Ethical Dilemmas – when Doing Things Right is not Doing The Right Thing

Defunding the police is about “reallocating funds, shifting responsibility away from roles that police have absorbed over time, and establishing guidelines on what society wants and needs from police, including how the police are expected to act in our service.” The issue is not better adherence to policies and practices – doing things right, but greater focus on outcomes for society – doing the right thing.

This is the point made by Suzette Woodward in her book about implementing patient safety. Safety I is ‘the absence of failure’ to follow existing policies and practices, doing things right. Safety II includes Safety I but focuses on outcomes, doing the right thing:

“the ability to succeed under varying conditions so that the number of intended and acceptable outcomes is as high as possible” (p43)

Safety I is thus work-as-prescribed, seeking to limit how far work-as-done diverges from work-as-prescribed in order to prevent errors of execution. When these prescriptions extend to define rules governing composite work-behaviors, for example in combining different drug treatments, Safety I also covers the prevention of errors of planning. The underlying assumption here is that design-time and run-time can be separated, the times at which plans are formed and behaviors prescribed able to take place long before the run-time of work-as-done.[1]

Work-as-prescribed is when we set clear rules and detailed instructions for carrying out tasks […] when the gap between work-as-done and work-as-prescribed needs to be as narrow as it possibly can be.” (p68)

Safety II becomes necessary when this separation is no longer possible because of the dynamic and fluid nature of situations that change with each action.[2] The wicked nature of such situations makes planning impossible, concern with the static nature of errors of planning having to give way to the avoidance of dynamic errors of alignment in each moment[3] and of errors of intent through misreading the demands in each situation.[4]

An environment in which the focus must be on outcomes under dynamic and fluid conditions is turbulent. It requires that an organisation takes power to its edges to minimise both errors of alignment and errors of intent. Such environments require a Safety II focus of horizontal accountabilities to the situation of the client at an organisation’s edges. This creates a new kind of challenge in which obedience to work-as-prescribed is no longer sufficient to ensure safety. New kinds of obstacle to avoiding errors of alignment and intent arise from assumptions derived from obedience to vertically-defined work-as-imagined and built into a individuals’ ways of thinking implicit in work-as-disclosed:

“Work-as-imagined refers to the way people who regulate, inspect and design interventions don’t really understand what reality is actually like (p67) […] work-as-disclosed is how people describe what they do whether in writing or when they talk to each other… (p70)

These new kinds of obstacle may be thought of as a series of three tensions that have to be held.[5] Work-as-prescribed top-down by management is never wholly commensurable with work-as-experienced bottom-up by the individuals doing the work. The assumption with Safety I is that top-down dominates.

Work-as-disclosed reflects the way this first top-down vs bottom-up tension is currently held while always falling short of fully accounting for the unthought known of work-as-done. The second tension is thus between work-as-disclosed and work-as-done, reflecting the limited ability of people’s ways of thinking to capture all of what is going on.

The way this second espoused vs unthought-known tension is held takes the form of work-as-imagined. There will be many ways of holding this tension, but the dominant way shared within an organisation will be the one to which its members are affiliated, referred to as an organisation’s culture:

“… ‘the way we do things around here (when people aren’t looking)’ and the sum of attitudes, customs and beliefs that distinguishes one group of people from another.” (p117)

Safety II introduces a third tension because of the alliance it demands with the situation of the patient, a work-as-demanded that is rooted in what constitutes a desirable outcome for the client-patient. This is a tension between an affiliation to work-as-imagined and an alliance with the work-as-demanded. The way this third affiliation vs alliance tension gets held presents an ethical dilemma for the individual empowered to hold the tension at the edge of the organisation – a dilemma in how to hold the balance between the interests of the organisation and of the client-patient.

The following table summarises the progression of tensions that culminate in this ethical dilemma:

1work-as-prescribed
top-down
vswork-as-experienced bottom-up=work-as-disclosed espoused theory
2work-as-disclosed espoused theoryvswork-as-done unthought known=work-as-imagined affiliation
3work-as-imagined affiliationvswork-as-demanded alliance=ethical dilemma

Wynton Marsalis speaks of a segregation within the USA that reflects failures in how this third tension is held in the interests of all US citizens, an example of such a failure currently giving rise to the calls to defund the police. But why an ethical dilemma? Mark Ruffalo, speaking about using his celebrity, had this to say about putting himself on the line:

“We’re past the point where a celebrity can just make a video and tell people what to do … we’ve been doing that for decades. Now we have to put our bodies and our money and our time and our comfort on the line. That’s what’s being asked of us when we’re being asked to be allies.”[1]

Holding the third affiliation vs alliance tension means questioning our identifications with the citizen-client as distinct from our identification with the organisation, questioning who we take ourselves to be. Mark’s point was that to hold the third tension means being prepared to put ourselves on the line – to be prepared to pay with our being[6]. It also means questioning for what are we, as individuals, using organisations.

Notes

[1] The replacement of people by machines, or at least AI software, thus appears to some to be the ultimate guarantee of Safety I. The crash of Air France Flight 447 is one of many instances showing the limitations of such a guarantee.

[2] As the famous quotation goes: “No plan of operations extends with any certainty beyond the first contact with the main hostile force”.

[3] This involves deconflicting behaviors so that they can be mutually reinforcing of an overall desired effect, the other side of which is to ensure interoperability between capabilities in order to reduce the potential for errors of alignment.

[4] Working at the edge of an organisation in this way involves being able to attend to the ‘something missing‘ in the way the client’s situation is understood. A misreading arises when a blind eye is turned to this ‘something missing’. The plus-one process is designed to develop the skills of working at the edge.

[5] These three tensions are the dilemmas of ignorance applied to the way power is exercised within an organisation: top-down vs bottom-up; espoused theory vs unthought known; and affiliation vs alliance.

[6] The 2nd crisis in the three moments is to be unable to get any further with an existing way of thinking/understanding. The third moment comes when we choose to act as if we know while knowing that we do not. Such a choice involves letting go of existing identifications, i.e. to ‘pay with our being’.

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