As we develop the discussion around the second theme of the project research – new ethical perspectives on 21st Century Public Servants – Mervyn Conroy outlines new ways to think about ethics in the NHS.
Recent scandals in the health and social care sector emphasize the need to gain a better understanding of the ethics of healthcare practice. In particular, the responses of staff who feel or see something is not right yet take no action. The Francis enquiry into Mid-Staffordshire Hospital Trust found shortcomings in the ‘care, compassion and humanity’ shown by staff, that staff showed a lack of ‘respect’ for patients’ dignity, showed ‘callous indifference to suffering’ and demonstrated ‘a lack of candour in reporting poor standards of care’ due to fearing repercussions or victimization . This suggests that fear plays a role in keeping us schtum but what else might be going on in the complex dynamics of organizational life? Can we convince ourselves into believing we are being ethical when in fact we are acting unethically. Foucault argued that we have an internal policeman that polices in accordance with the prevailing discourses into behaviours seen as acceptable and normalised in specific contexts.
The case is that ethical resistance is uncommon in organisations yet from time to time, despite such dynamics and pressures, people do ethically resist – but not always in their actions. Propp’s (1928) ground-breaking study of the people’s folklore (stories, songs, ballads, stories, jokes etc.) under Stalin’s rule demonstrated the powerful resistance contained in their form and construction. The folklore provided a cathartic expression of underlying feelings of discontent against oppression, exploitation and social injustice. An outlet that would not evoke violence repercussions as would have been the case if they had acted out their frustrations.
Returning to the NHS, what do we find if we study the folklore of clinicians and managers on the receiving end of reforms? In a study (Conroy 2011), NHS folklore in the form of frontline manager and clinician stories about changes to mental health expressed strong resistance. They also contained the paradox of being ethically torn between what they felt was right for the people they care for and rationalisations that carry them along with corrupting practice changes.
From a virtue ethics perspective keeping schtum or rationalising corrupt acts as justified would both be at one pole of the virtue continuum of courage with whistle blowing at the other pole. Both are extremes that from a virtues ethics perspective are unlikely to benefit the individual, the collective or the practice. In virtue ethics ‘phronesis’ or ‘practical wisdom’ is seen as the ability to find the median point on a virtue continuum for any particular context that will bring (internal) goods for the individual (e.g. job satisfaction), improve outcomes and experience for patients and contribute to practice excellence.
So how did those practitioners find a median point on the courage continuum at which they could still find a way of resisting the corruption to practices but not risking all with an act of whistle-blowing? John Anderson, the Australian philosopher, urges us to not to ask of a social institution ‘What end or purpose does it serve?’ but rather ‘Of what conflicts is it the scene?’ In other words, the individual and the meaning of individual action are framed by the wider culture in which the action takes place. By working with the clinicians and managers, mainly in seminar learning sets and taking a participative action research approach, they tracked their paradoxical practice dilemmas back to their ideological roots and differing standpoints. Once they understood that they were wittingly or unwittingly supporting practice corruptions then they became angry at becoming ‘emplotted’ in an ongoing and emergent narrative that they did not identify with. Courage to resist was found through externally facilitated peer group reflection, moral debate and collective action rather than individual whistleblowing. These findings suggest a reframing of ‘whistle blowing’ health and social care policy with its emphasis on individuals towards externally facilitated peer group reflection and ethical debate.
Mervyn Conroy is a Senior Fellow at the Health Services Management Centre, University of Birmingham. He is a qualified NHS counsellor by background and has worked in mental health services management and research.