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.