Individual doctors (and nurses and administrators) often do not see that they have any individual responsibility to take action to address preventable patient harm when it is attributed to “the system”. The “system” is seen as existing outside them and their sphere of influence. Any sense of personal responsibility to change what they are doing to prevent patient harm is thus reduced. As noted earlier, doing no harm to patients is a key element of most doctors’ perception of their moral selves and so the reduction of preventable patient harm would have been expected to be a top priority. However, it can be argued that the focus on “systems” has facilitated selective disengagement of medical moral agency. This reduction in moral agency occurs through both the displacement and the diffusion of responsibility for action to prevent patient harm, inherent in a system focus. As Bandura said “Moral control operates most strongly when people acknowledge that they are contributors to harmful outcomes”44.
Displaced responsibility arises when “the system” is seen as responsible. The logic of such reasoning states that if the system is responsible and the system is separate from the people in it, individuals do not see themselves as the potential agents of their own preventive actions. Displacement of responsibility can also occur when someone is kept intentionally uninformed or where someone chooses “not to know”.
Diffusion of responsibility also weakens personal agency. For example, where “the system” is seen as the problem, the notion of who is responsible to address the problem becomes unclear. If it is seen as a group responsibility, this also leads to a diffusion of responsibility -“When everyone is responsible, no one really feels responsible”.45 Everett C Hughes in his 1951 essay on “Mistakes at Work” goes so far as to say that in types of work where errors are frequent such as medicine, the collegial and structural systems involve the development of a “collective rationale … and defences” that tend to “spread the risk psychologically, morally and financially.”46 Some of these risk and guilt sharing practices include: supervision, consultation, cross-coverage and case
44 Bandura A. Selective exercise of moral agency. Chapter in Thorkildsen TA. Walberg HJ.
(editors) Nurturing morality. 2004 Kluwer Academic, Boston, pages 37-57: at page 42.
45 Bandura A. 2004 – see note 44: at page 44.
46 Hughes EC. Mistakes at Work. 1951 Canadian Journal of Economics and Political Science,
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conferences47. These all constitute processes of displacement and diffusion of
responsibility, which can undermine an individual’s sense of moral agency to identify or reduce the incidence of preventable patient harm.
An illustration of this occurred in relation to the highly critical series of reviews of the Mid Staffordshire Foundation Trust in England48. Following the release of the final report of the last Public Inquiry, the Chief Executive of the English National Health Service was asked to give evidence before the United Kingdom House of Commons Health Committee, which was considering the findings of the inquiry and the role played by Sir David Nicholson. Nicholson was, at the relevant time, Chief Executive of the Strategic Health Authority in which the Mid Staffordshire events occurred. Having admitted that he didn’t know of the unusually high death rate at the facility because that was not what was reported to him, he was extensively questioned about accountability and responsibility for the “system” failures49. His evidence was summarised by a
reporter in the following manner:
In any case, he wasn’t going to resign. Indeed, listening to him, you might have formed the impression that no one should resign. This was because the blame lay not with actual people but with a mysterious and sinister-sounding entity known as “the system”. “The system did not take seriously enough the input of patients” lamented Sir David. “Patients were not the centre of the way the system operated. … No culture of sharing information across the system … A basic system problem … A big failing in the whole system…” The system. The system. He might have been a character in a sci-fi film analysing a computer failure on a space ship. Rather than, say, the head of the NHS explaining why patients were given no water to drink, or left to lie in sheets soaked in urine.50
47 Bosk CL. Continuity and change in the study of medical error – the culture of safety on the shop
floor. Occasional Papers of the School of Social Sciences, Paper Number 20. February 2005 Unpublished: accessed 17 March 2014 at http://www.sss.ias.edu/files/papers/paper20.pdf : page 3.
48 There have been three major inquiries into the problems identified in Mid-Staffordshire – a
Healthcare Commission Report in 2009, an Independent Inquiry conducted by Robert Francis QC which published a two-volume report released in 2010 and a Public Inquiry also conducted by Francis, which produced a 3 volume report, which was released in 2013. All documents are available on the Inquiry Website at http://www.midstaffspublicinquiry.com/
49 Full evidence given at the UK House of Commons Health Committee on 5 March 2013 on this
issue by Sir David Nicholson can be viewed on
http://www.parliamentlive.tv/Main/Player.aspx?meetingId=12729 : for discussion on system failure and accountability, see especially the interchange between Andrew George MP and Sir David Nicholson at 10:16:49 am and following.
50 Deacon M. Sketch: Need an excuse? You can’t beat ‘the system’. 2013 UK Telegraph, 5 March
2013: sighted 17 June 2013 at http://www.telegraph.co.uk/news/politics/9910554/Sketch-Need- an-excuse -You-cant-beat-the-system.html.
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Where health administrators, doctors and others in positions of organisational power in health blame “the system”, they often do not recognise that it as their job to prevent patient harm continuing to occur. The system focus allows them to avoid personal responsibility for their role in preventable patient harm and their moral obligation to ensure harm is prevented from occurring again. As has been recognised in the literature on selective moral agency, where “the system” is seen to be at fault or to have failed, the result is often that no-one sees it as their responsibility to address the problem.