11 Why Do We Blame?

One important question is as yet unaddressed. And I don't even know if we can ever find an answer. But I do want to give it a try here, as it is a concern at the heart of a just culture. The question is this: Why do we want to blame individuals for failures of our systems?

We can easily glide into the idea that it is all about power. That some people or organizations or institutions have their own material goods or reputations to protect and will sacrifice individual operators in order to do so. This suggests that protection of vested elite interests is the reason why some people's actions are converted into culpable ones, into crimes or otherwise sanctionable acts. The reason for unjust responses to failure, in that idea, is located in some amorally calculating cabal.

But just like there is no single story that can capture the complexity of what happened to Lot or Mara or the Argentinian doctors or Captain Stewart or De Chaumerays, we should probably be skeptical of single-factor explanations for complex phenomena.

And, for that matter, we should be skeptical of rational-choice assumptions about human behavior. The overriding consensus in psychology today is not that people make decisions based on a careful weighting of preferences and priorities, and align those against a neat array of fully laid-out options with their future consequences attached. Rather, people continuously make provisional, incomplete assessments of situations, see whether what they were planning to do is still doable, and go from there. Like making the prescription disappear when you have the opportunity, and then seeing how things shake out. So blaming individuals for system failures is not likely the result of cool, rational, dispassionate calculation by those who have the power to do so.

Finding a Cause Because of Anxiety

So what else may be going on? Selecting a scapegoat for an accident or incident may be the easy price we pay for our illusion that we actually have control over our risky technologies. Sending pharmacists or nurses or controllers or pilots or maintenance technicians to jail may be morally wrenching (though not unequivocally so), but it could be preferable over its scary alternative: Acknowledging that we do not enjoy full control over the risky technologies we build and consume.

The alternative would force us to admit that failure is an emergent property without any clear causes that we can nail down, that "mistake, mishap and disaster are socially organized and systematically produced by social structures," that these mistakes are normal, and never entirely avoidable because they are "embedded in the banality of organizational life."¹ It would, as Diane Vaughan reminds us, force us to acknowledge the relentless inevitability of mistake in our organizations, to see that harmful outcomes can occur in the organizations constructed to prevent them, that harmful consequences can occur even when everybody follows the rules.

Scapegoating, pointing the finger at "unprofessional" pilots in an accident report, prosecuting a pharmacist or a nurse—it may be an existential quest on our part. In it, we personify risk, we manage our anxiety about an otherwise faceless, systemic danger that could spring up and bite us any day.

Whose fault?

Today, as anthropologist Mary Douglas says, almost every misfortune is followed by questions centering on "whose fault?" and "what damages, compensation?" Every death must be chargeable to somebody's account. Such responses approximate the primitives' resistance to the idea of natural death remarkably well.² Death in systems that are supposed to deliver healing, or safe transportation, is not considered natural, not the inevitable by-product of living with those technologies. For us, it may be safer to think that such death has to arise from some type of identifiable cause.

Such resistance to the notion that deaths actually can be accidental is obvious in responses to recent mishaps. For example, Scott Snook commented on his own disbelief, his struggle, in analyzing the friendly shoot-down of two U.S. Black Hawk helicopters by U.S. Fighter Jets over Northern Iraq in 1993:

Snook confronted this fear by asking what on earth we can do if we can find no wrongdoing, no surprises, if we cannot find some kind of deviance, some culprit. (A culprit of sorts was created in the Black Hawk shoot-down, by the way. The commander or the AWACS airplane that had tracked friendly traffic over the theater of OPC was charged, though not convicted.)

If everything was normal, then how could the system fail? Indeed, this must be among the greater fears that define society today. Investigations that do not turn up a "Eureka part," as the label became in the TWA800 inquiry, are feared not because they are bad investigations, but because they are scary. They provide no closure, nothing to point to, nothing to fix. If we can't find a Eureka part, we make one up. Nietzsche (1844–1900) wrote about such "imaginary causes" in his book Twilight of the Idols:

Nietzsche pointed out that the need for finding a cause is fundamental to human nature. Not being able to find a cause is profoundly distressing; it creates anxiety because it implies a loss of control. The desire to find a cause is driven by fear. So what do we do if there is no Eureka part, no fault nucleus, no seed of destruction? Is it possible to acknowledge that failure results from normal people doing business as usual in normal organizations? Not even many accident investigations succeed at this. As Galison noted:

Galison's remarks remind us of this fear (this nightmare) of not being in control over the systems we design, build, and operate. We dread the possibility that failures emerge from the intertwined complexity of normal everyday systems interactions. We would rather see failures emanate from a traceable, controllable single seed or nucleus. In assigning cause, or in identifying our imagined core of failure, accuracy does not seem to matter. Being afraid is worse than being wrong. And so we might turn to experts or other legitimate arbiters to offer us emotional and symbolic relief. Accident investigators and boards who label certain pilot behavior as "unprofessional" offer the relief that their incident really was unique, that this is not supposed to happen on the flight you might be on next. The court case against the pharmacist found how he had the duty to check that the preparation was correct, and how he failed at it.

Remember, as Nietzsche pointed out, few things make us as anxious as not having a cause for things that go wrong. Without a cause, there is nothing to fix. And with nothing to fix, things could go terribly, randomly wrong again—with us on the receiving end next time. Having a criminal justice system deliver us stories that clearly carve out the disordered from order, that excise evil from good, deviant from normal, is about creating some of the order that was lost in the disruption by the bad event. Such narratives reflect, said White, "a desire to have real events display a coherence, integrity, fullness and closure of an image of life that is and can only be imaginary."⁵

Courts, certainty, and rationality

At first glance, calls for disciplinary and even criminal-legal action may seem a sensible way to achieve White's image: A trial will supply truth and consequences. This expectation is not unreasonable. The U.S. Supreme Court put it most bluntly in 1966: "The basic purpose of a trial is the determination of the truth."⁶ A disinterested party takes an evenhanded look at the case, the appropriate person gets to be held accountable, consequences are meted out—in an immaculate capping of the Enlightenment project. The aim of this intellectual movement in the late seventeenth and eighteenth centuries, after all, was to give lay people (not the Church) the ability to search for truth, to understand the true nature of reality, to make up their own minds about right and wrong—all through the application of reason and rationality. Courts are thought to be the supremely reasonable arbiters that can do this on our behalf, making judgments based on objective evidence brought out by rational techniques.

The cost of such a selection of causes is considerable. The accounts of failure delivered to us by the criminal justice system, with one culprit excised from, for example, a hugely complex, discontinuous processes, are often far from just. They are also bad for safety and quality efforts, as shown before in this book. Criminalizing error erodes independent safety investigations, it promotes fear rather than mindfulness in people practicing safety-critical work, it makes organizations more careful in creating a paper trail, not more careful in doing their work, it discourages people from shouldering safety-critical, caring jobs such as nursing, and it cultivates professional secrecy, evasion, and self-protection. If, in the response to disaster, we act in ways that are so clearly not in our own, or in society's long-term interest, there must be deeper grounds for why such behavior would be deemed reasonable.

One such ground is that such actions in the wake of failure may offer symbolic and emotional relief that our systems are basically safe, as long as people who work in it have the moral fiber to live up to their professional duty. The relief offered is not chiefly epistemological, even though it may seem like it (oh good, now we know what happened). It is in an important way even more existential. It gives us some clues of where to locate the source of suffering, it offers us a reason for suffering, and a handle to do something about it, because we have found somebody whom we can remove, whom we can make repent for suffering caused.

Violations Seen From This Bench are Just Your Imagination

I used to fly out of a little airport in the U.S. Midwest. Between two hangars there was a wooden bench, where old geezers used to sit, watching airplanes and shooting the breeze. When nobody was sitting on the bench, you could see that it said, painted across the back rest: "Federal Aviation Regulation violations seen from this bench are just your imagination."

Whereas cases of criminalizing human error show that we sometimes drag rules and laws over an area where they have no business whatsoever, the bench at this little airfield showed a more hopeful side of the negotiation, or construction, of deviance. Even if it was meant tongue-in-cheek (though when I, on occasion, sat on that bench, I did see interesting maneuvers in the sky and on the ground) we, as humans, have the capacity to see certain things in certain ways. We have the capacity to distance ourselves from what we see and label things one way or another, and even know that we do so. That also means we can choose to label it something different, to not see it as deviance. When we are sitting on that bench, for example.

For a few generations now, deviance—whether it is an essential property of some people or acts, or the result of a construction, of a label, of a description—has been a topic of social-scientific interest in its own right. The latter idea says that turning an act into an error, and then an error into a crime, hinges on a successive social manufacturing of culpable deviance. "Crimes" do not exist out there, to be uncovered by good sleuthing or some other methodological trickery. Rather, we shape what becomes seen as a crime, what becomes the last word or the "accurate" story of the events. Whether something is deviant or a violation depends on our perspective, on whether we are sitting on that bench, and on the language we use to describe the act.

This perspective in social science, known to some as labeling theory, has been seen as empowering both inside and outside the Sciences. Rather than accepting that something is a crime or taking some prosecutor's word for it (or Lot's or anybody else's word), labeling invites us to see that acts "are not" (in Christie's words), but "become." If some people label acts some way, then that means other labels are possible too. It invites many more perspectives and "ways of how things are" into the dialogue, while never granting any of them an ultimate privilege to say "that's the way it is."

The idea of labeling allows us to abandon the true/false binary choice and invite a number of local "truths." What is true for the prosecutor doesn't have to be true for me, but that doesn't make it less true for the prosecutor. Another reason is that it makes for more interesting social science. Any knowledge claim becomes a rich trove for social analysis. An assertion like: "The Argentine doctors committed murder" is not engaging for its supposed substance, "Oh, those doctors committed murder, how interesting!" but for why and how the person or group who makes it claims to know this. "Who are you to say so? How do you know? What's in it for you?" Whether something is a crime or not, then, says as much or more about the one who calls it a crime, and who stands to benefit from calling it a crime. In many ways, this is more interesting than what it says about the supposed criminal or his or her act.

History as Present

Long-time CBS news anchor Walter Cronkite used to wrap up his broadcasts by saying: "That's the way it is." On first hearing, that's a truly realist commitment, not any different from Gericault's appeal in his painting of La Méduse. Whenever presented with such confidence in having the true story, we should ask: "Really, how do you know that that is the way it is, rather than some other way?"

In an interview long after his retirement, Cronkite explained that rather than having figured out for himself that "that's the way it is" in some factual historical sense, the remark was shorthand for his effort to be fair and balanced to all sides. He considered this his journalistic obligation. It was a kind of realist objectivity, in other words, that was no more than the best average of a number of subjectivities. That may work in a newscast because it can be stretched over time and corrected and adapted as more data comes in (though we should still ask which subjectivities are represented, and why and how). In a painting, which needs to present its depiction in one moment, or in a court case that needs to render a verdict about the guilt of one party, or in an accident report that needs to deliver a probably cause, such fair and balanced, "cubist" representation of many different sides is neither the point, nor really possible.

What it does mean, however, is that we should be acutely skeptical of any claims that sound or read like "that's the way it is" by investigators, by judges, by managers. Because of the position and credibility given to them, the accounts rendered by these people or parties Can become the canonical ones. As far as we know, we have only one painted account of what happened to the survivors on the raft of the Medusa, At least only one that has made it into the Louvre for public viewing. As far as we know, we have only one account of what happened to the daughters of Lot. These are the authoritative accounts. After all, the one account of Lot's daughters is in the first book of the Western Bible—it doesn't get much more authoritative in the West, even the post-secular West. But suppose that competing accounts had been circulating to this day. Which of these acts amount to a suitable amount of crime, and which of the hands emanating from the acts belong to a culprit, is the result of precisely such contending accounts of historical "reality." While competing accounts may seem founded on appeals for privileged access to historical fact (as both sides of a criminal court case will readily assert), they rather represent current experience and future concerns of those who construct them. This cannot mean that some accounts are "right" and some are "wrong" in some factual rather than moral sense (e.g. those who maintain that one particular human error amounted to a crime whereas other acts did not). It means that whether there was a crime at all (by Lot, by de Chaumareys) can never be established; it is forever contestable.

The truth value of a particular story from the past is asserted in present concerns and goals, not assessed against some commonly accessible past—which, after all, is merely a diverging set of images wrestled into view from competing stakes. This contradicts the objectification of history (captured, for example, in "probable cause" statements in accident reports, as much as in media-celebrated accident stories) that considers the past to be a bygone congealed object. Instead, the past can be seen as a dimension of our present experience, or a dimension of the contemporary context in which that "past" is written down, offering all kinds of opportunities to express and handle current issues. What separates past from present is arbitrary. In this view, a cause for an accident is never found. It is constructed with language or rhetoric ensuring that certain subsequent actions are legitimate or even possible (e.g. pursuing a single culprit), and others not.

Historical accuracy, if there were such a thing, may not even matter. What matters is the contemporary impact of the most persuasive account. After all, it does useful work for whoever's concerns are the most potent or pressing at the time. We are not told that Lot's daughters were raped by their father, but told that Lot's daughters were blessed with offspring (or rather, they blessed their father with offspring, preserving the patriarch's family name, the tribe, after a calamitous hiatus). Lot had some powerful connections: He was Abraham's nephew (in fact, Lot was Abraham's favorite nephew). It wasn't just Lot's seed that went into the daughters. It was, in a sense, Abraham's. The Abrahamic faith (Judaism, and later Christianity and Islam) might have needed its source material to survive. It may have been the kind of story that ancient tribes had to tell themselves during times when resource shortages and disease meant that the survival of the human race wasn't even guaranteed, let alone that of one tribe or family versus another.

The "truth" value of what happened and of who did what is coded not in some historical facts, but in the meaning that the events carried for the writer of the story and his (indeed, in Lot's case probably his) early audiences. Such a truth value is coded also in the political expediency of La Méduse for devoted anti-royalists in post-Napoleonic France. The crime is not about the crime, it is in large part about us, about the concerns that we have. We express these concerns by calling certain acts "crimes" and deciding not to give other acts the same name.

“The Nurse Who Gave" Unleashed a Moral Panic

How could it be, otherwise, that key players—the courts, the professional board, the media—all gathered around and mutually reinforced the notion that Mara's error was criminal? From where did they get the extraordinary energy and societal support to carry her conviction all the way through? To really, really prove that her act was one of criminal manslaughter? Back in 1964, a graduate student named Stanley Cohen got disturbed by what he saw as the overheated and exaggerated response to rebellious youths in some local small town brawl in England. The seriousness of events got distorted, blown out of proportion—in terms of the nature of the violence allegedly committed, the amount of damage inflicted, and the impact of it all on the community and society as a whole.⁷

Mara's role in the medication death of the infant similarly got amplified by singling her out as culprit, underplaying or ignoring the contributions of other people and the wider context. Not just that, Mara became known in the national media as "the nurse who gave...". As in, the nurse who gave the baby an overdose of lidocaine. But Mara did not give anything. Mara only mixed. She was at home, off-shift, by the time things were given to the baby. The fact that she did not give anything of course makes her culpability problematic (but not sufficiently so as to have the conviction thrown out). Rather, if she were deemed guilty of manslaughter, then Mara must have done something to really deserve the verdict. The media—we—inverted causal reasoning in the struggle to justify her severe punishment. In the popular imagination of what had gone on in the hospital on that Sunday, Mara's role was extended to include a morally most repugnant and criminally most liable act: Poisoning a little girl.

Cohen introduced the term "moral panic" to help explain such excessive reactions, inventions even, by the media, public, and government. In a moral panic, societal perils are seen to become personified in one or a group of protagonists, especially those who push the boundaries of what is considered normative or acceptable. In a moral panic, "a person ... emerges to become defined as a threat to societal values and interests; its nature is presented in a stylized and stereotypical fashion by the mass media".⁸

Myth-making, while a normal process in societies, is one way of stylizing that accelerates during a moral panic. A given myth (Mara gave the baby the drug) is likely to be believed with very little evidence, if anything because it helps justify or normalize the otherwise disproportionate response to the perceived threat.⁷ During a moral panic, there is very little interest in what "actually" happened: It is neither compelling nor even possible to establish this. Rather, what matters is how closely the account matches a stereotype. In Mara's case the stereotype was not that of a normal hospital, with eroded procedures and routines like many others, but one of a lone woman, blending lethal potions in the night, who ended up killing a baby.

As the tightly focused suit by the prosecutor (who had happened to read about the case in the newspaper one morning), made people believe: Mara "carelessly took the wrong concentration which meant that the mixture became ten times stronger than what was prescribed, which in turn led to the patient being poisoned by the substance lidocaine." The prosecutor could have seen herself as a "moral entrepreneur," believing that Mara, this one member of society, had willfully engaged in immoral and damaging behavior, and was not being sufficiently punished for it.

Moral entrepreneurs can play a key role in the unleashing of a moral panic. Not only do they help bring an otherwise obscure act out in the open, they have first takes on defining the act: As criminal or morally reprehensible. They create their own opportunity to not only construct a story, but to have it seen as fact; a fact around which other expressions of outrage can then begin to coalesce. Moral entrepreneurs do not consider themselves to be meddlers, but truly believe that other people should be forced to do what is right.⁹

Not everybody agreed, of course. Another defining quality of moral panics is the alignment of opinion along symbolic lines of opposition.¹⁰ While many indeed believed in the nurse's unvarnished guilt, large swathes of society were appalled at her prosecution, at the vindictive haunting of one scapegoat whose actions had merely represented the tip of a mountain of rotten, risky, patient-threatening procedures, routines, and traditions in a hospital. What really needed changing was the system. The removal of one individual, and subsequent retribution, would yield very little. Books and radio programs about the case were produced, and a patient-safety conference was organized in its wake. The moral panic had highlighted a form of deviance (putative carelessness in mixing medications for an infant) that generated both avid sympathizers and heated opposition.

The moral panic affirms how deviance—or more specifically: illegitimate, culpable deviance—does not exist in the wild. We create it culturally by setting boundaries that exclude some acts while enclosing others. Moral panics serve to (re-)draw those boundaries clearly, and widely, leaving only a tight, little space for what is non-deviant, or normal. Condemning certain behavior as culpably deviant grows out of the characteristics of a particular society; out of the social structure of a certain time and place. These, of course change.

Perhaps a third edition of this book will have to written soon.