder institutional cases.
"The WHO Surgical Safety Checklist reduced mortality by 47%—not through better surgeons, but through better architecture."
Medicine demonstrates the same invariant that appears in education, aviation, and military command: systems preserve judgment by removing pressure and embedding constraint.
The checklist does not make surgeons smarter. It removes the pressureof having to remember everything under stress. The sterile cockpit protocol does not make nurses braver. It embeds the constraint that hierarchy cannot silence safety concerns.
This is architecture doing what exhortation could not: creating structural conditions under which good judgment is the default, not the exception.
WHO Surgical Safety Checklist (2008)
Introduced in 8 hospitals across 8 countries, reduced surgical mortality by 47% and complications by 36%. Architecture, not training.
Crew Resource Management in Operating Rooms
Adapted from aviation, CRM protocols reduced preventable errors by creating psychological safety for junior team members to raise concerns.
Lucian Leape's "Error in Medicine" (JAMA, 1994)
Foundational paper arguing that medical errors should be treated as system failures, not individual failures—exactly RSA's framing.
Medicine demonstrates that judgment capacity requires architectural protection. See how RSA applies this insight across all five research domains.
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