Gross Mismanagement

Aidan Low

Many of the Therac-25 accidents could have been avoided if AECL had alerted its customers to possibly lethal malfunctions in the Therac-25 unit. After a lawsuit following an overdose by a Therac-25 unit in 1985, AECL knew of the dangers of the Therac-25, yet by not informing its customer base of the danger, AECL paved the way for four deaths and another serious injury. AECL was negligent in its handling of Therac-25 case, clearly preferring to cover up an accident rather than undermine its credibility among its customers. Because users were not informed of the possible dangers of the system, they were not able to take the necessary steps to prevent these accidents from happening again, and as a result several human lives were lost. AECL tried to conceal the Therac-25 accidents for as long as possible, and by doing so, maximized the damage that was done.

In October 1985, after a Therac-25 accident destroyed the breast of a 61-year old woman and paralyzed her arm and shoulder, she filed suit against AECL. The company clearly knew of the possible dangers of the system, and it is ridiculous to believe that such an accident would be an isolated occurrence. In spite of this, AECL failed to notify its clients of this accident or warn them of the possibility of this happening again. Indeed, when questioned by customers after later overdoses, AECL denied any previous accidents in the Therac-25 unit. AECL demonstrated not only gross mismanagement of the situation but inexcusable criminal negligence by knowingly lying to users about a potentially leth al problem in the Therac-25.

The real problem in covering up the problems of the Therac-25 is that many of these accidents could have been avoided if the customers of AECL had been warned of them. The problems with the Therac-25 involved the controlling software, thought by most customers to be completely foolproof. This point of view is understandable, as AECL repeatedly told customers "it was not possible for the Therac-25 to overdose a patient." As a result, operators ignored warning messages and continued to use the system to treat patients, even treating a patient repeatedly after he had suffered serious radiation burns as a result of the Therac-25. If the operators had known that this potential for lethal doses of radiation existed, they would have been far more less cavalier about ignoring error messages, and the other accidents might have been avoided. AECL covered up the Therac-25 accidents for as long as possible, allowing operators to unknowingly subject other patients to the same lethal radiation.

In this case, AECL acted out of self-interest, preferring its own survi val as a credible medical technology supplier to the survival of its patients. However, in any case involving accidents in medical technology, there is a tradeoff between deaths caused by malfunctioning equipment and lives saved when the technology actually worked. Perhaps if AECL had recalled the Therac-25 unit after the first accident occurred, the nameless people whose lives were saved by the system would have died in greater numbers than the highly visible accidents which occurred. However, the responsible thing for any company is to notify its customers of potential defects in its products, and allow them to make an informed decision about whether to use the technology, especially when those problems may be avoidable once aware of them. AECL's decision to cover up the Therac-25 overdoses allowed future patients to be killed by the radiation, and such conduct is inexcusable. Clearly, AECL should have notified its users of the potential for overdose in the Therac-25 from the very beginning, and perhaps this tragedy could have ended there.