This study examined experimentally the effect of retaliation strength and accounting students’ level of moral reasoning, on their propensity to blow the whistle (PBW) when faced with a serious wrongdoing. Fifty-one senior accounting students enrolled in an auditing course offered by a large New Zealand university participated in the study. Participants responded to three hypothetical whistle-blowing scenarios and completed an instrument that measured moral reasoning (Welton et al., 1994, Accounting Education . International Journal (Toronto, Ont.) 3 (1), 35–50) on one (...) of two conditions – i.e., strong or weak retaliation for whistle-blowing. Consistent with the results of Arnold and Ponemon (1991, Auditing: A Journal of Practice and Theory 10 , 1–15) this study found that the strength of retaliation and participants’ moral reasoning level positively affected their PBW. Unlike results reported in Arnold and Ponemon (1991, Auditing; A Journal of Practice and Theory 10 , 1–15) a significant interaction effect of moral reasoning level and retaliation on participants’ PBW was not found. However, results showed that a participant’s gender has a significant effect on the relationship between his or her moral reasoning level and PBW. These results support the need to improve ethical awareness through accounting education and to increase protection for whistle-blowing (Miceli 2004, Journal of Management Inquiry 13 , 364–366). Furthermore, many participants found it difficult to take a stand when serious wrongdoing is discovered. Therefore, policymakers must exercise caution when placing heavy reliance on whistle-blowing, especially when whistle-blower protection processes are complex and not easily accessible, and processes to facilitate whistle-blowing may vary substantially between public and private sector organizations (Scholtens, 2003, Review of the operation of the Protected Disclosures Act 2000: Report to the Minister of State Services ). (shrink)

Speaking of the public response to the deaths of children at the Bristol Royal Infirmary before 2001, the BMJ commented that the NHS would be ‘all changed, changed utterly’. Today, two inquiries into the Mid Staffordshire Foundation Trust suggest nothing changed at all. Many patients died as a result of their care and the stories of indifference and neglect there are harrowing. Yet Bristol and Mid Staffordshire are not isolated reports. In 2011, the Health Services Ombudsman reported on the care (...) of elderly and frail patients in the NHS and found a failure to recognise their humanity and individuality and to respond to them with sensitivity, compassion and professionalism. Likewise, the Care Quality Commission and Healthcare Commission received complaints from patients and relatives about the quality of nursing care. These included patients not being fed, patients left in soiled bedding, poor hygiene practices, and general disregard for privacy and dignity. Why is there such tolerance of poor clinical standards? We need a better understanding of the circumstances that can lead to these outcomes and how best to respond to them. We discuss the findings of these and other reports and consider whether attention should be devoted to managing individual behaviour, or focus on the systemic influences which predispose hospital staff to behave in this way. Lastly, we consider whether we should look further afield to cognitive psychology to better understand how clinicians and managers make decisions? (shrink)

‘Organisational failure’ is central to medical ethics. In the National Health Service (NHS), we usually examine failures at hospital level. We have had around 100 hospital inquiries since the first in 1969, into Ely Hospital, Cardiff. This year, we had the Ockenden Report into Shrewsbury and Telford Hospital. Last year, we had the Outram Inquiry into West Suffolk Hospital. In 2020, the James Inquiry into Ian Paterson. And, before that, Morecombe Bay, Gosport War Memorial, Mid Staffordshire, Liverpool Community Health, Winterbourne (...) View, Anthony Ledward, Stoke Mandeville, Bristol Royal Infirmary and so on. As Taylor says, these reports teach us clinical failure usually has an institutional setting and that blaming individuals overlooks working ‘culture’. They have also led to: (a) new regulatory bodies to manage, investigate and improve NHS standards, (b) new codes of conduct to mandate reporting of serious accidents—backed up by the Whistle-blower’s Act and explicit statutory duties of disclosure, (c) root cause analysis to encourage consistent investigations so we can learn from reliable data and (d) new ‘Speaking Up Guardians’ and a Patient Safety Commissioner to encourage informal discussion about patient safety. What is so surprising is how little these inquiries and reforms have achieved on the larger scale. Of course, we must …. (shrink)

Tragic choices arise during the COVID-19 pandemic when the limited resources made available in acute medical settings cannot be accessed by all patients who need them. In these circumstances, healthcare rationing is unavoidable. It is important in any healthcare rationing process that the interests of the community are recognised, and that decision-making upholds these interests through a fair and consistent process of decision-making. Responding to recent calls to safeguard individuals’ legal rights in decision-making in intensive care, and for new authoritative (...) national guidance for decision-making, this paper seeks to clarify what consistency and fairness demand in healthcare rationing during the COVID-19 pandemic, from both a legal and ethical standpoint. The paper begins with a brief review of UK law concerning healthcare resource allocation, considering how community interests and individual rights have been marshalled in judicial deliberation about the use of limited health resources within the National Health Service. It is then argued that an important distinction needs to be drawn between procedural and outcome consistency, and that a procedurally consistent decision-making process ought to be favoured. Congruent with the position that UK courts have adopted for resource allocation decision-making in the NHS more generally, specific requirements for a procedural framework and substantive triage criteria to be applied within that framework during the COVID-19 pandemic are considered in detail. (shrink)

Modern health care rhetoric promotes choice and individual patient rights as dominant values. Yet we also accept that in any regime constrained by finite resources, difficult choices between patients are inevitable. How can we balance rights to liberty, on the one hand, with equity in the allocation of scarce resources on the other? For example, the duty of health authorities to allocate resources is a duty owed to the community as a whole, rather than to specific individuals. Macro-duties of this (...) nature are founded on the notion of equity and fairness amongst individuals rather than personal liberty. They presume that if hard choices have to be made, they will be resolved according to fair and consistent principles which treat equal cases equally, and unequal cases unequally.In this paper, we argue for greater clarity and candour in the health care rights debate. With this in mind, we discuss (1) private and public rights, (2) negative and positive rights, (3) procedural and substantive rights, (4) sustainable health care rights and (5) the New Zealand booking system for prioritising access to elective services. This system aims to consider: individual need and ability to benefit alongside the resources made available to elective health services in an attempt to give the principles of equity practical effect. We describe a continuum on which the merits of those, sometimes competing, values—liberty and equity—can be evaluated and assessed. (shrink)

What is the link between patients' rights to NHS treatment and PCTs' duties to live within their budgets? This was the issue in Rogers v Swindon PCT [2006], in which a patient had been denied trastuzamab (Herceptin®) for early-stage breast cancer. In principle, rationing is lawful and PCTs have to make hard choices about spending priorities, but they may not ignore the interests of needy patients in doing so. Rather, they must balance the 'corporate' interests of the PCT with the (...) 'clinical' interests of individuals. One way of doing so is to adopt an Ethical Framework at the macro-level to guide NHS resource allocation, but to also recognize 'exceptional cases' at the micro-level, even if the treatment is generally considered to be a low priority. This article is primarily concerned with these micro-level cases. Patients and clinicians should know how the balance is struck. Such a system operates in Berkshire, but there is plenty of room for debate about how it should develop. (shrink)

Most now recognize the inevitability of rationing in modern health care systems. The elastic nature of the concept of “health need,” our natural human sympathy for those in distress, the increased range of conditions for which treatment is available, the “greying” of the population; all expand demand for care in ways that exceed the supply of resources to provide it. UK governments, however, have found this truth difficult to present and have not encouraged open and candid public debate about choices (...) in health care. Indeed, successive governments have presented the opposite view, that “if you are ill or injured there will be a national health service there to help; and access to it will be based on need and need alone.” And they have been rightly criticized for misleading the public and then blaming clinical and managerial staffin the National Health Service when expectations have been disappointed. (shrink)

Most now recognize the inevitability of rationing in modern health care systems. The elastic nature of the concept of “health need,” our natural human sympathy for those in distress, the increased range of conditions for which treatment is available, the “greying” of the population; all expand demand for care in ways that exceed the supply of resources to provide it. UK governments, however, have found this truth difficult to present and have not encouraged open and candid public debate about choices (...) in health care. Indeed, successive governments have presented the opposite view, that “if you are ill or injured there will be a national health service there to help; and access to it will be based on need and need alone.” And they have been rightly criticized for misleading the public and then blaming clinical and managerial staffin the National Health Service when expectations have been disappointed. (shrink)