How should researchers cope with the ethical demands of discovering research misconduct? Going beyond reporting and whistleblowing.

In this paper, I will argue that making it mandatory to report research misconduct is too demanding, as this kind of intervention can at times be self-destructive for the researcher reporting the misconduct. I will also argue that posing the question as a binary dilemma masks important ethical aspects of such situations. In situations that are too demanding for individual researchers to rectify through reporting, there can be other forms of social control available. I will argue that researchers should explore these. Finally, framing the issue as a question about the responsibilities of individual researchers masks the responsibilities of research institutions. Until institutions introduce measures that make this safe and effective, we should not consider reporting research misconduct mandatory. I will discuss this in light of both quantitative and qualitative data gathered as part of a survey in the PRINTEGER-project.

Humiliating Whistle-Blowers: Li Wenliang, the Response to Covid-19, and the Call for a Decent Society.

The ethical experience and lessons of China's and the world's response to COVID-19 will be debated for many years to come. But one feature of the Chinese authoritarian response that should not be overlooked is its practice of silencing and humiliating the whistle-blowers who told the truth about the epidemic. In this article, we document the humiliation of Dr Li Wenliang (1986-2020), the most prominent whistle-blower in the Chinese COVID-19 epidemic. Engaging with the thought of Israeli philosopher Avishai Margalit, who argues that humiliation constitutes an injury to a person's self-respect, we discuss his contention that a decent society is one that abolishes conditions which constitute a justification for its dependents to consider themselves humiliated. We explore the ways that institutions humiliate whistle-blowers in Western countries as well as in China.

The Climate Emergency: Are the Doctors who take Non-violent Direct Action to Raise Public Awareness Radical Activists, Rightminded Professionals, or Reluctant Whistleblowers?

When doctors become aware of a threat to public health, they have a professional duty to try to mitigate the threat. Climate change is a recognized major threat to planetary and public health that requires actions to both mitigate, and adapt to, climate change. The limited time and resources available to change what humankind are doing and protect planetary health add urgency to the threat. Some doctors take non-violent direct actions if their governments fail to take the effective actions needed. Professional regulatory organizations like the UK's General Medical Council (GMC) are charged with protecting the health of patients by setting standards for, giving ethical advice about, and supervising the behaviour of doctors. This article examines the conflict between climate activist doctors and the GMC interpretation of a doctor's duty of care when there is threat to public health from climate change.

Hypervisible Nurses: Effects of Circulating Ignorance and Knowledge on Acts of Whistleblowing in Health.

Whistleblowing has been examined from various angles over the past 40 years, but not yet as a matter of epistemology. Whistleblowing can be understood as resulting from the improper transmission of critical knowledge in an organization (eg, knowledge about poor care or wrongdoing). Using the sociology of ignorance, we wish to rethink whistleblowing and the failures it brings to light. This article examines how nurses get caught in the strategic circulation of knowledge and ignorance, which can culminate in acts of whistleblowing. The sociology of ignorance helps understand how whistleblowing is borne out of the complex and strategic circulation of knowledge and ignorance that spells multiple and intersecting epistemic positions for nurses. In particular, various organizational blind spots position nurses as untrustworthy and illegitimate speakers in the "business" of the organization. Organizational failings therefore remain concealed while nurses become hypervisible, both as faulty care providers and as problematic information brokers.

La comunicación de los efectos adversos en un servicio de urgencias / Reporting Adverse Events at an Emergency Unit

OBJETIVO: examinar las barreras comunicativas que tienen los profesionales sanitarios cuando se enfrentan a un efecto adverso. MÉTODO: estudio cualitativo de orientación fenomenológica, desarrollado en el Servicio de Urgencias del Hospital de Tortosa Virgen de la Cinta (Tarragona), entre octubre y diciembre de 2018. Muestreo por conveniencia. Se llevaron a cabo dos grupos focales formados por seis-siete profesionales sanitarios que se agrupan en función del tiempo de experiencia profesional (mayor o menor a tres años). Los candidatos a participar se diferencian por edad, sexo y categoría profesional. Se usa el programa Atlas.Ti para el análisis. Se identifican tres categorías analíticas y 14 subcategorías. RESULTADOS: participaron 13 profesionales en dos grupos focales. Categorías que emergen del discurso: definición de efecto adverso, información y mejoras. Se normaliza la frecuencia de los errores. Hablan de errores leves y graves, diferenciando su actuación y los sentimientos. Refieren que parte de su aprendizaje es debido al ensayo-error de la práctica. Expresan miedo a informar en situaciones de gravedad. Hay una infrautilización del sistema de registro. Coinciden en dar la información en equipo, previo consenso, y expresan desprotección institucional. Proponen la implantación de los debriefings, identificación positiva, comunicación entre servicios, informatización y un cambio de turno estructurado. CONCLUSIÓN: el miedo a las respuestas, la pérdida de reputación y la falta de apoyo institucional aparecen como las principales barreras a la hora de admitir y comunicar los incidentes. Hay un amplio consenso sobre la falta de responsabilidad en la comunicación y disculpa de los eventos adversos y sobre la necesidad de aportar soporte y formación a los profesionales

OBJECTIVE: to review the communication barriers in healthcare professionals when faced with an adverse event. METHOD: a qualitative phenomenological study conducted at the Emergency Unit from the Hospital de Tortosa Virgen de la Cinta (Tarragona) between October and December, 2018, through convenience sampling. Two focus groups were set up, with six-seven healthcare professionals grouped by time of professional experience (over or below three years). The participants were differentiated by age, gender and professional category. The Atlas.Ti program was used for analysis. Three analytical categories and 14 subcategories were identified. RESULTS: the study included 13 professionals in two focus groups. The categories emerging from their speech were: definition of adverse event, information and improvements. The frequency of errors was normalized. They mentioned mild and severe mistakes, differentiating their action and feelings. They reported that part of their learning consists in trial-error during practice. They expressed fear to report in severe situations. The recording system is underused. They coincided in reporting as a team, after consensus, and they expressed lack of institutional protection. They proposed implementing debriefings, positive identification, communication between hospital units, information technologies, and a structured change of shift. CONCLUSION: fear of answers, loss of reputation, and lack of institutional support appeared as the main barriers at the time of acknowledging and reporting incidents. There was wide consensus about lack of responsibiility in communication and excuse for adverse events, and about the need to provide support and training to professionals

Differing Perspectives on Paradox.

In this article, the author describes two differing perspectives on paradox: the humanbecoming paradigm perspective and the management/organizational theory perspective. Examples of paradoxes from these two differing views are presented.

Nuevas perspectivas en la resolución del error médico: National Health Service Resolution y CARe / New perspectives in resolving medical error: National Health Service Resolution and CARe

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Whistle-blowing process in healthcare: From suspicion to action.

BACKGROUND:: Whistle-blowing is an ethical activity that tries to end wrongdoing. Wrongdoing in healthcare varies from inappropriate behaviour to illegal action. Whistle-blowing can have negative consequences for the whistle-blower, often in the form of bullying or retribution. Despite the wrongdoing and negative tone of whistle-blowing, there is limited literature exploring them in healthcare. OBJECTIVE:: The aim was to describe possible wrongdoing in Finnish healthcare and to examine whistle-blowing processes described on the basis of the existing literature in healthcare as perceived by healthcare professionals. RESEARCH DESIGN:: The study was a cross-sectional descriptive survey. The data were collected using the electronic questionnaire Whistle-blowing in Health Care and analysed statistically. PARTICIPANTS AND RESEARCH CONTEXT:: A total of 397 Finnish healthcare professionals participated, 278 of whom had either suspected or observed wrongdoing in healthcare, which established the data for this article. ETHICAL CONSIDERATIONS:: Ethical approval was obtained from the Ethics Committee of the University (20/2015). Permission to conduct the study was received according to the organisation's policies. FINDINGS:: Wrongdoing occurs in healthcare, as 96% of the participants had suspected and 94% had observed wrongdoing. Regarding the frequency, wrongdoing was suspected (57%) and observed (52%) more than once a month. Organisation-related wrongdoing was the most common type of wrongdoing (suspected 70%, observed 66%). In total, two whistle-blowing processes were confirmed in healthcare: (1) from suspicion to consequences occurred to 27%, and (2) from observation to consequences occurred to 37% of the participants. DISCUSSION AND CONCLUSION:: Wrongdoing occurs in healthcare quite frequently. Whistle-blowing processes were described based on the existing literature, but two separate processes were confirmed by the empirical data. More research is needed on wrongdoing and whistle-blowing on it in healthcare.

Clinical governance breakdown: Australian cases of wilful blindness and whistleblowing.

BACKGROUND: After their attempts to have patient safety concerns addressed internally were ignored by wilfully blind managers, nurses from Bundaberg Base Hospital and Macarthur Health Service felt compelled to 'blow the whistle'. Wilful blindness is the human desire to prefer ignorance to knowledge; the responsibility to be informed is shirked. OBJECTIVE: To provide an account of instances of wilful blindness identified in two high-profile cases of nurse whistleblowing in Australia. RESEARCH DESIGN: Critical case study methodology using Fay's Critical Social Theory to examine, analyse and interpret existing data generated by the Commissions of Inquiry held into Bundaberg Base Hospital and Macarthur Health Service patient safety breaches. All data was publicly available and assessed according to the requirements of unobtrusive research methods and secondary data analysis. ETHICAL CONSIDERATIONS: Data collection for the case studies relied entirely on publicly available documentary sources recounting and detailing past events. FINDINGS: Data from both cases reveal managers demonstrating wilful blindness towards patient safety concerns. Concerns were unaddressed; nurses, instead, experienced retaliatory responses leading to a 'social crisis' in the organisation and to whistleblowing. CONCLUSION: Managers tasked with clinical governance must be aware of mechanisms with the potential to blind them. The human tendency to favour positive news and avoid conflict is powerful. Understanding wilful blindness can assist managers' awareness of the competing emotions occurring in response to ethical challenges, such as whistleblowing.

Institutional Betrayal and Gaslighting: Why Whistle-Blowers Are So Traumatized.

Despite whistle-blower protection legislation and healthcare codes of conduct, retaliation against nurses who report misconduct is common, as are outcomes of sadness, anxiety, and a pervasive loss of sense of worth in the whistle-blower. Literature in the field of institutional betrayal and intimate partner violence describes processes of abuse strikingly similar to those experienced by whistle-blowers. The literature supports the argument that although whistle-blowers suffer reprisals, they are traumatized by the emotional manipulation many employers routinely use to discredit and punish employees who report misconduct. "Whistle-blower gaslighting" creates a situation where the whistle-blower doubts her perceptions, competence, and mental state. These outcomes are accomplished when the institution enables reprisals, explains them away, and then pronounces that the whistle-blower is irrationally overreacting to normal everyday interactions. Over time, these strategies trap the whistle-blower in a maze of enforced helplessness. Ways to avoid being a victim of whistle-blower gaslighting, and possible sources of support for victims of whistle-blower gaslighting are provided.

Views on mandatory reporting of impaired health practitioners by their treating practitioners: a qualitative study from Australia.

OBJECTIVE: To explore the views and experiences of health sector professionals in Australia regarding a new national law requiring treating practitioners to report impaired health practitioners whose impairments came to their attention in the course of providing treatment. METHOD: We conducted a thematic analysis of in-depth, semistructured interviews with 18 health practitioners and 4 medicolegal advisors from Australia's 6 states, each of whom had experience with applying the new mandatory reporting law in practice. RESULTS: Interviewees perceived the introduction of a mandatory reporting law as a response to failures of the profession to adequately protect the public from impaired practitioners. Mandatory reporting of impaired practitioners was reported to have several benefits: it provides treating practitioners with a 'lever' to influence behaviour, offers protections to those who make reports and underscores the duty to protect the public from harm. However, many viewed it as a blunt instrument that did not sufficiently take account of the realities of clinical practice. In deciding whether or not to make a report, interviewees reported exercising clinical discretion, and being influenced by three competing considerations: protection of the public, confidentiality of patient information and loyalty to their profession. CONCLUSIONS: Competing ethical considerations limit the willingness of Australian health practitioners to report impaired practitioner-patients under a mandatory reporting law. Improved understanding and implementation of the law may bolster the public protection offered by mandatory reports, reduce the need to breach practitioner-patient confidentiality and help align the law with the loyalty that practitioners feel to support, rather than punish, their impaired colleagues.