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Philosophy 162F

Lecture 6 Notes

Corporate Character and Individual Responsibility

  • One of the worries of Velasquez was that we will avoid holding individuals properly responsibly if we focus on organizational responsibility.
  • But can't we do both?
  • Boisjoly, et al. present a case that is troubling for the analysis of organizational responsibility.

 

Russell P. Boisjoly, Ellen Foster Curtis and Eugene Mellican

Roger Boisjoly and the Challenger Disaster: The Ethical Dimensions

The Challenger disaster was an example of an accident that may people, experts on the nature of the accident in question, tried to prevent.

Businesses rely on experts to deliver the basis on which to make business decisions.

Business, whether profit or non-profit, must often take risks.

Ideally, businesses assess the probability of risk along with the nature, extent and magnitude of possible harm and benefits.

Some risks are deemed too great for certain outcomes. Generally loss of life risks are only acceptable if the probability is low and the potential benefits are great.

For any business that relies on expert testimony in making decisions of dire risk, it is important that the management structure of that business take the best account of expert testimony that it can.

It may be the case that in cases of dire risk, the organizational structure of a business is not merely a bottom-line concern, it is an ethical concern due to the dangers involved.

By focusing on the problematic relationship between individual and organizational responsibility, this analysis reveals that the organizational structure governing the space shuttle program became the locus of responsibility in such a way that not only did it undermine the responsibilities of individual decision makers within the process, but it also became a means of avoiding real, effective responsibility throughout the entire system. (Pg. 131)

The claim made by Boisjoly, et al. is that the organizational structure impeded the activity of ethical decision making.

Two types of responsibility:

  1. Individual responsibility to assess a situation and act accordingly.
  2. Organizational responsibility to enact review measures to ensure that each step in corporate activity proceeds properly.

The second type of responsibility can be seen as a way to get corporations to act in a way that is analogous to the way that individual responsibility (in this sense) operates.

Organizations have no mind to assess and act on a situation. To mimic this process, an organization can have formal rules for specific agents to review information, make recommendations, and take action.

These formal rules often have strict requirements of evidence before a decision can be endorsed by the organization.

Strict rules that impede or slow down action are good when attempting to prevent the initiation of courses of action that may cause harm.

However, these same rules can be a problem if immediate action must be taken by the organization to prevent ongoing harm or harm that is likely to occur in the near future.

Example of Structure Impeding Decision: Level III to Level II (pp. 131-132)

  • The concern about the O-rings was kept at a low level of analysis, Level III, and not passed on to a higher level of scrutiny.
  • Lawrence Mulloy, a manager at Level III, gave two reasons for not passing along the concern.
  • The issue was properly under one of the areas specified for Level III consideration.
  • The concern did not meet the list of those concerns that were deemed relevant when considering whether or not to launch the shuttle.
  • The first reason was strictly true, yet Mulloy did have the authority to pass the concern on to Level II.
  • However, the issue of joint temperature was not one that was recognized as a launch-threatening issue, thus it was not, by the strict rules of the organization, an item that was to be deemed of serious concern.
  • Thus the two reasons together encouraged the limited the action taken within the organization.
  • Mulloy should have had the motivation to pass the concern up to a higher level of scrutiny. He effectively ignored the dire risk to the crew of the Challenger due to the management structure.

The formal structure of decision making within the organization required individual managers to base their decisions upon formal memos and strict chain of command.

Thus a serious flaw in the shuttle was legitimately not part of the knowledge of individual managers:

  • either literally because they only communicated with team leaders who presented the results of previous decision procedure
  • or effectively, as they felt that they were not in a power to act on or acknowledge the information that they received

This type of situation is not unique to businesses that work on the basis of engineering reports.

In any business with employees, there are certain concerns with these employees that, while important, must nevertheless be put aside for organizational reasons.

For example, an employer or a manager may have to assign duties or even extra reward to an employee that they do not trust with the task.

  • An employee that has received a letter of warning for misconduct and has appealed that letter through appropriate channels might enjoy, by the nature of their contract, the rights and privileges of all other employees until the dispute over the letter has been resolved.
  • Similarly, a manager might have information about an employee's misconduct and yet still be prevented from acting on that misconduct. For example, a letter of warning may have been warranted yet be set aside due to a technicality of law or contract. Thus the manager has information of the misconduct, yet she, in an institutional sense, cannot acknowledge the information.

Boisjoly, et al. identify part of the organizational problem at NASA and MTI as groupthink.

Their definition of groupthink comes from Irving L. Janis (Victims of Groupthink, 1972):

…a mode of thinking that people engage in when they are deeply involved in a cohesive in-group, when the members' strivings for unanimity override their motivation to realistically appraise alternative courses of action…. Groupthink refers to the deterioration of mental efficiency, reality testing, and moral judgment that results from in-group pressures. (Janis, pg. 9)

Boisjoly, et al. suggest that instances of groupthink influenced the way that the information about the O-ring problems were processed at different points in the organization.

The organizational structure turned from a demand for documentation in order to assess actual probabilities of risk into an adversarial system that placed a high demand on arguments against the status quo.

 

Though this analysis is useful, Boisjoly et al do not want the organizational analysis of the disaster to obfuscate the actions of individuals as part of this organization.

The organizational structure makes demands of individuals at different stages to take personal responsibility for different aspects of the launch. This must be recognized and highlighted.

Even though the organizational structure should change, individuals must take responsibility for their actions in refusing to acknowledge the evidence in their possession.

 

The commission investigating the disaster reported that, "There was no system in place which made it imperative that launch constraints be considered by all levels of management." (Report of the Presidential Commission on the Space Shuttle Challenger Accident, 1986, pg. 104) This contradicts the findings of the Commission that there had been a violation of such a system (pg. 113 of text) and that the individual responsible for this failure had been identified (pg. 104).

 

Criteria for holding individuals responsible for an outcome:

  1. Their acts or omissions are in some way a cause of the outcome
  2. These acts or omissions are not done in ignorance or under coercion.

 

The Challenger disaster shows that no matter the organizational structure, individuals can still play key roles in the outcome of the actions of the organization.

  • The MTI supported the launch of the shuttle.
  • The decision to support the launch was made on the basis of the reporting of engineering findings.
  • The engineers involved recommended against launch.
  • Management chose to discount the recommendations of the engineers.
  • This management action produced the support of MTI.
  • Without the decision of MTI the shuttle would not have launched and thus the accident would not have occurred.
  • Therefore the decision of the management to discount the recommendations of the engineers was in a way the cause of the accident.

 

Lisa Belkin

How Can We Save the Next Victim?

Belkin's piece comes to a position that is almost the opposite of that of Boisjoly, et al.

Boisjoly, et al. argue that we must look past systematic features to reveal the human causes of the outcome.

Belkin argues that we must look past individual human actions to see the systematic effects that brought about the outcome.

The recent history of medical error is an example of systems where there is no blame to attach to any individual.

Systematic hospital error, she claims, are often the result of trusting in the ability of individuals to correct for mistakes that can only be corrected for systematically.

Belkin draws our attention to ways that we can improve these systems, in medicine and in other organizations.

Belkin does allow that there may be some difference between systemic medical error and that in other systems. Other organizations usually only have to deal with difficulties in personnel and equipment. Medical organizations have an additional complication in the form of patients.

It is also worth noting that Belkin is writing about error. What she says may not be applicable to cases where there is genuine malfeasance on the part of an organization or its management.

 

Jose Martinez Case

 

  • A sequence of events lead to the death of 2-month old Jose Martinez.
    1. Martinez diagnosed with a ventricular septal defect.
    2. A short-term prescription for Digoxin was recommended.
    3. Attending physician and a resident discussed the diagnosis and determined the correct dosage.
    4. The dosage was determined in one measurement scale and then converted to another scale.
    5. After discussing other issues with the doctor, the resident wrote down the dosage in the correct scale, but with an error in decimal place.
    6. The chart with the prescription was reviewed but primarily for another purpose than ascertaining the correctness of the prescription.
    7. A copy of the prescription was faxed to a pharmacist. The pharmacist suspected an error and attempted to contact the resident. The resident had left for the day yet this information did not reach the pharmacist.
    8. An assistant of the pharmacist filled the prescription.
    9. The pharmacist did not remember the earlier suspicion and verified that the amount of Digoxin supplied was the amount requested.
    10. The pharmacist sent the Digoxin to the pediatric floor.
    11. A nurse noticed the dosage and questioned another resident about the dosage.
    12. The resident performed a calculation for the dosage but failed to notice the decimal place error.
    13. The nurse asked a second nurse to verify that the order on the chart was the same as the one on the vial. The second nurse provided this verification.
    14. The Digoxin was given at the specified dosage, leading to an irreversible overdose.

The fallout from this incident was that the hospital in question was placed on accreditation watch by a regulatory body.

This category was intended to encourage the hospital to report on and address the systematic processes that had lead to the death. This would lead to a reduction of the likelihood of similar errors.

 

In many of the cases that Belkin cites, the original source of error is innocuous.

This innocuous source of error is then compounded when individuals within the system rely upon the results of the initial error in carrying out their tasks.

Successful organizations, she seems to suggest, are those that adopt procedures to recheck crucial elements of their processes independently.

An important part of this is making sure that information flows back and forth between individuals who carry out diverse elements of complicated procedures. This is not something that can be accounted for simply by individuals as individuals.


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