Analyzing The Therac-25

Analyize the the case carefully, as follows:

Gather data

  1. List the relevant stakeholders. Start with some of the groups mentioned in the socio-technical system page. However, do not end there. Notice that our accident victims, the patients, are not included. Other important groups may also be omitted (e.g. "the public").
  2. Outline the duties and rights the stakeholders have toward each other. This is best done with a drawing of each stakeholder with arrows indicating duties one owes to other and rights one has. Duties always have targets, one has duties to a particular person (even to oneself). Rights may appear to be free floating (e.g. not to be harmed) but they can often be translated into duties that others have toward the individual (avoid harming X).
Analyze the data
  1. List the relevant opportunities and vulnerabilities that each stakeholder had in the case. This is the beginning of what Collins and Miller call a utilitarian ethical analysis. Who is being helped and harmed? What advantages or opportunities does each party receive in this case? What costs or dangers, or vulnerabilities does each party experience?
  2. Determine to what degree each stakeholder's duties were fulfilled or neglected.
  3. Determine to what degree each stakeholder's rights were violated or protected, and by whom.
Consider the Alternatives

  1. For each major actor, construct a promising, realistic alternative that might plusibly have prevented or reduced the impact of the error.
  2. Consider what factors prevented such an alternative action from occuring for each case.
Produce a presentation of yoiur findings which will take 20 minutes.


Topic revision: r2 - 2016-04-08 - JimSkon
 
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