Beginning the operation, the surgeon had one nurse retrieve the local anesthetic, lidocaine, in order to inject it into the patient's tear duct. Both of the nurses and the surgeon confirmed the bottle was lidocaine by checking the label on the small bottle. Nevertheless, once the surgeon injected the "lidocaine" into the woman's left tear duct, he realized that there was an unusual smell in the air. The American nurse immediately recognized that the smell was that of formaldehyde. As the formaldehyde destroyed the patient's eye, the woman cried out in agony, "Why is the serpent causing me so much pain?" The team then made an immediate attempt to irrigate her eye. However, it was too late. The woman would never see again out of her left eye and her other eye was still covered by the original cataract.
The surgeon then contacted the chief surgeon, and along with the American nurse left to meet at the chief surgeon's home. The chief surgeon, surgeon, and American nurse met to make a decision on what to do about the disturbing incident. The chief surgeon "felt that no matter what course of action we took, in no way should we put ourselves or the continued practice of providing safe and clean surgery to locals at risk," simply because of the improper labeling of a bottle. They decided to "let the incident pass without further comment." They came to this decision by realizing that people who most desperately needed their medical assistance would stay away if the incident was made public. In addition, the incident could "put the training program in jeopardy, thus denying local citizens the opportunity to learn medical skills" because the government had been trying to obstruct the training and were looking for any reason to end the program. .
Now using Cavanagh's "Basic Method," one is capable to deciding if the decision made by the chief surgeon, surgeon, and nurse was ethical. The first step in the basic method is gathering relevant "factual" information concerning the act or policy under review.