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Blowing the Whistle on a Therapeutic Experiment
Secondary Title Whistleblowing at Private Psychiatric Facility



Authoring Institution Association for Practical and Professional Ethics (APPE)
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Contributor(s) Brian Schrag
Notes Brian Schrag, ed., Research Ethics: Cases and Commentaries, Volume 1, Bloomington, Indiana: Association for Practical and Professional Ethics, 1997
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Rights The Association for Practical and Professional Ethics (APPE) grants permission to use these case and commentary material with the citation indicated above.
Volume 1
Year 1997
Publisher Association for Practical and Professional Ethics
Language English
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  • Vivian  Weil

    Posted 13 years and 4 months ago

    Vivian Weil 

    Illinois Institute of Technology

    Roger Boisjoly, who is well known as the whistleblower on the Challenger disaster, often mentions Albert Hirschman's book, Exit, Voice, and Loyalty. He looks back on his own experience from the perspective of those choices. In light of the way Jan's case history is written, it may be useful to frame the analysis in terms of those broad options. At choice points in the story, the leading question would be, "Given her perceptions of her situation in the research facility, should Jan leave, should she exercise voice, or should she remain?" If the answer is "Remain," then the further question is, "Whom should she consult about her concerns?"

    Some revision in the telling of the story is still needed to create some distance between the author of the case study and Jan. These are Jan's perceptions of the situation as it evolved; they cannot be the author's. So, for example, the last sentence of the first paragraph of "Situation" might read, "As she understood it, the basic premise of the therapy was that psychiatric illness. . . ."

    The first choice point should come when Jan begins to suspect that patients are being mistreated. The first question might then be, "What options does Jan have for dealing with her concerns about the treatment of patients?" The list of options should include as A. Discuss her perceptions with other nurses and the nurses association, and as F. Quit her job. A. would be a good response if she does not choose to exit from working in a situation in which she thinks she observes the systematic mistreatment of patients. Discussing the situation with other nurses might give her an opportunity to check her perceptions, to determine whether others are reacting similarly, and to note whether there is any possibility of joint action. Talking to people in the nurses association might give her an overview of her work situation, with information about the employer's almost unlimited right to fire. She might learn how to proceed responsibly with least damage to herself in this situation of perceived mistreatment of patients. As the situation evolves, Jan seems dangerously isolated, without peers to give her a "reality check" or any form of support.

    Segment 2 of the case history is puzzling. It is hard to understand how a professional who had heard such a response from the orthomolecular physician and witnessed the incidents described could remain on the job for another six months. In light of her perceptions of the experimental program, she had reason to consult the hospital administrator at a much earlier point. Once she had consulted the administrator and gathered more evidence of what seemed to her to be failure to comply with federal regulations, she was at a choice point, facing the options of exit, voice or loyalty. (Unfortunately, the narrative includes no discussion of how she assessed her options at this or any other choice point.)

    If Jan's description of the situation is accurate, at this juncture, the situation is not rectifiable internally. Jan has all the evidence she needs to conclude that she is in a thoroughly corrupt operation. Remaining in the situation as she perceived it would mean not only acting unprofessionally but might even mean becoming implicated in the mistreatment of patients. The most likely outcome of exercising voice in some way before resigning (perhaps even whistleblowing) would would be that she would be forced to resign. Unless she has some reason not hinted at in the case for preferring that choice, her best option is to exit. She cannot make a difference or get satisfaction from her work. Given her perceptions and account of the operation of the program, she has no reason to trust the administrator's offer of a better job in a new facility.

    Assuming that Jan decides to exit, we should ask whether she has a duty to do anything more about the mistreatment of the patients. Response A. in Part 3 would be responsible professional conduct. Her own circumstances might make it too costly for her to report the situation promptly since she needs to find a job to support her family. But she should eventually transmit a report to any agency with oversight responsibility for this facility and to her local nursing professional association.

    According to the narrative, Jan remained in the situation for a considerable time and eventually came into conflict with her employer. By that time, her employment situation had deteriorated beyond the point when the intervention of the state nurses association could help. From a practical point of view, Jan should have contacted the nurses association at a much earlier point (see above). We reasonably expect professional associations to supply the information practitioners need to make decisions that do not expose them to undue risk when they find themselves in what appear to be corrupt organizations.

    I suggest that after the meeting with the hospital administrator, the narrative should not be interrupted with questions about what Jan should do. It is the story of Jan's perception of the deterioration of her work situation and ends with the observation that Jan received no damage award. The story does post questions about where professionals can turn for good information about how to deal with work situations that seem to be corrupt and what information professional associations should be expected to make available to professionals for their self-protection in dealing with employers.

    From: Graduate Research Ethics: Cases and Commentaries - Volume 1, 1997 

    edited by Brian Schrag

  • P. Aarne  Vesilind

    Posted 13 years and 4 months ago

    P. Aarne Vesilind 

    Duke University

    Jan's story is sad, but predictable. We all presume a high level of professional conduct on the part of our colleagues, and it takes a while finally to recognize a situation where this standard is not met. We are just not willing to recognize the situation for what it is. We assume there must be something we don't understand about the situation, and we give our colleagues the benefit of the doubt.

    With hindsight, Jan should have become aware of the unethical conduct and her own untenable situation immediately and, before she spoke with anyone, gathered irrefutable evidence of wrongdoing. With this evidence in hand, but not necessarily revealed to anyone except her attorney, she should have approached the option of whistleblowing by first discussing the problems with the Director of Nursing (DON) and so on up the ladder to the hospital administration, using as little of her ammunition as needed at every step. It is possible that somewhere up the ladder the situation would have been resolved. If not, Jan should have found herself a good job in nursing or even outside nursing and then quit, blowing the whistle from a position of security and power.

    But that's easy to say, of course. As I suggest, few people have such foresight.

    Jan's actions in this case are not nearly as interesting as the ethical problems of the Director of Nursing. The DON would certainly be aware of the central issues in the situation (maltreatment of patients), and he/she would be in a situation similar to that of the Morton-Thiokol managers who made the decision to allow Challenger to fly. As engineers (and they were all engineers), they saw the long-range problems to the company if they did not acquiesce to NASA's clear wishes. The DON, both a nurse and a manager, would be in a similar situation. Just as it is more interesting to consider the problems of the Morton-Thiokol managers than the decisions by Roger Boisjoly and his colleagues, so it would be more interesting in this case to evaluate the actions of the DON. What should he/she have done? Does he/she have any responsibility now for what has happened to Jan? Jan clearly did the ethical thing and suffered for it. But we don't know what the DON has done, and what effect these actions have had on his/her career. By focusing on the DON, the case might have been written with less passion and more disinterested journalism.

    From: Graduate Research Ethics: Cases and Commentaries - Volume 1, 1997 

    edited by Brian Schrag

  • Anonymous Participant

    Posted 13 years and 4 months ago

    From: Graduate Research Ethics: Cases and Commentaries - Volume 1, 1997 

    edited by Brian Schrag

    For the purposes of this case, whistleblower refers to any employee who reports unethical, illegal or incompetent acts to appropriate agencies outside the employer's facility. On the basis of this definition, the decision to blow the whistle to external authorities is a potentially risky endeavor fraught with moral conflicts and professional and personal risks. In reflecting upon when and how to report violations, many questions arise: Will the potential benefit outweigh the possible harms? Who can be trusted? Will confidentiality be maintained so that the whistleblower is protected against retaliation? What is the likelihood that change will occur if the person goes public? Will professional associations stand behind whistleblowers when they follow through on their professional obligations to exhaust all internal mechanisms before blowing the whistle?

    As Jan's situation and other whistleblowing cases demonstrate, there are no definitive answers to whether a given act results in the desired outcome until the consequences of the action can be evaluated. Hindsight is often credited with 20-20 vision, but in reality it may or may not provide the insights necessary to protect the public welfare or future whistleblowers from retaliation. I will argue that the nursing profession (and other so-called helping professions) must re-evaluate the paradigm that currently underlies the profession's goals, values and ethics. I suggest that unless the paradigm shifts to include the care giver as a recipient of the same ethic of care, then current codes of professional ethics and statutory protections for the whistleblower will fail to provide the comprehensive protection needed for professionals and the clients they serve.

    Jan did deliberate on the correct ethical and legal questions and opted to act upon her professional obligations -- obligations that are grounded in the Nurse Practice Act, standards of care and the profession's code of ethics. The Code for Nurses (American Nurses' Association 1985) explicates the values and goals of the profession and provides a framework to guide the nurse's ethical deliberations and actions. The notion that the nurse acts as a client advocate is a pervasive theme throughout the code and is a core element of nursing education. According to the code, nurses as client advocates act "to safeguard the client and the public when health care and safety are affected by incompetent, unethical, or illegal practices by any person." (ANA 1985, p. 6)

    The ANA expands on this guideline to include specific recommendations for appropriate action

    1. Express concerns about inappropriate or questionable practices to the person carrying out the practice and attention called to the detrimental effect such practices have on client welfare.

    2. When factors in the health care delivery systems threaten the welfare of the client, similar action should be directed to the responsible administrative person. If indicated, the practice should then be reported to the appropriate authority within the institution, agency or larger system.

    3. There should be an established process for reporting and handling of incompetent, unethical or illegal practice within the employment setting so that such reporting can go through official channels without causing fear of reprisal.

    4. Written documentation of the observed practices or behaviors must be available to the appropriate authorities.

    5. State nurses associations should be prepared to provide assistance and support in the development and evaluation of such processes and in reporting procedures.

    6. When incompetent, unethical or illegal practice on the part of anyone concerned with the client's care is not corrected within the employment setting and continues to jeopardize the client's welfare and safety, the problem should be reported to other appropriate authorities such as practice committees of the pertinent professional organizations or the legally constituted bodies concerned with licensing of specific categories of health workers or professional practitioners. Some situations may warrant the concern and involvement of all such groups. (ANA, 1985, 6). The code specifies that if internal mechanisms are followed and change does not occur, then the nurse may need to go outside the institution to protect the welfare and safety of clients.

    Jan followed the ethical and legal guidelines of her profession. So what went wrong? The same thing that went wrong when the Thiokol engineers blew the whistle on the Challenger explosion. The same thing that can go wrong when any professional who follows their codes of ethics. If the organization views whistleblowers as trouble makers who should be punished for violating organizational norms of silence, then no professional code of ethics is adequate to protect whistleblower from retaliation. Furthermore, even the most comprehensive legislation is inadequate to protect whistleblower from personal and professional risks if the ethical milieu of the organization does not assist and reward employees for reporting unethical or illegal behavior. Even when structural mechanisms are in place (e.g., ethics committees, misconduct committees, IRBs), the political structure and power dynamics of corrupt organizations may find a way around these safeguards.

    Jan's case is an exemplar of the way altruistic professions, such as nursing, are caught in a Catch 22. Nurses are taught that it is their professional obligation to act as client advocates. An ethic of care is one of the profession's most cherished values, if not its highest moral ideal. It seems that something is fundamentally wrong when we teach students in health-related fields the value of caring for others but neglect to teach them how to care for themselves as professionals. It is a no-win situation for the client and the nurse. Within the current system, a nurse who is committed to maintaining her professional integrity within an organization that refuses to change its unethical or illegal behaviors has limited options, most of which entail high stakes for the nurse, both personally and professionally.

    Lennane (1993) conducted a survey of whistleblowers from various occupations who had exposed corruption or danger to the public. All subjects (N=35) in this nonrandom sample suffered adverse consequences. For 20 of the subjects, victimization started after the first internal complaint. Retaliation took many forms including dismissal, demotion, resignation or early retirement due to illnesses associated with victimization. Twenty-nine subjects had stress-related symptoms, 15 were started on long-term treatment with medication, 17 considered suicide, 30 reported adverse effects on their children, and almost half subjects reported reductions in income of 75 percent. One could raise questions about the generalizability of these findings. However, when one reviews the literature on whistleblowers and attends to the actual stories of whistleblowers, Lennane's observations and conclusions are, more often than not, supported. Lennane concludes, Although whistleblowing is important in protecting society, the typical organizational response, causes severe and long lasting health, financial, and personal problems for whistleblowers and their families. (Lennane 1993, 667)

    Ethical decision making among professionals in health care and the scientific community is about ethical principles and scientific integrity as much as it is about politics and power. Ethical theory and professional codes of ethics will remain abstract entities unrelated to real-life situations until we acknowledge that inequities of power and status in the hierarchy of systems have a profound impact on individuals who witness misconduct and not only want to protect the public, but deserve to be protected from professional and personal retaliation.

    The nursing profession is particularly vulnerable to retaliation if misconduct is reported. In a predominantly female profession, employed primarily in hospital settings where they are paid by the institution, nurses have a variety of potentially conflicting loyalties: to the patient, the physician, the institution, to society at large, and (let us not forget) to self. When unethical or illegal conduct is reported through appropriate channels and nothing is done, the nurse is forced to choose between ignoring the situation and doing nothing, or ultimately finding it necessary to hire an attorney for legal representation. How many nurses are willing to take this risk, given their economic situation? Jan ended up having to act in isolation because she could not rally any of her nursing colleagues to stand with her.

    Nothing less than a paradigm shift is needed to protect the public welfare and safety, as well as the welfare and safety of nurse professionals. The preparation and socialization of health care personnel must allow them to maintain their professional and moral integrity and also enable them to report colleagues' unethical, illegal or incompetent behavior. The public has entrusted its faith and its economic resources in health care professionals, who should be able to act in the best interests of the public without fear of retaliation.

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    • American Nurses' Association, Code for Nurses With Interpretive Statements. Kansas City, Mo.: American Nurses'Association, 1985.

    • Lennane, J. K. "Whistleblowing: A Health Issue." British Medical Journal 307 (1993): 667-70.

    • Whistleblowing. Video production through the University of Illinois at Chicago, College of Nursing, 1988.

    • Witt, P. Personal communication, May 26 and June 1, 1996.

    • Witt, P. "Notes of a Whistleblower." American Journal of Nursingg 83 (1983): 1649-1651.

    • Zorn, E. "Whistle-blower Saved Lives, Lost Everything Else." Chicago Tribune, June 21, 1987, pp. 1, 2.

Cite this page: "Blowing the Whistle on a Therapeutic Experiment" Online Ethics Center for Engineering 2/16/2006 OEC Accessed: Friday, July 12, 2019 <>