ethics responsibility case study

Annual Review of Ethics Case Studies

What are research ethics cases.

For additional information, please visit Resources for Research Ethics Education

Research Ethics Cases are a tool for discussing scientific integrity. Cases are designed to confront the readers with a specific problem that does not lend itself to easy answers. By providing a focus for discussion, cases help staff involved in research to define or refine their own standards, to appreciate alternative approaches to identifying and resolving ethical problems, and to develop skills for dealing with hard problems on their own.

Research Ethics Cases for Use by the NIH Community

• Theme 23 – Authorship, Collaborations, and Mentoring (2023)
• Theme 22 – Use of Human Biospecimens and Informed Consent (2022)
• Theme 21 – Science Under Pressure (2021)
• Theme 20 – Data, Project and Lab Management, and Communication (2020)
• Theme 19 – Civility, Harassment and Inappropriate Conduct (2019)
• Theme 18 – Implicit and Explicit Biases in the Research Setting (2018)
• Theme 17 – Socially Responsible Science (2017)
• Theme 16 – Research Reproducibility (2016)
• Theme 15 – Authorship and Collaborative Science (2015)
• Theme 14 – Differentiating Between Honest Discourse and Research Misconduct and Introduction to Enhancing Reproducibility (2014)
• Theme 13 – Data Management, Whistleblowers, and Nepotism (2013)
• Theme 12 – Mentoring (2012)
• Theme 11 – Authorship (2011)
• Theme 10 – Science and Social Responsibility, continued (2010)
• Theme 9 – Science and Social Responsibility - Dual Use Research (2009)
• Theme 8 – Borrowing - Is It Plagiarism? (2008)
• Theme 7 – Data Management and Scientific Misconduct (2007)
• Theme 6 – Ethical Ambiguities (2006)
• Theme 5 – Data Management (2005)
• Theme 4 – Collaborative Science (2004)
• Theme 3 – Mentoring (2003)
• Theme 2 – Authorship (2002)
• Theme 1 – Scientific Misconduct (2001)

For Facilitators Leading Case Discussion

For the sake of time and clarity of purpose, it is essential that one individual have responsibility for leading the group discussion. As a minimum, this responsibility should include:

• Reading the case aloud.
• Defining, and re-defining as needed, the questions to be answered.
• Encouraging discussion that is “on topic”.
• Discouraging discussion that is “off topic”.
• Keeping the pace of discussion appropriate to the time available.
• Eliciting contributions from all members of the discussion group.
• Summarizing both majority and minority opinions at the end of the discussion.

How Should Cases be Analyzed?

Many of the skills necessary to analyze case studies can become tools for responding to real world problems. Cases, like the real world, contain uncertainties and ambiguities. Readers are encouraged to identify key issues, make assumptions as needed, and articulate options for resolution. In addition to the specific questions accompanying each case, readers should consider the following questions:

• Who are the affected parties (individuals, institutions, a field, society) in this situation?
• What interest(s) (material, financial, ethical, other) does each party have in the situation? Which interests are in conflict?
• Were the actions taken by each of the affected parties acceptable (ethical, legal, moral, or common sense)? If not, are there circumstances under which those actions would have been acceptable? Who should impose what sanction(s)?
• What other courses of action are open to each of the affected parties? What is the likely outcome of each course of action?
• For each party involved, what course of action would you take, and why?
• What actions could have been taken to avoid the conflict?

Is There a Right Answer?

Acceptable solutions.

Most problems will have several acceptable solutions or answers, but it will not always be the case that a perfect solution can be found. At times, even the best solution will still have some unsatisfactory consequences.

Unacceptable Solutions

While more than one acceptable solution may be possible, not all solutions are acceptable. For example, obvious violations of specific rules and regulations or of generally accepted standards of conduct would typically be unacceptable. However, it is also plausible that blind adherence to accepted rules or standards would sometimes be an unacceptable course of action.

Ethical Decision-Making

It should be noted that ethical decision-making is a process rather than a specific correct answer. In this sense, unethical behavior is defined by a failure to engage in the process of ethical decision-making. It is always unacceptable to have made no reasonable attempt to define a consistent and defensible basis for conduct.

This page was last updated on Friday, July 7, 2023

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Case Study: Protect Your Company or Your Cousin?


• Joseph L. Badaracco

A manager gets inside information that could affect the future of her firm.

After a long week, all Marguerite Espinoza wanted to do was shut down her computer. It was 5:30 on Friday afternoon, and she’d just finished her workday as a customer experience manager at Spring Fire, a manufacturer of outdoor smokeless firepits. But she was supposed to log in to her extended family’s weekly Zoom call, a tradition they’d started at the beginning of the pandemic.

• Joseph L. Badaracco is the John Shad Professor of Business Ethics at Harvard Business School, where he has taught courses on leadership, strategy, corporate responsibility, and management. His books on these subjects include New York Times bestseller Leading Quietly , Defining Moments , and his latest book, Step Back: How to Bring the Art of Reflection into Your Busy Life (HBR Press, 2020).

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The Boeing 737 MAX: Lessons for Engineering Ethics

• Original Research/Scholarship
• Published: 10 July 2020
• Volume 26 , pages 2957–2974, ( 2020 )

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• Joseph Herkert 1 ,
• Jason Borenstein 2 &
• Keith Miller 3  

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The crash of two 737 MAX passenger aircraft in late 2018 and early 2019, and subsequent grounding of the entire fleet of 737 MAX jets, turned a global spotlight on Boeing’s practices and culture. Explanations for the crashes include: design flaws within the MAX’s new flight control software system designed to prevent stalls; internal pressure to keep pace with Boeing’s chief competitor, Airbus; Boeing’s lack of transparency about the new software; and the lack of adequate monitoring of Boeing by the FAA, especially during the certification of the MAX and following the first crash. While these and other factors have been the subject of numerous government reports and investigative journalism articles, little to date has been written on the ethical significance of the accidents, in particular the ethical responsibilities of the engineers at Boeing and the FAA involved in designing and certifying the MAX. Lessons learned from this case include the need to strengthen the voice of engineers within large organizations. There is also the need for greater involvement of professional engineering societies in ethics-related activities and for broader focus on moral courage in engineering ethics education.

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Introduction

In October 2018 and March 2019, Boeing 737 MAX passenger jets crashed minutes after takeoff; these two accidents claimed nearly 350 lives. After the second incident, all 737 MAX planes were grounded worldwide. The 737 MAX was an updated version of the 737 workhorse that first began flying in the 1960s. The crashes were precipitated by a failure of an Angle of Attack (AOA) sensor and the subsequent activation of new flight control software, the Maneuvering Characteristics Augmentation System (MCAS). The MCAS software was intended to compensate for changes in the size and placement of the engines on the MAX as compared to prior versions of the 737. The existence of the software, designed to prevent a stall due to the reconfiguration of the engines, was not disclosed to pilots until after the first crash. Even after that tragic incident, pilots were not required to undergo simulation training on the 737 MAX.

In this paper, we examine several aspects of the case, including technical and other factors that led up to the crashes, especially Boeing’s design choices and organizational tensions internal to the company, and between Boeing and the U.S. Federal Aviation Administration (FAA). While the case is ongoing and at this writing, the 737 MAX has yet to be recertified for flight, our analysis is based on numerous government reports and detailed news accounts currently available. We conclude with a discussion of specific lessons for engineers and engineering educators regarding engineering ethics.

Overview of 737 MAX History and Crashes

In December 2010, Boeing’s primary competitor Airbus announced the A320neo family of jetliners, an update of their successful A320 narrow-body aircraft. The A320neo featured larger, more fuel-efficient engines. Boeing had been planning to introduce a totally new aircraft to replace its successful, but dated, 737 line of jets; yet to remain competitive with Airbus, Boeing instead announced in August 2011 the 737 MAX family, an update of the 737NG with similar engine upgrades to the A320neo and other improvements (Gelles et al. 2019 ). The 737 MAX, which entered service in May 2017, became Boeing’s fastest-selling airliner of all time with 5000 orders from over 100 airlines worldwide (Boeing n.d. a) (See Fig.  1 for timeline of 737 MAX key events).

737 MAX timeline showing key events from 2010 to 2019

The 737 MAX had been in operation for over a year when on October 29, 2018, Lion Air flight JT610 crashed into the Java Sea 13 minutes after takeoff from Jakarta, Indonesia; all 189 passengers and crew on board died. Monitoring from the flight data recorder recovered from the wreckage indicated that MCAS, the software specifically designed for the MAX, forced the nose of the aircraft down 26 times in 10 minutes (Gates 2018 ). In October 2019, the Final Report of Indonesia’s Lion Air Accident Investigation was issued. The Report placed some of the blame on the pilots and maintenance crews but concluded that Boeing and the FAA were primarily responsible for the crash (Republic of Indonesia 2019 ).

MCAS was not identified in the original documentation/training for 737 MAX pilots (Glanz et al. 2019 ). But after the Lion Air crash, Boeing ( 2018 ) issued a Flight Crew Operations Manual Bulletin on November 6, 2018 containing procedures for responding to flight control problems due to possible erroneous AOA inputs. The next day the FAA ( 2018a ) issued an Emergency Airworthiness Directive on the same subject; however, the FAA did not ground the 737 MAX at that time. According to published reports, these notices were the first time that airline pilots learned of the existence of MCAS (e.g., Bushey 2019 ).

On March 20, 2019, about four months after the Lion Air crash, Ethiopian Airlines Flight ET302 crashed 6 minutes after takeoff in a field 39 miles from Addis Ababa Airport. The accident caused the deaths of all 157 passengers and crew. The Preliminary Report of the Ethiopian Airlines Accident Investigation (Federal Democratic Republic of Ethiopia 2019 ), issued in April 2019, indicated that the pilots followed the checklist from the Boeing Flight Crew Operations Manual Bulletin posted after the Lion Air crash but could not control the plane (Ahmed et al. 2019 ). This was followed by an Interim Report (Federal Democratic Republic of Ethiopia 2020 ) issued in March 2020 that exonerated the pilots and airline, and placed blame for the accident on design flaws in the MAX (Marks and Dahir 2020 ). Following the second crash, the 737 MAX was grounded worldwide with the U.S., through the FAA, being the last country to act on March 13, 2019 (Kaplan et al. 2019 ).

Design Choices that Led to the Crashes

As noted above, with its belief that it must keep up with its main competitor, Airbus, Boeing elected to modify the latest generation of the 737 family, the 737NG, rather than design an entirely new aircraft. Yet this raised a significant engineering challenge for Boeing. Mounting larger, more fuel-efficient engines, similar to those employed on the A320neo, on the existing 737 airframe posed a serious design problem, because the 737 family was built closer to the ground than the Airbus A320. In order to provide appropriate ground clearance, the larger engines had to be mounted higher and farther forward on the wings than previous models of the 737 (see Fig.  2 ). This significantly changed the aerodynamics of the aircraft and created the possibility of a nose-up stall under certain flight conditions (Travis 2019 ; Glanz et al. 2019 ).

(Image source: https://www.norebbo.com )

Boeing 737 MAX (left) compared to Boeing 737NG (right) showing larger 737 MAX engines mounted higher and more forward on the wing.

Boeing’s attempt to solve this problem involved incorporating MCAS as a software fix for the potential stall condition. The 737 was designed with two AOA sensors, one on each side of the aircraft. Yet Boeing decided that the 737 MAX would only use input from one of the plane’s two AOA sensors. If the single AOA sensor was triggered, MCAS would detect a dangerous nose-up condition and send a signal to the horizontal stabilizer located in the tail. Movement of the stabilizer would then force the plane’s tail up and the nose down (Travis 2019 ). In both the Lion Air and Ethiopian Air crashes, the AOA sensor malfunctioned, repeatedly activating MCAS (Gates 2018 ; Ahmed et al. 2019 ). Since the two crashes, Boeing has made adjustments to the MCAS, including that the system will rely on input from the two AOA sensors instead of just one. But still more problems with MCAS have been uncovered. For example, an indicator light that would alert pilots if the jet’s two AOA sensors disagreed, thought by Boeing to be standard on all MAX aircraft, would only operate as part of an optional equipment package that neither airline involved in the crashes purchased (Gelles and Kitroeff 2019a ).

Similar to its responses to previous accidents, Boeing has been reluctant to admit to a design flaw in its aircraft, instead blaming pilot error (Hall and Goelz 2019 ). In the 737 MAX case, the company pointed to the pilots’ alleged inability to control the planes under stall conditions (Economy 2019 ). Following the Ethiopian Airlines crash, Boeing acknowledged for the first time that MCAS played a primary role in the crashes, while continuing to highlight that other factors, such as pilot error, were also involved (Hall and Goelz 2019 ). For example, on April 29, 2019, more than a month after the second crash, then Boeing CEO Dennis Muilenburg defended MCAS by stating:

We've confirmed that [the MCAS system] was designed per our standards, certified per our standards, and we're confident in that process. So, it operated according to those design and certification standards. So, we haven't seen a technical slip or gap in terms of the fundamental design and certification of the approach. (Economy 2019 )

The view that MCAS was not primarily at fault was supported within an article written by noted journalist and pilot William Langewiesche ( 2019 ). While not denying Boeing made serious mistakes, he placed ultimate blame on the use of inexperienced pilots by the two airlines involved in the crashes. Langewiesche suggested that the accidents resulted from the cost-cutting practices of the airlines and the lax regulatory environments in which they operated. He argued that more experienced pilots, despite their lack of information on MCAS, should have been able to take corrective action to control the planes using customary stall prevention procedures. Langewiesche ( 2019 ) concludes in his article that:

What we had in the two downed airplanes was a textbook failure of airmanship. In broad daylight, these pilots couldn’t decipher a variant of a simple runaway trim, and they ended up flying too fast at low altitude, neglecting to throttle back and leading their passengers over an aerodynamic edge into oblivion. They were the deciding factor here — not the MCAS, not the Max.

Others have taken a more critical view of MCAS, Boeing, and the FAA. These critics prominently include Captain Chesley “Sully” Sullenberger, who famously crash-landed an A320 in the Hudson River after bird strikes had knocked out both of the plane’s engines. Sullenberger responded directly to Langewiesche in a letter to the Editor:

… Langewiesche draws the conclusion that the pilots are primarily to blame for the fatal crashes of Lion Air 610 and Ethiopian 302. In resurrecting this age-old aviation canard, Langewiesche minimizes the fatal design flaws and certification failures that precipitated those tragedies, and still pose a threat to the flying public. I have long stated, as he does note, that pilots must be capable of absolute mastery of the aircraft and the situation at all times, a concept pilots call airmanship. Inadequate pilot training and insufficient pilot experience are problems worldwide, but they do not excuse the fatally flawed design of the Maneuvering Characteristics Augmentation System (MCAS) that was a death trap.... (Sullenberger 2019 )

Noting that he is one of the few pilots to have encountered both accident sequences in a 737 MAX simulator, Sullenberger continued:

These emergencies did not present as a classic runaway stabilizer problem, but initially as ambiguous unreliable airspeed and altitude situations, masking MCAS. The MCAS design should never have been approved, not by Boeing, and not by the Federal Aviation Administration (FAA)…. (Sullenberger 2019 )

In June 2019, Sullenberger noted in Congressional Testimony that “These crashes are demonstrable evidence that our current system of aircraft design and certification has failed us. These accidents should never have happened” (Benning and DiFurio 2019 ).

Others have agreed with Sullenberger’s assessment. Software developer and pilot Gregory Travis ( 2019 ) argues that Boeing’s design for the 737 MAX violated industry norms and that the company unwisely used software to compensate for inadequacies in the hardware design. Travis also contends that the existence of MCAS was not disclosed to pilots in order to preserve the fiction that the 737 MAX was just an update of earlier 737 models, which served as a way to circumvent the more stringent FAA certification requirements for a new airplane. Reports from government agencies seem to support this assessment, emphasizing the chaotic cockpit conditions created by MCAS and poor certification practices. The U.S. National Transportation Safety Board (NTSB) ( 2019 ) Safety Recommendations to the FAA in September 2019 indicated that Boeing underestimated the effect MCAS malfunction would have on the cockpit environment (Kitroeff 2019 , a , b ). The FAA Joint Authorities Technical Review ( 2019 ), which included international participation, issued its Final Report in October 2019. The Report faulted Boeing and FAA in MCAS certification (Koenig 2019 ).

Despite Boeing’s attempts to downplay the role of MCAS, it began to work on a fix for the system shortly after the Lion Air crash (Gates 2019 ). MCAS operation will now be based on inputs from both AOA sensors, instead of just one sensor, with a cockpit indicator light when the sensors disagree. In addition, MCAS will only be activated once for an AOA warning rather than multiple times. What follows is that the system would only seek to prevent a stall once per AOA warning. Also, MCAS’s power will be limited in terms of how much it can move the stabilizer and manual override by the pilot will always be possible (Bellamy 2019 ; Boeing n.d. b; Gates 2019 ). For over a year after the Lion Air crash, Boeing held that pilot simulator training would not be required for the redesigned MCAS system. In January 2020, Boeing relented and recommended that pilot simulator training be required when the 737 MAX returns to service (Pasztor et al. 2020 ).

Boeing and the FAA

There is mounting evidence that Boeing, and the FAA as well, had warnings about the inadequacy of MCAS’s design, and about the lack of communication to pilots about its existence and functioning. In 2015, for example, an unnamed Boeing engineer raised in an email the issue of relying on a single AOA sensor (Bellamy 2019 ). In 2016, Mark Forkner, Boeing’s Chief Technical Pilot, in an email to a colleague flagged the erratic behavior of MCAS in a flight simulator noting: “It’s running rampant” (Gelles and Kitroeff 2019c ). Forkner subsequently came under federal investigation regarding whether he misled the FAA regarding MCAS (Kitroeff and Schmidt 2020 ).

In December 2018, following the Lion Air Crash, the FAA ( 2018b ) conducted a Risk Assessment that estimated that fifteen more 737 MAX crashes would occur in the expected fleet life of 45 years if the flight control issues were not addressed; this Risk Assessment was not publicly disclosed until Congressional hearings a year later in December 2019 (Arnold 2019 ). After the two crashes, a senior Boeing engineer, Curtis Ewbank, filed an internal ethics complaint in 2019 about management squelching of a system that might have uncovered errors in the AOA sensors. Ewbank has since publicly stated that “I was willing to stand up for safety and quality… Boeing management was more concerned with cost and schedule than safety or quality” (Kitroeff et al. 2019b ).

One factor in Boeing’s apparent reluctance to heed such warnings may be attributed to the seeming transformation of the company’s engineering and safety culture over time to a finance orientation beginning with Boeing’s merger with McDonnell–Douglas in 1997 (Tkacik 2019 ; Useem 2019 ). Critical changes after the merger included replacing many in Boeing’s top management, historically engineers, with business executives from McDonnell–Douglas and moving the corporate headquarters to Chicago, while leaving the engineering staff in Seattle (Useem 2019 ). According to Tkacik ( 2019 ), the new management even went so far as “maligning and marginalizing engineers as a class”.

Financial drivers thus began to place an inordinate amount of strain on Boeing employees, including engineers. During the development of the 737 MAX, significant production pressure to keep pace with the Airbus 320neo was ever-present. For example, Boeing management allegedly rejected any design changes that would prolong certification or require additional pilot training for the MAX (Gelles et al. 2019 ). As Adam Dickson, a former Boeing engineer, explained in a television documentary (BBC Panorama 2019 ): “There was a lot of interest and pressure on the certification and analysis engineers in particular, to look at any changes to the Max as minor changes”.

Production pressures were exacerbated by the “cozy relationship” between Boeing and the FAA (Kitroeff et al. 2019a ; see also Gelles and Kaplan 2019 ; Hall and Goelz 2019 ). Beginning in 2005, the FAA increased its reliance on manufacturers to certify their own planes. Self-certification became standard practice throughout the U.S. airline industry. By 2018, Boeing was certifying 96% of its own work (Kitroeff et al. 2019a ).

The serious drawbacks to self-certification became acutely apparent in this case. Of particular concern, the safety analysis for MCAS delegated to Boeing by the FAA was flawed in at least three respects: (1) the analysis underestimated the power of MCAS to move the plane’s horizontal tail and thus how difficult it would be for pilots to maintain control of the aircraft; (2) it did not account for the system deploying multiple times; and (3) it underestimated the risk level if MCAS failed, thus permitting a design feature—the single AOA sensor input to MCAS—that did not have built-in redundancy (Gates 2019 ). Related to these concerns, the ability of MCAS to move the horizontal tail was increased without properly updating the safety analysis or notifying the FAA about the change (Gates 2019 ). In addition, the FAA did not require pilot training for MCAS or simulator training for the 737 MAX (Gelles and Kaplan 2019 ). Since the MAX grounding, the FAA has been become more independent during its assessments and certifications—for example, they will not use Boeing personnel when certifying approvals of new 737 MAX planes (Josephs 2019 ).

The role of the FAA has also been subject to political scrutiny. The report of a study of the FAA certification process commissioned by Secretary of Transportation Elaine Chao (DOT 2020 ), released January 16, 2020, concluded that the FAA certification process was “appropriate and effective,” and that certification of the MAX as a new airplane would not have made a difference in the plane’s safety. At the same time, the report recommended a number of measures to strengthen the process and augment FAA’s staff (Pasztor and Cameron 2020 ). In contrast, a report of preliminary investigative findings by the Democratic staff of the House Committee on Transportation and Infrastructure (House TI 2020 ), issued in March 2020, characterized FAA’s certification of the MAX as “grossly insufficient” and criticized Boeing’s design flaws and lack of transparency with the FAA, airlines, and pilots (Duncan and Laris 2020 ).

Boeing has incurred significant economic losses from the crashes and subsequent grounding of the MAX. In December 2019, Boeing CEO Dennis Muilenburg was fired and the corporation announced that 737 MAX production would be suspended in January 2020 (Rich 2019 ) (see Fig.  1 ). Boeing is facing numerous lawsuits and possible criminal investigations. Boeing estimates that its economic losses for the 737 MAX will exceed $18 billion (Gelles 2020 ). In addition to the need to fix MCAS, other issues have arisen in recertification of the aircraft, including wiring for controls of the tail stabilizer, possible weaknesses in the engine rotors, and vulnerabilities in lightning protection for the engines (Kitroeff and Gelles 2020 ). The FAA had planned to flight test the 737 MAX early in 2020, and it was supposed to return to service in summer 2020 (Gelles and Kitroeff 2020 ). Given the global impact of the COVID-19 pandemic and other factors, it is difficult to predict when MAX flights might resume. In addition, uncertainty of passenger demand has resulted in some airlines delaying or cancelling orders for the MAX (Bogaisky 2020 ). Even after obtaining flight approval, public resistance to flying in the 737 MAX will probably be considerable (Gelles 2019 ).

Lessons for Engineering Ethics

The 737 MAX case is still unfolding and will continue to do so for some time. Yet important lessons can already be learned (or relearned) from the case. Some of those lessons are straightforward, and others are more subtle. A key and clear lesson is that engineers may need reminders about prioritizing the public good, and more specifically, the public’s safety. A more subtle lesson pertains to the ways in which the problem of many hands may or may not apply here. Other lessons involve the need for corporations, engineering societies, and engineering educators to rise to the challenge of nurturing and supporting ethical behavior on the part of engineers, especially in light of the difficulties revealed in this case.

All contemporary codes of ethics promulgated by major engineering societies state that an engineer’s paramount responsibility is to protect the “safety, health, and welfare” of the public. The American Institute of Aeronautics and Astronautics Code of Ethics indicates that engineers must “[H]old paramount the safety, health, and welfare of the public in the performance of their duties” (AIAA 2013 ). The Institute of Electrical and Electronics Engineers (IEEE) Code of Ethics goes further, pledging its members: “…to hold paramount the safety, health, and welfare of the public, to strive to comply with ethical design and sustainable development practices, and to disclose promptly factors that might endanger the public or the environment” (IEEE 2017 ). The IEEE Computer Society (CS) cooperated with the Association for Computing Machinery (ACM) in developing a Software Engineering Code of Ethics ( 1997 ) which holds that software engineers shall: “Approve software only if they have a well-founded belief that it is safe, meets specifications, passes appropriate tests, and does not diminish quality of life, diminish privacy or harm the environment….” According to Gotterbarn and Miller ( 2009 ), the latter code is a useful guide when examining cases involving software design and underscores the fact that during design, as in all engineering practice, the well-being of the public should be the overriding concern. While engineering codes of ethics are plentiful in number, they differ in their source of moral authority (i.e., organizational codes vs. professional codes), are often unenforceable through the law, and formally apply to different groups of engineers (e.g., based on discipline or organizational membership). However, the codes are generally recognized as a statement of the values inherent to engineering and its ethical commitments (Davis 2015 ).

An engineer’s ethical responsibility does not preclude consideration of factors such as cost and schedule (Pinkus et al. 1997 ). Engineers always have to grapple with constraints, including time and resource limitations. The engineers working at Boeing did have legitimate concerns about their company losing contracts to its competitor Airbus. But being an engineer means that public safety and welfare must be the highest priority (Davis 1991 ). The aforementioned software and other design errors in the development of the 737 MAX, which resulted in hundreds of deaths, would thus seem to be clear violations of engineering codes of ethics. In addition to pointing to engineering codes, Peterson ( 2019 ) argues that Boeing engineers and managers violated widely accepted ethical norms such as informed consent and the precautionary principle.

From an engineering perspective, the central ethical issue in the MAX case arguably circulates around the decision to use software (i.e., MCAS) to “mask” a questionable hardware design—the repositioning of the engines that disrupted the aerodynamics of the airframe (Travis 2019 ). As Johnston and Harris ( 2019 ) argue: “To meet the design goals and avoid an expensive hardware change, Boeing created the MCAS as a software Band-Aid.” Though a reliance on software fixes often happens in this manner, it places a high burden of safety on such fixes that they may not be able to handle, as is illustrated by the case of the Therac-25 radiation therapy machine. In the Therac-25 case, hardware safety interlocks employed in earlier models of the machine were replaced by software safety controls. In addition, information about how the software might malfunction was lacking from the user manual for the Therac machine. Thus, when certain types of errors appeared on its interface, the machine’s operators did not know how to respond. Software flaws, among other factors, contributed to six patients being given massive radiation overdoses, resulting in deaths and serious injuries (Leveson and Turner 1993 ). A more recent case involves problems with the embedded software guiding the electronic throttle in Toyota vehicles. In 2013, “…a jury found Toyota responsible for two unintended acceleration deaths, with expert witnesses citing bugs in the software and throttle fail safe defects” (Cummings and Britton 2020 ).

Boeing’s use of MCAS to mask the significant change in hardware configuration of the MAX was compounded by not providing redundancy for components prone to failure (i.e., the AOA sensors) (Campbell 2019 ), and by failing to notify pilots about the new software. In such cases, it is especially crucial that pilots receive clear documentation and relevant training so that they know how to manage the hand-off with an automated system properly (Johnston and Harris 2019 ). Part of the necessity for such training is related to trust calibration (Borenstein et al. 2020 ; Borenstein et al. 2018 ), a factor that has contributed to previous airplane accidents (e.g., Carr 2014 ). For example, if pilots do not place enough trust in an automated system, they may add risk by intervening in system operation. Conversely, if pilots trust an automated system too much, they may lack sufficient time to act once they identify a problem. This is further complicated in the MAX case because pilots were not fully aware, if at all, of MCAS’s existence and how the system functioned.

In addition to engineering decision-making that failed to prioritize public safety, questionable management decisions were also made at both Boeing and the FAA. As noted earlier, Boeing managerial leadership ignored numerous warning signs that the 737 MAX was not safe. Also, FAA’s shift to greater reliance on self-regulation by Boeing was ill-advised; that lesson appears to have been learned at the expense of hundreds of lives (Duncan and Aratani 2019 ).

The Problem of Many Hands Revisited

Actions, or inaction, by large, complex organizations, in this case corporate and government entities, suggest that the “problem of many hands” may be relevant to the 737 MAX case. At a high level of abstraction, the problem of many hands involves the idea that accountability is difficult to assign in the face of collective action, especially in a computerized society (Thompson 1980 ; Nissenbaum 1994 ). According to Nissenbaum ( 1996 , 29), “Where a mishap is the work of ‘many hands,’ it may not be obvious who is to blame because frequently its most salient and immediate causal antecedents do not converge with its locus of decision-making. The conditions for blame, therefore, are not satisfied in a way normally satisfied when a single individual is held blameworthy for a harm”.

However, there is an alternative understanding of the problem of many hands. In this version of the problem, the lack of accountability is not merely because multiple people and multiple decisions figure into a final outcome. Instead, in order to “qualify” as the problem of many hands, the component decisions should be benign, or at least far less harmful, if examined in isolation; only when the individual decisions are collectively combined do we see the most harmful result. In this understanding, the individual decision-makers should not have the same moral culpability as they would if they made all the decisions by themselves (Noorman 2020 ).

Both of these understandings of the problem of many hands could shed light on the 737 MAX case. Yet we focus on the first version of the problem. We admit the possibility that some of the isolated decisions about the 737 MAX may have been made in part because of ignorance of a broader picture. While we do not stake a claim on whether this is what actually happened in the MAX case, we acknowledge that it may be true in some circumstances. However, we think the more important point is that some of the 737 MAX decisions were so clearly misguided that a competent engineer should have seen the implications, even if the engineer was not aware of all of the broader context. The problem then is to identify responsibility for the questionable decisions in a way that discourages bad judgments in the future, a task made more challenging by the complexities of the decision-making. Legal proceedings about this case are likely to explore those complexities in detail and are outside the scope of this article. But such complexities must be examined carefully so as not to act as an insulator to accountability.

When many individuals are involved in the design of a computing device, for example, and a serious failure occurs, each person might try to absolve themselves of responsibility by indicating that “too many people” and “too many decisions” were involved for any individual person to know that the problem was going to happen. This is a common, and often dubious, excuse in the attempt to abdicate responsibility for a harm. While it can have different levels of magnitude and severity, the problem of many hands often arises in large scale ethical failures in engineering such as in the Deepwater Horizon oil spill (Thompson 2014 ).

Possible examples in the 737 MAX case of the difficulty of assigning moral responsibility due to the problem of many hands include:

The decision to reposition the engines;

The decision to mask the jet’s subsequent dynamic instability with MCAS;

The decision to rely on only one AOA sensor in designing MCAS; and

The decision to not inform nor properly train pilots about the MCAS system.

While overall responsibility for each of these decisions may be difficult to allocate precisely, at least points 1–3 above arguably reflect fundamental errors in engineering judgement (Travis 2019 ). Boeing engineers and FAA engineers either participated in or were aware of these decisions (Kitroeff and Gelles 2019 ) and may have had opportunities to reconsider or redirect such decisions. As Davis has noted ( 2012 ), responsible engineering professionals make it their business to address problems even when they did not cause the problem, or, we would argue, solely cause it. As noted earlier, reports indicate that at least one Boeing engineer expressed reservations about the design of MCAS (Bellamy 2019 ). Since the two crashes, one Boeing engineer, Curtis Ewbank, filed an internal ethics complaint (Kitroeff et al. 2019b ) and several current and former Boeing engineers and other employees have gone public with various concerns about the 737 MAX (Pasztor 2019 ). And yet, as is often the case, the flawed design went forward with tragic results.

Enabling Ethical Engineers

The MAX case is eerily reminiscent of other well-known engineering ethics case studies such as the Ford Pinto (Birsch and Fielder 1994 ), Space Shuttle Challenger (Werhane 1991 ), and GM ignition switch (Jennings and Trautman 2016 ). In the Pinto case, Ford engineers were aware of the unsafe placement of the fuel tank well before the car was released to the public and signed off on the design even though crash tests showed the tank was vulnerable to rupture during low-speed rear-end collisions (Baura 2006 ). In the case of the GM ignition switch, engineers knew for at least four years about the faulty design, a flaw that resulted in at least a dozen fatal accidents (Stephan 2016 ). In the case of the well-documented Challenger accident, engineer Roger Boisjoly warned his supervisors at Morton Thiokol of potentially catastrophic flaws in the shuttle’s solid rocket boosters a full six months before the accident. He, along with other engineers, unsuccessfully argued on the eve of launch for a delay due to the effect that freezing temperatures could have on the boosters’ O-ring seals. Boisjoly was also one of a handful of engineers to describe these warnings to the Presidential commission investigating the accident (Boisjoly et al. 1989 ).

Returning to the 737 MAX case, could Ewbank or others with concerns about the safety of the airplane have done more than filing ethics complaints or offering public testimony only after the Lion Air and Ethiopian Airlines crashes? One might argue that requiring professional registration by all engineers in the U.S. would result in more ethical conduct (for example, by giving state licensing boards greater oversight authority). Yet the well-entrenched “industry exemption” from registration for most engineers working in large corporations has undermined such calls (Kline 2001 ).

It could empower engineers with safety concerns if Boeing and other corporations would strengthen internal ethics processes, including sincere and meaningful responsiveness to anonymous complaint channels. Schwartz ( 2013 ) outlines three core components of an ethical corporate culture, including strong core ethical values, a formal ethics program (including an ethics hotline), and capable ethical leadership. Schwartz points to Siemens’ creation of an ethics and compliance department following a bribery scandal as an example of a good solution. Boeing has had a compliance department for quite some time (Schnebel and Bienert 2004 ) and has taken efforts in the past to evaluate its effectiveness (Boeing 2003 ). Yet it is clear that more robust measures are needed in response to ethics concerns and complaints. Since the MAX crashes, Boeing’s Board has implemented a number of changes including establishing a corporate safety group and revising internal reporting procedures so that lead engineers primarily report to the chief engineer rather than business managers (Gelles and Kitroeff 2019b , Boeing n.d. c). Whether these measures will be enough to restore Boeing’s former engineering-centered focus remains to be seen.

Professional engineering societies could play a stronger role in communicating and enforcing codes of ethics, in supporting ethical behavior of engineers, and by providing more educational opportunities for learning about ethics and about the ethical responsibilities of engineers. Some societies, including ACM and IEEE, have become increasingly engaged in ethics-related activities. Initially ethics engagement by the societies consisted primarily of a focus on macroethical issues such as sustainable development (Herkert 2004 ). Recently, however, the societies have also turned to a greater focus on microethical issues (the behavior of individuals). The 2017 revision to the IEEE Code of Ethics, for example, highlights the importance of “ethical design” (Adamson and Herkert 2020 ). This parallels IEEE activities in the area of design of autonomous and intelligent systems (e.g., IEEE 2018 ). A promising outcome of this emphasis is a move toward implementing “ethical design” frameworks (Peters et al. 2020 ).

In terms of engineering education, educators need to place a greater emphasis on fostering moral courage, that is the courage to act on one’s moral convictions including adherence to codes of ethics. This is of particular significance in large organizations such as Boeing and the FAA where the agency of engineers may be limited by factors such as organizational culture (Watts and Buckley 2017 ). In a study of twenty-six ethics interventions in engineering programs, Hess and Fore ( 2018 ) found that only twenty-seven percent had a learning goal of development of “ethical courage, confidence or commitment”. This goal could be operationalized in a number of ways, for example through a focus on virtue ethics (Harris 2008 ) or professional identity (Hashemian and Loui 2010 ). This need should not only be addressed within the engineering curriculum but during lifelong learning initiatives and other professional development opportunities as well (Miller 2019 ).

The circumstances surrounding the 737 MAX airplane could certainly serve as an informative case study for ethics or technical courses. The case can shed light on important lessons for engineers including the complex interactions, and sometimes tensions, between engineering and managerial considerations. The case also tangibly displays that what seems to be relatively small-scale, and likely well-intended, decisions by individual engineers can combine collectively to result in large-scale tragedy. No individual person wanted to do harm, but it happened nonetheless. Thus, the case can serve a reminder to current and future generations of engineers that public safety must be the first and foremost priority. A particularly useful pedagogical method for considering this case is to assign students to the roles of engineers, managers, and regulators, as well as the flying public, airline personnel, and representatives of engineering societies (Herkert 1997 ). In addition to illuminating the perspectives and responsibilities of each stakeholder group, role-playing can also shed light on the “macroethical” issues raised by the case (Martin et al. 2019 ) such as airline safety standards and the proper role for engineers and engineering societies in the regulation of the industry.

Conclusions and Recommendations

The case of the Boeing 737 MAX provides valuable lessons for engineers and engineering educators concerning the ethical responsibilities of the profession. Safety is not cheap, but careless engineering design in the name of minimizing costs and adhering to a delivery schedule is a symptom of ethical blight. Using almost any standard ethical analysis or framework, Boeing’s actions regarding the safety of the 737 MAX, particularly decisions regarding MCAS, fall short.

Boeing failed in its obligations to protect the public. At a minimum, the company had an obligation to inform airlines and pilots of significant design changes, especially the role of MCAS in compensating for repositioning of engines in the MAX from prior versions of the 737. Clearly, it was a “significant” change because it had a direct, and unfortunately tragic, impact on the public’s safety. The Boeing and FAA interaction underscores the fact that conflicts of interest are a serious concern in regulatory actions within the airline industry.

Internal and external organizational factors may have interfered with Boeing and FAA engineers’ fulfillment of their professional ethical responsibilities; this is an all too common problem that merits serious attention from industry leaders, regulators, professional societies, and educators. The lessons to be learned in this case are not new. After large scale tragedies involving engineering decision-making, calls for change often emerge. But such lessons apparently must be retaught and relearned by each generation of engineers.

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Herkert, J., Borenstein, J. & Miller, K. The Boeing 737 MAX: Lessons for Engineering Ethics. Sci Eng Ethics 26 , 2957–2974 (2020). https://doi.org/10.1007/s11948-020-00252-y

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Providing radiation therapy to cancer patients, Therac-25 had malfunctions that resulted in 6 deaths. Who is accountable when technology causes harm?

The Therac-25 machine was a state-of-the-art linear accelerator developed by the company Atomic Energy Canada Limited (AECL) and a French company CGR to provide radiation treatment to cancer patients. The Therac-25 was the most computerized and sophisticated radiation therapy machine of its time. With the aid of an onboard computer, the device could select multiple treatment table positions and select the type/strength of the energy selected by the operating technician. AECL sold eleven Therac-25 machines that were used in the United States and Canada beginning in 1982.

Unfortunately, six accidents involving significant overdoses of radiation to patients resulting in death occurred between 1985 and 1987 (Leveson & Turner 1993). Patients reported being “burned by the machine” which some technicians reported, but the company thought was impossible. The machine was recalled in 1987 for an extensive redesign of safety features, software, and mechanical interlocks. Reports to the manufacturer resulted in inadequate repairs to the system and assurances that the machines were safe. Lawsuits were filed, and no investigations took place. The Food and Drug Administration (FDA) later found that there was an inadequate reporting structure in the company, to follow up with reported accidents.

There were two earlier versions of the Therac-25 unit: the Therac-6 and the Therac-20, which were built from the CGR company’s other radiation units–Neptune and Sagittaire. The Therac-6 and Therac-20 units were built with a microcomputer that made the patient data entry more accessible, but the units were operational without an onboard computer. These units had built-in safety interlocks and positioning guides, and mechanical features that prevented radiation exposure if there was a positioning problem with the patient or with the components of the machine. There was some “base duplication” of the software used from the Therac-20 that carried over to the Therac-25. The Therac-6 and Therac-20 were clinically tested machines with an excellent safety record. They relied primarily on hardware for safety controls, whereas the Therac-25 relied primarily on software.

On February 6, 1987, the FDA placed a shutdown on all machines until permanent repairs could be made. Although the AECL was quick to state that a “fix” was in place, and the machines were now safer, that was not the case. After this incident, Leveson and Turner (1993) compiled public information from AECL, the FDA, and various regulatory agencies and concluded that there was inadequate record keeping when the software was designed. The software was inadequately tested, and “patches” were used from earlier versions of the machine. The premature assumption that the problem(s) was detected and corrected was unproven. Furthermore, AECL had great difficulty reproducing the conditions under which the issues were experienced in the clinics. The FDA restructured its reporting requirements for radiation equipment after these incidents.

As computers become more and more ubiquitous and control increasingly significant and complex systems, people are exposed to increasing harms and risks. The issue of accountability arises when a community expects its agents to stand up for the quality of their work. Nissenbaum (1994) argues that responsibility in our computerized society is systematically undermined, and this is a disservice to the community. This concern has grown with the number of critical life services controlled by computer systems in the governmental, airline, and medical arenas.

According to Nissenbaum, there are four barriers to accountability: the problem of many hands, “bugs” in the system, the computer as a scapegoat, and ownership without liability. The problem of too many hands relates to the fact that many groups of people (programmers, engineers, etc.) at various levels of a company are typically involved in creation of a computer program and have input into the final product. When something goes wrong, there is no one individual who can be clearly held responsible. It is easy for each person involved to rationalize that he or she is not responsible for the final outcome, because of the small role played. This occurred with the Therac-25 that had two prominent software errors, a failed microswitch, and a reduced number of safety features compared to earlier versions of the device. The problem of bugs in the software system causing errors in machines under certain conditions has been used as a cover for careless programming, lack of testing, and lack of safety features built into the system in the Therac-25 accident. The fact that computers “always have problems with their programming” cannot be used as an excuse for overconfidence in a product, unclear/ambiguous error messages, or improper testing of individual components of the system. Another potential obstacle is ownership of proprietary software and an unwillingness to share “trade secrets” with investigators whose job it is to protect the public (Nissenbaum 1994).

The Therac-25 incident involved what has been called one of the worst computer bugs in history (Lynch 2017), though it was largely a matter of overall design issues rather than a specific coding error. Therac-25 is a glaring example of what can go wrong in a society that is heavily dependent on technology.

Discussion Questions

1. Who should be responsible for the errors in a medical device?

2. What moral responsibility do creators of software have for the adverse consequences that flow from flaws in that software?

3. What steps are creators of software morally required to take to minimize the risk that they will sell flawed software with dangerous consequences?

4. What should constitute FDA approval of a medical device?

• Should the benefit outweigh the harm?
• Should the device be 100% safe prior to approval?
• Should FDA approval guidelines take into consideration novel therapies for protected populations such as children or patients with rare conditions?

5. Should updated medical devices be reviewed by the FDA as a new device or as an improvement in an older design?

• If reviewed as an improvement, at what point can/should a device be subject to a full review process?
• If reviewed as a novel device, how might this effect the production of modified/ improved devices and the overall companies that produce medical devices?

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Causing harm explores the types of harm that may be caused to people or groups and the potential reasons we may have for justifying these harms.

Bibliography

Gotterbarn, Donald, “Software Engineering Ethics,” Encyclopedia of Software Engineering (2002), https://onlinelibrary.wiley.com/doi/abs/10.1002/0471028959.sof314 .

Leveson, Nancy & Turner, Clark, “An Investigation of the Therac-25 Accidents,” Computer 26:7, p. 18 (July 19993), https://web.stanford.edu/class/cs240/old/sp2014/readings/therac-25.pdf

Leveson, Nancy, Medical Devices: The Therac—25 (1995), http://sunnyday.mit.edu/papers/therac.pdf .

Lynch, Jamie, “Therac-25 Causes Radiation Overdoses,” Bugsnag Blog ( 2017) https://www.bugsnag.com/blog/bug-day-race-condition-therac-25

Nissenbaum, Helen, “Computing and Accountability,“ Communications of the ACM , 37:1, p. 73 ( 1994). http://delivery.acm.org/10.1145/180000/175228/p72-nissenbaum.pdf?ip=128.62.211.38&id=175228&acc=ACTIVE%20SERVICE&key=603D2E7028CD4EF5%2E4D4702B0C3E38B35%2E4D4702B0C3E38B35%2E4D4702B0C3E38B35&__acm__=1576603038_0292b9d0b31643bd7b06dde8efa509f7

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The MIT Case Studies in Social and Ethical Responsibilities of Computing (SERC) aims to advance new efforts within and beyond the Schwarzman College of Computing. The specially commissioned and peer-reviewed cases are brief and intended to be effective for undergraduate instruction across a range of classes and fields of study, and may also be of interest for computing professionals, policy specialists, and general readers. The series editors interpret “social and ethical responsibilities of computing” broadly. Some cases focus closely on particular technologies, others on trends across technological platforms. Others examine social, historical, philosophical, legal, and cultural facets that are essential for thinking critically about present-day efforts in computing activities. Special efforts are made to solicit cases on topics ranging beyond the United States and that highlight perspectives of people who are affected by various technologies in addition to perspectives of designers and engineers. New sets of case studies, produced with support from the MIT Press’ Open Publishing Services program, will be published twice a year and made available via the Knowledge Futures Group’s  PubPub  platform. The SERC case studies are made available for free on an open-access basis , under Creative Commons licensing terms. Authors retain copyright, enabling them to re-use and re-publish their work in more specialized scholarly publications. If you have suggestions for a new case study or comments on a published case, the series editors would like to hear from you! Please reach out to [email protected] .

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Responsibility

Commentary and Part 7 of the Occidental Engineering Case Study by Michael McFarland, S.J.

Occidental Engineering Case Study: Part 7

When Wayne in the Occidental case loses his argument with Deborah, his manager, he still faces an ethical dilemma. If he is still convinced that there is something wrong with certifying the defective software, he must decide whether he should go ahead and do it as ordered, refuse to cooperate, or actively oppose any such action. If he does nothing, and an accident does occur because of the flawed software, is it his fault? This raises the issue of responsibility.

In making an ethical judgement, it is not enough to decide what is right to do or what should have been done in a certain case. It is also necessary to decide to what extent one is or was responsible for doing what is right. It is certainly wrong for the driver of a car to crash into another car parked by the side of the road; but if the driver had lost control of his car because he suffered a heart attack or if he didn't see the parked car, he cannot be blamed for the accident, unless he could have avoided the circumstances that led to it.

In the case of an individual act, assessing responsibility is relatively straightforward. To be held responsible, the agent must have knowledge of the act and its consequences and must have the freedom to choose or not choose the act. The driver who has a heart attack and loses control of his car is not in a position to choose whether or not to hit the parked car. The driver who comes around a corner driving at a safe speed in what he has every reason to believe is a clear travel lane and unexpectedly plows into a car that has been left in the road did not know and could not be expected to know that his actions would lead to a crash. In neither case would the driver be ethically responsible for the crash. In the first case he lacked the freedom, in the second the knowledge.

When a person acts in a social and institutional context, the problem of responsibility is much more complex. As part of a group, one may be asked to take part in, or at least not interfere with, actions with which one does not agree, as in Wayne's case. Or it may be clear that some action is called for, but not at all clear who should take that action. The Red Cross says the blood supply has fallen so low that there is a crisis for the hospitals. Someone ought to donate; but why should it be me?

Another problem is that institutions so constrain people's options and their ability to act that sometimes they cannot satisfy all the ethical demands on them. Prior to the disastrous flight of the space shuttle Challenger, engineer Roger Boisjoly of Thiokol, Inc., the maker of the rocket motor that failed and led to the crash, had serious doubts about the safety of the O-ring seals, especially at low temperatures. He made his misgivings known to his managers, but when they chose to ignore him, he went no further. To do more, he felt, would have been disloyal and disrespectful of the prerogatives of management. As he later told investigators, "I must emphasize, I had my say, and I never take [away] any management right to take the input of an engineer and then make a decision based upon that input, and I truly believe that....So there was no point in me doing anything any further." 40 Ben Powers of NASA was in the same position. Both were aware of an inordinate risk to the lives of the astronauts, and both wanted to act to protect them; but they were frustrated by both the personnel and the procedures of the organizations in which they worked. If management had been more responsive, or if there had been alternative procedures for airing safety concerns, the tragedy might have been prevented. As it was, Boisjoly and Powers could not do anything effective without violating what they saw as their obligations to their employers. Ironically, even the loyalty they showed was not enough. Boisjoly was treated as a traitor at Thiokol and eventually put on permanent leave for speaking publicly about the company's part in the disaster. 41

Incidents like this show the power of institutions to influence and shape our ethical decisions. But we must also acknowledge the power of our ethical decisions to shape institutions. Therefore there are two aspects of responsibility to consider in a social context: our responsibility  within  institutions and our responsibility  for  institutions.

Responsibility within Institutions

In a social or institutional context, ethical responsibility can be so diffused that no one feels responsible, even when organizational roles are well-defined. This is especially true when positive action is required to bring about some good or avoid some harm. If it is wrong to lie, then it is wrong no matter how many people are involved. But who is required to step forward and tell the unpleasant truth? Beating someone with a baseball bat is wrong no matter whether one is alone or in a mob. But when is one required to step forward from a crowd of bystanders and stop such a beating, or, for that matter, to alert the public to the dangers of a particular technology? These questions become even more obscure and difficult when the people involved are bound together by institutional loyalties and contractual obligations.

In their study of corporate responsibility, 42 Simon, Powers and Gunnerman looked at these questions. They used as an analogy the case of Kitty Genovese, who was stabbed to death outside her apartment in Queens while at least thirty-eight of her neighbors looked on, none of whom even called the police, let alone intervened. She was attacked three different times by her assailant over a half hour, so there was time to save her. It is obvious enough that the failure of the neighbors to help was wrong, but more difficult to explain why and how. When is there an obligation to take positive action to prevent harm to another? The authors identified four conditions that must be met:

• Critical need.  Some fundamental good or right must be threatened.
• Proximity.  This is "largely a function of notice," but it also involves role relationships. "We do expect certain persons and perhaps institutions to look harder for information about critical need. In this sense proximity has to do with the network of social relations that follow from notions of civic duty, duties to one's family, and so on." 43
• Ability to help without damage to self and without interference with important duties owed to others.
• Absence of other sources of help.

Condition 2 says that those who are in the best position to know about a serious threat have the strongest obligation to act. In particular, when the threat comes from a certain piece of technology, the engineers who are most intimately involved with the technology and best understand its consequences have a special duty to protect the safety of the public. However, condition 3 qualifies that obligation: it only exists if action can be taken without any serious risk to the agent. This is a very conservative requirement. If the threat is serious enough, say the near-certain, catastrophic meltdown of a nuclear power plant, an engineer ought to be willing even to risk his or her job if there was a chance of preventing the disaster.

The reason for the reluctance to  require  an engineer to take on significant personal risks to help out is that it is unfair. The engineer did not cause the danger, at least not intentionally, so he or she should not have to pay so high a price for preventing it. Yet in many instances that is the only choice, because of the way the organization is structured. That is why whistle-blowing cases like Boisjoly's are often so tragic. 44 Either the engineer suffers unfairly or the public suffers even more unfairly. There is no choice that satisfies all the ethical demands of the situation.

That is why it is not enough in such cases to ask what the individual should do, that is, what is the ethical choice. The more important question is how to change the institutional context so that there is an ethical choice.

Responsibility for Institutions

To return once more to our original case, the corporate structure and climate at Occidental Engineering was part of the reason why Deborah and Wayne faced such difficult ethical decisions and why the outcome was so unsatisfactory. If the company had had an uncompromising commitment to quality and safety, it would not have put itself and its engineers in the position of having to cut corners to satisfy its commitments; and when safety concerns arose, it would not have tried to suppress them. Furthermore if the company had had more respect for its engineers, especially those like Wayne who are ultimately responsible for safety, it would have given them more input in formulating the bid, to make sure they could do what they promised, and it would have provided channels for concerned employees and managers like Wayne and Deborah to pursue concerns about safety and integrity without feeling they were endangering their jobs or those of their employees. As it was, Wayne and Deborah found themselves in a position where whatever they decided, they would violate some ethical obligation. This did not excuse them of the responsibility to do what was right under the circumstances, but it was unfair to them. Because of the institutional context, they were in a position where any choice they made would be hurtful in some way. A satisfactory resolution of this case, therefore, would have to include more than a prescription for how Wayne and Deborah should have acted. It must include an analysis of how the organizational context in which they operate should change to enable and support ethical action.

Robert N. Bellah and his associates, in The Good Society, 45 have written about the importance of institutions in our moral life:

It is tempting to think that the problems that we face today, from the homeless in our streets and poverty in the Third World to ozone depletion and the greenhouse effect, can be solved by technology or technical expertise alone. But even to begin to solve these daunting problems, let alone problems of emptiness and meaninglessness in our personal lives, requires that we greatly improve our capacity to think about our institutions. We need to understand how much of our lives is lived in and through institutions, and how better institutions are essential if we are to lead better lives....We Americans tend to think all we need are energetic individuals and a few impersonal rules to guarantee fairness; anything more is not only superfluous but dangerous–corrupt, oppressive, or both....It is hard for us to think of institutions as affording the necessary context within which we become individuals; of institutions as not just restraining but enabling us; of institutions not as an arena of hostility within which our character is tested but an indispensable source from which character is formed. 46

Institutions embody and perpetuate the values of those who shape them. If those values are harmful, like carelessness and greed, the institution will be destructive, and will frustrate the efforts of those within and around it to do what is right. On the other hand, if those values are good, the institution by its normal operation will bring about much good, and will make it much easier for its members to be ethical.

Institutions do not just happen. They are the result of human choices. Ultimately we are responsible for them. Our ethical obligations are not just to act ethically in whatever situation we find ourselves, but to build ethical institutions. This means institutions that are fair, that respect human dignity and freedom, and whose purpose is to achieve some good in whatever domain they operate in. This may seem like an impossible task. The institutions are too large and powerful, and we have so little influence on them. That is true if we think ourselves only as isolated individuals. But that is where our thinking needs to change, as Bellah and his coauthors point out. Institutions are powerful because they can mobilize purposeful, organized, collective action. It takes purposeful, organized, collective action to change them. That is part of our ethical responsibility.

It is not always enough, then, for ethics to evaluate individual judgements and actions. It must also step back and examine the social and institutional context in which ethical issues arise, and to ask how that context needs to be changed to enable and support ethical behavior.

Next " Summary: Part 8 "

• Trudy E. Bell and Karl Esch, "The Fatal Flaw in Flight 51-L," IEEE Spectrum, Vol. 24, No. 2, February, 1987, p. 49. ^
• ibid, p. 51. ^
• John G. Simon, Charles W. Powers, and Jon P. Gunnerman, The Ethical Investory: Universities and Corporate Responsibility, New York: Yale University Press, 1972. ^
• Ibid, p. 24. ^
• See, for example, Alan F. Westin (ed.), Whistle-blowing: Loyalty and Dissent in the Corporation, New York: McGraw-Hill, 1981. ^
• Robert N. Bellah, Richard Madsen, William M. Sullivan, Ann Swidler, Steven M. Tipton, The Good Society, New York: Alfred A. Knopf, 1991. ^
• ibid, pp. 5f. ^

Author: Michael McFarland, S.J., a computer scientist, is the former president of College of the Holy Cross and was a visiting scholar at the Markkula Ethics Center. June 2012.

Originally published by the Markkula Center for Applied Ethics.

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This material is based upon work supported by the National Science Foundation under Award No. 2055332. Any opinions, findings, and conclusions or recommendations expressed in this material are those of the author(s) and do not necessarily reflect the views of the National Science Foundation.

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University Module Series: Integrity & Ethics

Module 12: integrity, ethics and law.

  This module is a resource for lecturers  

Case studies.

Choose one or more of the following case studies and lead a discussion which allows students to address and debate issues of integrity, ethics and law. If time allows, let the students vote on which case studies they want to discuss.

For lecturers teaching large classes, case studies with multiple parts and different methods of solution lend themselves well to the group size and energy in such an environment. Lecturers can begin by having students vote on which case study they prefer. Lecturers could break down analysis of the chosen case study into steps which appear to students in sequential order, thereby ensuring that larger groups stay on track. Lecturers may instruct students to discuss questions in a small group without moving from their seat, and nominate one person to speak for the group if called upon. There is no need to provide excessive amounts of time for group discussion, as ideas can be developed further with the class as a whole. Lecturers can vary the group they call upon to encourage responsive participation.

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Speaking Up: Veterinary Ethical Responsibilities and Animal Welfare Issues in Everyday Practice

Elein hernandez.

1 Department of Pathobiology, University of Guelph, Guelph, ON N1G 2W1, Canada; ac.hpleugou@niele (E.H.); ac.hpleugou@rewuorbe (E.B.)

Anne Fawcett

2 Sydney School of Veterinary Science, University of Sydney, Camperdown, NSW 2006, Australia; [email protected]

Emily Brouwer

3 Department of Population Medicine, University of Guelph, Guelph, ON N1G 2W1, Canada; ac.hpleugou@uaraj

Patricia V. Turner

Simple summary.

Veterinarians have an ethical obligation to provide good care for the animals that they see in practice. However, at times, there may be conflicts between the interests of animal caregivers or owners, the interests of veterinarians and the interests of animals. We provide an overview of why and how veterinary ethics is taught to veterinary students, as well as providing a context for thinking about veterinary ethical challenges and animal welfare issues. We argue that veterinarians are ethically obliged to speak up and ask questions when problems arise or are seen and provide a series of clinical case examples in which there is scope for veterinarians to improve animal welfare by ‘speaking up’.

Although expectations for appropriate animal care are present in most developed countries, significant animal welfare challenges continue to be seen on a regular basis in all areas of veterinary practice. Veterinary ethics is a relatively new area of educational focus but is thought to be critically important in helping veterinarians formulate their approach to clinical case management and in determining the overall acceptability of practices towards animals. An overview is provided of how veterinary ethics are taught and how common ethical frameworks and approaches are employed—along with legislation, guidelines and codes of professional conduct—to address animal welfare issues. Insufficiently mature ethical reasoning or a lack of veterinary ethical sensitivity can lead to an inability or difficulty in speaking up about concerns with clients and ultimately, failure in their duty of care to animals, leading to poor animal welfare outcomes. A number of examples are provided to illustrate this point. Ensuring that robust ethical frameworks are employed will ultimately help veterinarians to “speak up” to address animal welfare concerns and prevent future harms.

1. Introduction

Expectations for appropriate animal management exist in most developed countries and provide the scaffolding supporting societal expectations for veterinary care of animals. Although veterinarians are assumed to be working in the best interests of animals at all times, in reality, this may depend upon the willingness and ability of any given veterinarian to engage in ethical reasoning and openly question accepted practices that occur routinely with animals or that they may be asked to do. In this paper, we explore the importance of strong ethical training of veterinarians as a means of ensuring good animal welfare in a given society. We also present a series of case examples in which veterinary advocacy and ethical decision-making may or may not have occurred to demonstrate common ethical issues in veterinary practice.

2. Ethics in Veterinary Education

2.1. why is ethics taught.

Veterinary ethics teaching and application in practice have changed considerably over the past decade. When it was first formally taught, veterinary ethics dealt mostly with aspects of professionalism, for example, how to refer cases, issues around steering and advertising—what Rollin called matters of “professional etiquette” [ 1 ]. Ethical questions around euthanasia decision-making (for example, is it ever acceptable to euthanize a healthy animal?) were not examined [ 2 ].

Since then, the teaching of veterinary ethics has expanded. Ethics is now included in most veterinary curricula, not least because it is an expected Day One Competency for veterinary graduates. For example, in its Day One Competencies, the UK’s Royal College of Veterinary Surgeons states that new graduates should be able to “understand the ethical and legal responsibilities of the veterinary surgeon in relation to patients, clients, society and the environment” and have underpinning knowledge and understanding of “the ethical framework within which veterinary surgeons should work, including important ethical theories that inform decision-making in professional and animal welfare-related ethics” [ 3 ].

There is scope for further development and refinement of veterinary ethics teaching. A joint report of the Federation of Veterinarians of Europe (FVE) and the European Association of Establishments for Veterinary Education (EAEVE) called for more uniform, comprehensive teaching of animal welfare, ethics and law across veterinary schools, stating that “one cannot be a good clinician without being aware of the ethical issues in decision-making in practice” [ 4 ]. European Directive 2005/36/EC states that ethics is a core subject of veterinary education, without providing clear competencies for students to achieve in this area [ 5 ]. In its revised Principles of Veterinary Medical Ethics, the Canadian Veterinary Medical Association called for veterinary schools to “stress the teaching of ethical and value issues as part of the professional curriculum for all veterinary students” and for the National Board of Veterinary Medical Examiners to “prepare and include questions regarding professional ethics in the North American Veterinary Licensing Examination (NAVLE)” [ 6 ].

The North American Veterinary Medical Education Consortium (NAVMEC) identified ethics as a core component of leadership, as well as an emerging area of concern for veterinarians, stating that “(veterinarians) are committed to the health and welfare of animals and the protection of human health through ethical practice, professional self-regulation, legal compliance and high personal standards of behaviour and practice. They are guided by a code of ethics and law and a commitment to professional competence, appropriate attitudes and behaviour, integrity, personal well-being and the public good” [ 7 ]. NAVMEC has called for colleges of veterinary medicine to create and update course materials on ethics and leadership for use in and sharing among, veterinary schools. The report also identifies the need for “increasing awareness on ethical issues, including genetic modification” [ 7 ]. Similarly, the World Organisation for Animal Health (OIE) recommends that veterinary education establishments “… teach ethics and value issues to promote high standards of conduct and maintain the integrity of the profession” [ 8 ]. The OIE states that Day 1 veterinary graduates should “understand and apply high standards of veterinary medical ethics in carrying out day-to-day duties” and “provide leadership to society on ethical considerations involved in the use and care of animals by humans” [ 8 ]. In a study of veterinary educators examining why ethics was taught, four major themes emerged: ethical awareness, ethical knowledge, ethical skills and developing individual and professional qualities [ 9 ]. Ethical skills, including ethical reasoning and reflection, value-aware communication skills and informed decision-making skills may be taught to help reduce moral stress [ 10 ].

2.2. How Is Veterinary Ethics Taught?

In a discussion of how ethics should be taught to veterinary students (alongside animal welfare science and law), Main and colleagues suggest exposing students to a range of ethical frameworks, including utilitarianism, deontology, rights-based theories, virtue ethics, principle-based ethics and social justice, as well as examination of value systems, alternative views, conflict resolution and decision-making processes [ 11 ].

Ethical reasoning is not simply learned by a process of repeated exposure to ethical issues [ 12 ]. It remains unknown to what extent the teaching of ethics to veterinary students enables them to minimise or avoid moral stress. There is no accepted gold standard for veterinary ethics education and curricula vary, with ethics taught as a standalone subject in some programs and integrated into other subjects in other programs [ 13 , 14 ].

In a review of published European veterinary curricula, the amount of ethics teaching was variable, as was its contextual framing and where it appeared in the curriculum [ 4 ]. An in-depth study of ethics teaching was conducted in three European veterinary schools (Copenhagen, Lisbon and Nottingham). Prominent topics taught were classified under four overarching concepts: theories and concepts (including ethical frameworks and approaches), laws and regulations (including codes of conduct), animal welfare science and professionalism [ 15 ]. All three schools taught students one or more ethical theories or frameworks to aid decision making. Similar variability in ethics instruction has been noted in North American veterinary colleges. In a 2011 survey of veterinary colleges in Canada, the USA and the Caribbean, only 62% of responding colleges (13 of 21) indicated that ethics was a core component of the curriculum and a mean of 15.5 h of ethics instruction occurred over the curriculum. Further, only 33% (7 of 21) of colleges indicated that students were formally assessed for ethical knowledge and decision-making [ 13 ].

Animal welfare and ethics scholars from eight Australasian veterinary schools developed the One Welfare Portal ( http://onewelfare.cve.edu.au/ ), a shared online curriculum resource incorporating a range of interactive features, including case-based scenarios with guided ethical discussion [ 16 ]. The resource includes eight subsections, agreed upon by animal welfare and ethics educators on animal welfare science, ethics, companion animals, production animals, wild animals, animals used in research and teaching, animal use within sport, recreation and display and aquatic animals [ 13 , 14 , 15 , 16 ]. It incorporates a virtual online debating platform to facilitate student discussion of potentially polarising topics [ 17 ].

The global charity World Animal Protection developed a welfare and ethics syllabus and teaching resource, designed to be used globally [ 18 ]. This resource incorporates discussion of five ethical frameworks or approaches: contractarianism, utilitarianism, deontology, ethics of care and respect for nature [ 19 ]. Other online tools include www.aedilemma.net , an interactive learning tool that allows users to determine whether their ethical reasoning is most consistent with contractarian, utilitarian, relational, animal rights or respect for nature ethical frameworks and approaches [ 20 ]. It is not known to what extent such online resources are formally embedded into veterinary school curricula.

Key ethics textbooks, as well as regular columns such as In Practice’s Everyday Ethics column and the ethical question of the month in the Canadian Veterinary Journal, tend to apply ethical frameworks and approaches to case-based scenarios and are useful ethics training tools for veterinary students and veterinarians alike [ 1 , 21 , 22 ].

One of the challenges of providing veterinary students with multiple frameworks in a didactic setting is that they may not have time to become properly acquainted with the strengths and limitations of each approach. Additionally, by critiquing every framework and approach, students may develop the impression that all have flaws and that ethics is therefore no more than opinion, leading to disenchantment [ 10 ]. Ethical frameworks should not be looked at as being in competition, rather they are complementary [ 14 ]. A comparison of the relative strengths and weaknesses of commonly taught ethical frameworks with an interpretation of the veterinarian’s responsibility to “speak up” are presented in Table 1 .

Strengths and limitations of key ethical frameworks and approaches taught to veterinary students and an interpretation of how “speaking up” may be conceived according to each framework or approach. Adapted from Mullan and Fawcett [ 21 ].

Extracurricular activities, such as participation in the annual Intercollegiate Animal Welfare Judging and Assessment Contest, open to veterinary students and licensed veterinarians, may help to strengthen student and practitioner ethics and welfare vocabulary and reasoning skills [ 25 ]. Participants have the opportunity to assess the welfare of animals in different contexts and settings, including live animal scenarios, weigh evidence and develop scientifically-based evaluations. This requires veterinary students and practitioners to integrate science-based knowledge about animal husbandry and preferences with ethical values [ 25 ].

3. Understanding Veterinary Ethical Challenges and Animal Welfare Issues

Veterinary oaths and professional codes of conduct highlight the obligations of veterinarians to animals, clients, colleagues, the wider community, and, increasingly, themselves. For example, the Canadian Veterinary Medical Association oath states that “veterinarians will use their knowledge and skills for the benefit of society, promote animal health and welfare and relieve suffering, protect public and environmental health and advance comparative medical knowledge, whilst improving their own knowledge and competence and upholding the standards of the profession” [ 5 ]. Similarly, the UK’s Royal College of Veterinary Surgeon’s Code of Professional Conduct for Veterinary Surgeon’s outlines veterinarian’s responsibilities to animals, clients, the profession, the veterinary team, the RCVS and the public [ 26 ].

According to the Canadian Veterinary Medical Association’s principles, veterinarians must practice “within their own area of competence” (III Professional Responsibilities, III.A.4) and “report to the appropriate authority any unprofessional conduct by colleagues” (III.C. Veterinarians’ responsibilities to the profession, 3) [ 6 ]. In Canada, where animal welfare oversight is largely enforced at a provincial level, both provincial legislation as well as provincial veterinary licensing bodies contain similar requirements for veterinary reporting [ 27 , 28 ].

Yet these principles may be challenged in practice and it is not always clear to the veterinarian where their responsibilities lie. For example, a veterinarian who is instructed that cases must be dealt with as far as possible “in-house” may be reluctant to refer, or one whose employer struggles with addiction that impairs his or her performance may be fearful of ramifications for reporting unprofessional conduct. Indeed, there may be little guidance as to how to act in such a case. For example, the Australian Veterinary Association’s Code of Professional Conduct (currently under review) states that “Veterinarians who become aware of misconduct, or unprofessional or discreditable conduct by a colleague should take such action as seems appropriate in the circumstances” [ 29 ].

3.1. Ethical Decision-Making in Veterinary Practice

One of the key areas of conflict in veterinary practice is conflict between the interests of the animal or patient and the interests of the client, who typically is paying for treatment. In most jurisdictions, the animal is legally the property of the owner. Therefore, an owner may request humane killing of an animal with a treatable condition. Should the veterinarian proceed with the request even if they disagree? Or should she take a role as patient advocate. This is what Rollin calls the “fundamental question of veterinary ethics”: “to whom does the veterinarian owe primary obligation: owner or animal?” [ 1 ].

The veterinarian’s actions can fall into what Rollin refers to as either the garage mechanic or the paediatrician model, based on the moral value of the animal. In the garage mechanic or human-centred (anthropocentric) model, the animal’s needs are not directly taken into consideration. Conversely, a veterinarian in the paediatrician model would primarily look after the well-being of the animal and discuss potential ethical concerns with the owner.

Many veterinarians claim to follow the paediatrician model [ 1 , 30 ]; however, they may fail to truly advocate for animal welfare in practice [ 31 ]. Veterinarians embedded within certain animal production industries may find it particularly challenging to separate their ethical obligations to animals from their professional responsibilities to the corporation within which they are employed.

Another question is whether ethical dilemmas are common in veterinary practice. A true ethical dilemma arises when veterinarians have competing responsibilities with no obvious way to prioritise one over the other [ 32 ]. In addition, a more controversial definition of an ethical dilemma is when there is a clear ethical choice but it is challenging to execute due to contextual factors (i.e., client interests) [ 32 ]. In reality, many ethical dilemmas are “solved” by prioritising the interests of the client over the interests of the animal. This is facilitated by legislation that reinforces the status of animals as property, without equivalent legal (and by extension, moral) standing to humans. If animals had equal legal and moral standing, it would be difficult to justify their use, for example, as sources of food or fibre.

Veterinary decisions can also be driven by personal ethical viewpoints that may vary according to the type of client-veterinarian relationship. In human and veterinary medicine, patient-clinician relationships have generally moved from a paternalistic (clinician is responsible for all-decision making) towards a shared decision-making model. This can be challenged by the degree of involvement from the client and also the increased awareness and expectations from formally and informally (i.e., internet) educated clients [ 33 , 34 ].

Regardless, there are numerous ethical issues that arise in practice that create moral stress. Moral stress is defined as “the experience of psychological distress that results from engaging in, or failing to prevent, decisions or behaviours that transgress, or come to transgress, personally held moral or ethical beliefs” [ 35 ]. Several studies have found that killing of healthy animals, euthanasia of sick animals, dealing with clients with financial limitations and being asked to continue treatment when the veterinarian believes that euthanasia is indicated are all experienced as stressful situations by veterinarians [ 36 , 37 , 38 ].

Some of the above-mentioned issues could be the result of poor communication skills in veterinary practice. The latter is a well-recognized problem in human medicine with lesser or greater degree of professional health care consequences including malpractice claims. During stressful and complex situations, clients look for professional medical and non-medical advice, in which the veterinarian usually plays an authority figure. In addition, the increasing and rapidly changing position of companion animals as family members further accentuates the veterinarians’ responsibilities towards the animal and the client’s well-being and needs [ 34 , 39 ]. Chronic medical cases can be especially challenging. Clients may have been willing to have their family pet undergo weeks to months of expensive therapy or therapy with challenging side effects in the hopes of effecting a cure. They may find it difficult to accept the point at which a condition changes from being potentially curable to being definitely incurable. Sometimes veterinarians may feel responsible, in part, for the downturn in an animal’s condition, because a treatment did not work as hoped for a particular patient. As a result, they may be reluctant to make further recommendations for other treatments or euthanasia, despite having proceeded in the case using their best knowledge and skills to manage the condition. It may also be challenging to make further recommendations to a client who is lashing out because of grief over the impending loss of a beloved pet. There are many ethical parallels between these types of veterinary ethical dilemmas and parental acceptance of terminal illnesses in human paediatric patients [ 40 ].

Veterinarians may be concerned about speaking up about ethical medical concerns for fear of offending or alienating the client, for concerns about potential ramifications for their employment or because of conflicts of interest. In addition, lack of ethical literacy may impact their ability to articulate or justify their concerns [ 9 ]. On the other hand, veterinarians who fail to speak up risk being accused of weak morality or being complicit in animal welfare problems [ 33 ]. In recent years, curricular changes in veterinary teaching programs and continuing education offerings have been made to address some of these issues but the impacts of these interventions (for example, on the moral reasoning abilities of veterinary graduates) are yet to be seen [ 41 ]. Communications skills are usually an informal practical experience that can be difficult to assess or include in the curricula but they are the highlight of a good client-veterinarian relationship [ 34 , 42 ].

To circumvent being blamed for poor case outcome and to side-step being labelled as paternalistic, some veterinarians may avoid providing an opinion on which treatment approach they would recommend. Instead, they present a menu of treatment options to the client and then stand back to allow the client to select their preference. This “vending machine medicine” approach [ 38 ] provides the client with complete autonomy in decision-making but it also allows the veterinarian to avoid their professional responsibilities to the patient—an animal possibly with a declining state of well-being. While it may be true that the ultimate decision for care rests with the client, clients often seek guidance and support from the veterinarian when faced with difficult decisions, and, in fact, may expect veterinarians to exert their Aesculapian authority in these situations [ 43 , 44 ]. It has been suggested that the veterinarian must be highly attuned to the client needs and be able to balance the client’s individual preference for decision autonomy, shared decision-making and decision delegation in determining patient outcome [ 45 ]. However, in countries in which there is no legal framework for veterinarians to intervene to prevent terminal suffering of an animal, the patient’s welfare must remain a foremost consideration of the veterinarian and the veterinarian may be morally obligated to attempt to influence client decisions [ 44 ].

Inevitably, these cases can be stressful for the veterinarian as well as the client. There is little research on the efficacy of interventions in reducing moral stress; however, gathering evidence and speaking up or communicating concerns have been suggested to be beneficial in the human medical literature [ 21 , 46 , 47 ].

3.2. Ethics and Animal Welfare in Veterinary Practice

Animal welfare is a multidisciplinary science and researchers, veterinarians, clients, producers, consumers, politicians and others commonly use the term to describe the states that they hope to optimize in animals. Despite common usage of the term, there is no standard definition since animal welfare can be studied from different, overlapping approaches (for example, biologic function, affective state and ability to live naturally) and the definition will largely depend upon individual values and the emphasis placed on each of these three parameters [ 48 ]. When a commitment to uphold high standards of animal welfare is put into practice, the veterinary team has the potential to play an important role in animal advocacy and if there is a mature understanding of these concepts, they also have the ability and ethical imperative to be aware of and identify other human-animal interests. Rollin [ 1 ] describes animal welfare as “what we owe animals and to what extent” but also emphasizes the important role of veterinarians in ensuring good animal welfare by indicating, “… it is the natural ethical responsibility of the veterinarian to lead in putting animal welfare into practice.”

Despite similar biologic function and life interests of animals, the degree to which animal welfare is given consideration depends upon the species, purpose (e.g., production, research, companion, entertainment, etc.), local regulations, client, veterinary practitioner and individual religious and cultural values. Professional veterinary medical training provides veterinarians and veterinary technicians with tools for providing medical care, and, increasingly, include those needed for identifying and assessing animal welfare risk factors [ 13 ]. Yeates describes this role of veterinary oversight of animal welfare as a key veterinary privilege [ 49 ].

In many developed countries, there are four primary forms of guidance that veterinarians use to inform their standards of practice, including the advice and expectations related to animal welfare conveyed to clients and patients at the individual and herd or group level. These are found (i) in the legislative and regulatory requirements for a particular animal or animal-related industry in a given jurisdiction, (ii) general and specific veterinary professional standards and guidance documents, (iii) generally accepted animal husbandry practices and (iv) livestock industry animal welfare assurance programs. These will be each be discussed in more detail in the following paragraphs.

The legal requirements for good stewardship of animals, such as those promulgated by the OIE, European Food Safety Authority (EFSA), U.S. Department of Agriculture (USDA), etc., are a reasonable starting point for ensuring good animal welfare, as these regulations are generally reflective of societal expectations for basic animal care. In many countries, federal and state or provincial animal health, welfare and transport acts and regulations dictate the minimum expectations for animal care. For food animal species, many of these regulations extend beyond the farm gate. As such, food and production animal veterinarians need a full understanding of all aspects of the production, transportation and marketing systems in which their clients and patients are found to be able to provide comprehensive advice and education to ensure good animal welfare during all phases of an animal’s life.

Beyond federal and state/provincial laws and regulations, professional standards for veterinarians are set through national, provincial and local veterinary associations and statutory licensing bodies. Most licensing bodies in developed countries require veterinarians to actively participate in continuing education (also known as continuing professional development or CPD) as a condition of licensure (e.g., see the RCVS policy on continuing professional development, https://www.rcvs.org.uk/lifelong-learning/continuing-professional-development-cpd/ ). Animal welfare is increasingly present as a theme in veterinary conferences, journals and discussion fora. Professional standards and expectations with respect to animal welfare reflect a peer-reviewed and evidence-based approach to considerations of aspects of veterinary medicine including animal welfare and ethical decision-making (for example, the American Veterinary Medical Association Guidelines on Euthanasia) [ 50 ].

In terms of nationally accepted animal husbandry practices, there may be published national standards, such as those produced by the Canadian Veterinary Medical Association (CVMA), i.e., the CVMA Kennel Code and Cattery Code, which cover general husbandry expectations for these companion animals [ 51 , 52 ]. These documents are used to establish standards for husbandry and care of dogs and cats in boarding kennels, shelters, pet stores and other places. Plans are underway at the CVMA to develop a code of care for small mammal species, such as rabbits and ferrets. For large animal species, the National Farm Animal Care Council (NFACC) in Canada has published Codes of Practice for the care and handling of 15 different food or fur-bearing animal commodity groups, as well as a general transportation standard [ 53 ]. These codes have been developed in consultation and cooperation with livestock industry stakeholder groups, including scientific advisory committees, farmers and food industry representatives, animal welfare advocacy groups and government representatives. Such codes provide an agreed upon set of standards for animal husbandry and while adherence to them is voluntary, the codes have been used to enforce charges for animal welfare violations in some provinces.

Assessment drives change and ensures adherence to accepted practices of care, thus more mature animal welfare oversight programs include an assessment tool to permit benchmarking of progress. In Canada, NFACC has also developed and published a framework for animal care assessment from which livestock commodity groups can develop animal care assessment tools and programs. Many of the Canadian livestock commodity groups have adopted the species-specific codes as standards and have begun the process of adoption and implementation of animal care assessment programs. Many USA and Canadian livestock commodity groups also have self-mandated quality assurance programs that include animal welfare components, such as the Dairy Farmers of Canada Canadian Quality Milk Pro-Action Program and the Pork Quality Assurance Plus program in the U.S.A. [ 54 , 55 ]. Veterinary awareness and participation in these programs is mandated and the programs require training and ongoing communication between veterinarians and their clients to ensure consultations with producers. The goal of most of these programs is to establish, then meet and exceed animal care and welfare program benchmarks, by using both on-farm animal-based measures and evaluation of standard operating procedures and records related to appropriate mature and immature animal care and comfort, health and behavioural monitoring, culling procedures and on-farm euthanasia. Industry-led assessment and assurance schemes are not currently available for companion animal care and many other animal-related businesses (e.g., rodent breeding operations for reptile feeding, aviary breeders for the pet trade, etc.) as well as various animal holding facilities (e.g., exotic animal sanctuaries and private roadside zoos), except through specific veterinary clinic accreditation schemes (e.g., the American Animal Hospital Association (AAHA) [ 56 ]. For these species, there may be more of a reliance on general quality of life and physiologic measures for welfare assessment, as well as a post factum review of forensic evidence in more egregious animal abuse and neglect cases [ 57 ].

Where they exist, animal regulatory frameworks, a clear understanding of acceptable animal husbandry practices, nationally accepted peer-reviewed standards of animal care and animal welfare assessment schemes all provide a strong sense of acceptable animal care and veterinary practice standards for veterinarians and their clients; however, these are only theoretical frameworks. To truly and positively impact animal welfare in the long run and meet societal expectations for the profession, the veterinarian must combine this knowledge with their ethical obligations to animals and actively speak up and ask questions when they observe or suspect that animal well-being is compromised.

4. Failure to Meet Animal Welfare Needs

Developing useful welfare guidance documents and schemes and then actively engaging clients in discussion, education and implementation of these legal and voluntary standards and available animal welfare assurance programs are ongoing, evolving and necessary processes. For reasons mentioned previously, despite exposure to these various tools during veterinary medical training, veterinarians may not always act on their knowledge and in the best interests of animals in their care. When interviewed about processes underlying medical decision-making, veterinarians frequently admitted to making decisions about their clients that were unspoken and that could adversely impact animal welfare [ 31 ]. This included classifying clients as ‘good’ or ‘bad’ in terms of willingness to pursue treatments or make payments, as well as holding perceptions about whether clients could afford certain therapies or techniques for their animals, such as analgesia. Thus, if the veterinarian judged that the client could not afford analgesia or would not wish to pay for it, analgesia was not offered, thereby depriving the client the opportunity to elect analgesia use [ 58 ]. Limiting disclosure of options because of client categorization can both limit client care of their animals and the veterinarian’s ability to promote animal welfare [ 40 ]. It can also be profoundly uncomfortable to ask difficult and sensitive questions related to possible neglect of an animal, particularly of longstanding and trusted clients and may result in ‘emotional blocks’ or cognitive dissonance within the veterinarian [ 58 ].

In a large veterinary referral or teaching hospital with both small and large animal capabilities or at a multispecies livestock auction, it is common to observe on a near daily basis instances of animals suffering from poor welfare and for which poor decisions have been made by clients, their veterinarians or both. The true prevalence of these types of issues is unknown, since there is rarely open discussion about welfare failures within the veterinary literature and these would need to be considered against a denominator of all client cases treated. Almost all of these cases are preventable, although the etiology of each problem may be slightly different. Note that there is no single and correct framework for approaching such cases, as each must consider the needs of the animal and the context in which the case is presented. The following represent examples of different root causes resulting in poor animal welfare. These cases were selected for their complexity and apparent challenging translation of veterinary ethics theory into practice. These cases are not representative of all types of ethical challenging situations in veterinary medicine but we have tried to cover a range of possible areas of ethical conflict, such as those seen in companion and food animal practice and exotic animal sanctuary medicine.

4.1. Example 1: Poor Food Animal Transportation Decision

In this case, a severely lame cull cow, as depicted in Figure 1 , was transported from a farm to a livestock sales barn. In most developed countries, severely lame cattle are considered to be unfit for transport, save for the purpose of seeking veterinary medical treatment (for example, Livestock Transport Requirements [ 59 ]). This is because it is accepted that transportation of severely lame cattle through normal production channels (i.e., to livestock auctions or slaughter facilities) has reasonable potential to cause undue pain and suffering, further compromising individual animal welfare.

Severely lame dairy cow in very poor body condition presented at a livestock sales barn.

Livestock sales and their associated regulations are observed and enforced, respectively, by regulatory veterinarians with responsibilities for segregating, inspecting and making decisions about animals that arrive and are deemed to be compromised. In this case, the cow was unloaded at the sales barn and found to be severely lame and non-weight bearing on her right hind leg. The cow was segregated by sales barn staff for veterinary inspection. The regulatory veterinarian determined that the cow was dull, extremely thin, reluctant to move, unable to keep up with a group of conspecifics, moderately lame in her left hind and right front limbs with severe swelling of her right carpus and non-weight bearing in her right hind limb while standing. The cow was euthanized and submitted for post-mortem examination to investigate the cause of the lameness and to offer insight into the chronicity of any causative lesions. Post-mortem examination of this cow revealed severe, chronic bilateral digital dermatitis and marked heel horn erosion in the hind feet. Of note, digital dermatitis is part of a spectrum of, mostly treatable, hoof lesions in cattle [ 60 ].

This case represents an example of how on-farm decisions can have serious consequences for animal welfare well beyond the farm-gate. On-farm preventive medicine, lameness identification and treatment protocols, as well as culling decision procedures, all developed in consultation with the herd veterinarian and properly implemented, could have prevented this cow from developing severe lameness and poor body condition and being transported off the farm.

Veterinary involvement in the enforcement of federal and provincial regulations worked to limit further suffering at the sales barn. While the exact reasons underlying the decision to transport this cow are unknown, this example highlights a need for the herd veterinarian to provide more support on-farm. Animal transportation is a complex issue because of possible conflict between the veterinarian’s recommendations and producer’s interests as well as the availability of suitable methods for on-farm euthanasia and the cost of animal disposal [ 61 ]. Despite this, veterinarians are an integral member of the livestock production, health and welfare team and they should be strongly grounded in the ethics of care ( Table 1 ) and they can provide resources to clients to assist them with better animal management practices ( Figure 2 ). The outcome in this particular case demonstrates how the veterinary-client relationship failed. Improved communication and veterinary involvement in on-farm ethical decision-making could have significantly reduced the impact of disease on animal welfare.

Example of guidelines available to assist producers and veterinarians with decisions surrounding animal transportation [ 62 ].

4.2. Example 2: Animal Neglect

A nine-year-old Amazon parrot was presented to a referral hospital for a second opinion regarding chronic non-union fractures incurred several months previously. Following an unknown injury, the fractures were treated by another veterinarian using body bandages. When collecting the history, the client indicated that the bird used to fly in the house and they were concerned that the bird could no longer fly or ambulate properly since the injury. Radiographs performed by the tertiary care veterinarian identified several non-union fractures in the pelvis and limbs, as well as evidence of serious metabolic bone disease in the femurs, tibiotarsi and synsacrum with major skeletal abnormalities that likely contributed to the inability to ambulate. The bird was euthanized and the presence of multiple healed and unhealed fractures and other chronic bone deformities that likely arose secondary to metabolic bone disease were confirmed at post-mortem ( Figure 3 ). The report noted that similar injuries in other birds are commonly associated with marked pain.

Chronic clockwise deviation of the pelvis and sacrum and multiple chronic rib fractures ( left ); Chronic non-union mid-diaphysis fracture of the left tibiotarsus with firm callus and chronic non-union fracture of the proximal metaphysis of the right femur and tibiotarsus ( right ).

Metabolic bone disease is common and treatable condition in birds receiving inappropriate diets and, if untreated, can lead to bone deformities and fractures, as in this case [ 63 ]. Based on information received from the referring and tertiary care veterinarians there was a sense that the client was unable to pay for expensive treatments but there was also no indication that either had questioned the client in-depth about the bird’s diet or about how the multiple fractures had been incurred. Veterinary and medical care can often be influenced by tunnel vision or decision-making biases, in which the client and veterinarian focus on diagnosing and treating a specific injury and lose sight of the overall prognosis or presence of intercurrent disease [ 64 ]. Veterinarians rely heavily on the history provided by the client as well as on physical examination findings and these must always be placed in context with their knowledge of common conditions of any given species. Regardless of the bond or level of commitment that a veterinarian may feel that a given client has towards an animal, they should not assume that the client is aware of how best to meet an animal’s needs, even in the face of longstanding ownership. There is an increasing awareness of animal welfare issues associated with exotic companion animals, largely related to the client’s lack of knowledge about appropriate care, husbandry and needs of these animals [ 64 , 65 , 66 ]. From a virtue ethics framework ( Table 1 ), the referring veterinarian could have asked specific questions about the diet and husbandry of the bird and provided information about appropriate nutritional and husbandry needs, in addition to instituting appropriate treatment and follow-up for the fractures. By not speaking up, the veterinarian contributed to ongoing negligence and this potentially treatable condition went unrecognized for many years, culminating in significant animal suffering. Potential and disturbing questions about animal neglect and abuse were also not investigated by either veterinarian for reasons unknown.

4.3. Example 3: Economic Decisions Impacting Animal Welfare

An aged female rat was presented to a newly hired veterinarian in an exotic animal clinic for a perineal mass that the client indicated had appeared only one week prior. Due to financial constraints, it was reported that the owners elected to pursue surgical debulking of the mass without further diagnostics. The owners brought the rat back to the veterinarian one month after the initial surgery, as the mass had regrown and had ulcerated ( Figure 4 ). On physical examination, the rat was in poor body condition and had a large irregular perineal mass. Diagnostic testing was declined and the rat was euthanized. Subsequent post-mortem and microscopic follow-up indicated that the mass consisted of a rapidly growing and invasive vaginal leiomyosarcoma.

Dorsal view of a perineal mass in a mature female pet rat ( left ); Ventral view of ulcerated perineal mass in the same rat ( right ).

In this case, by trying to provide an inexpensive solution to satisfy the client and not taking into full consideration the circumstances of the animal, the veterinarian inadvertently created a more significant welfare problem and unnecessarily prolonged the suffering of this rat. While resulting in a short-term, cost effective and aesthetically acceptable solution, superficial debulking of a tumour without knowing the type of tumour that was present and whether adequate surgical margins were achieved was unnecessarily risky. When electing any type of empirical treatment, the client must be informed of all potential outcomes. In this case, the potential for a poor outcome due to the presence of a rapidly growing mass in a geriatric animal and in a location with significant potential for impairing normal bodily functions together with the client’s significant financial constraints should have been used to make a recommendation for euthanasia based on a utilitarian framework and the potential for animal suffering as a result of surgery and potential for tumour recurrence. The underlying reasoning of the veterinarian in the case is unknown. It could also be argued that the veterinarian was in a conflict of interest situation in that they were in a position to gain more financially from performing the surgery or that they were interested in increasing their service caseload, clinical skills or clinical reputation. Veterinarians must be prepared to speak up and provide advice to clients that is in the best interests of the animal regardless of whether they would prefer to attempt a different treatment approach. In addition, the veterinarian could have consulted with a veterinary colleague as to the most appropriate course of action and should have disclosed the necessity for pursuing further diagnostics to the client [ 43 , 67 ]. When clients are financially constrained (or appear to be so), as in this case, the consequences of proceeding with further treatment without the benefit of appropriate diagnostic insight must be carefully weighed against the potential for the animal to incur more significant harms. This should be a common means of influencing the decision-making process for clients and veterinarians when dealing with cancer patients [ 68 ]. Suboptimal evaluation of animals with cancer, as in this case, can be problematic.

4.4. Example 4: Inability of the Client to Accept a Poor Quality of Life

A 14-year-old spayed female American Bulldog was under the care of a veterinarian at a primary clinic for chronic osteoarthritis and a large ulcerated and necrotic cutaneous mass on the shoulder of many months duration. For reasons not specified in the history, the client and the veterinarian did not pursue biopsy or staging, or analgesia and instead, the client elected to cover the thorax with a t-shirt. The dog was referred to a tertiary care centre because the mass continued to ‘split open’ and ultimately, the dog was euthanized due to poor quality of life concerns. The dog was submitted for post-mortem examination and was noted to be wearing a blue t-shirt that was heavily stained with malodorous fluid ( Figure 5 ). When the t-shirt was removed, a large and markedly necrotic mass was present within the skin and subcutaneous tissues of the left shoulder. Histologic examination identified this tumour as a grade II soft tissue sarcoma, with no evidence of metastatic disease. Degenerative joint disease was noted in the right coxofemoral joint and several other previously undiagnosed and unrelated tumours were detected in other organ systems.

Lateral view of the dog with the t-shirt on demonstrating staining from the underlying necrotic mass ( left ). T-shirt removed and the large ulcerated mass revealed ( right ).

While the mass and associated wound in this case were not lethal in nature, the chronic festering quality would have contributed to long term discomfort for the animal and an inability to lie on the affected side, increased susceptibility to infection and even the ability to take this animal into public places and possibly spend time with the animal, given the extremely malodorous and oozing nature of the wound. Respecting patient or client autonomy in decision-making is a common ethical challenge for human and veterinary practitioners [ 40 , 45 ]. Obtaining informed consent in veterinary medicine provides legal protection to practitioners but it should not be used as a sole means for justifying their actions or inactions [ 67 ]. While being respectful of client wishes, veterinarians must also play a more active role when animal welfare concerns are present by providing tools to assist with decision-making, such as formal or informal quality of life assessments [ 68 , 69 , 70 ], to help clients to better understand and appreciate welfare problems and to avoid unnecessary pain and suffering, which takes into consideration a more utilitarian ethical framework ( Table 1 ) Certainly, the results of these assessments can be subjective and may still require the veterinarian to speak up and advocate for the animal if further treatment cannot be pursued.

4.5. Example 5: Refusal to Accept End of Life of an Animal

A 6-year-old male ringtail lemur from an exotic animal sanctuary was attacked by a Japanese macaque following a public health quarantine that was placed in the sanctuary for unrelated reasons. The two nonhuman primates had to be placed together within a relatively confined area, because there was insufficient caging to keep them separated. The sanctuary was approved by a regional SPCA office as an official site for rehoming exotic animals seized by inspectors. The injuries to the lemur were severe and extensive and included marked, multifocal bites, skin loss and lacerations, tail mutilation, bilateral hind limb lacerations and fractures and bilateral forelimb fractures. Following this emergency, the client sought medical attention for the lemur from a local companion animal practice with which they had a longstanding relationship but which did not have specific exotic animal or primate medicine expertise. Several successive surgeries were performed on this animal over the ensuing 3 weeks resulting in amputations of the tail and both hind limbs, plating of fractures in both forearms and later amputation of the right forelimb. The lemur was left in a completely non-ambulatory condition with only the pinned left forelimb remaining. The owners refused the initial veterinary recommendation of euthanasia and elected to carry the lemur using an infant sling while providing oral antimicrobials and once daily dosing of a nonsteroidal anti-inflammatory drug. Four weeks following the injury the lemur died spontaneously after a 1-day history of coughing and diarrhea and was submitted for post-mortem examination. At post-mortem, an open comminuted fracture was noted in the left forearm as well as evidence of chronic ulceration on the dorsum of the distal trunk, suppuration around surgical wounds, acute enteritis, aspiration pneumonia and early renal failure ( Figure 6 ).

One-armed ring-tailed lemur presented for post-mortem examination ( left ); A deep suppurating ulcer was present on the dorsal trunk ( right ).

Because of the severity of the injuries, consideration should have been given to immediate euthanasia of the lemur at the time of initial examination, according to utilitarian and ethics of care viewpoints ( Table 1 ). Nonhuman primates can suffer myoglobinuric nephropathy secondary to severe trauma from fighting [ 71 ]. In this case, the client was angry about the unnecessary public health quarantine that had resulted in trauma to this animal and the client was also unduly influenced by their deep attachment to and affection for the lemur. The veterinarian subsequently admitted that the clinic had discussed the ethical and quality of life implications of successive amputations for the lemur but indicated that ultimately, the clinic owner had made the decision to proceed with surgeries when the client refused euthanasia, particularly since there were no financial limitations for the client. The veterinarian also admitted to insufficient knowledge about primate medicine and care as well as feelings of unease with how this case had been handled. When subsequent problems developed in this animal over the course of the three weeks, the clinic felt heavily invested in the case and continued to provide medical and surgical support, up to three days before the lemur was found dead. Subsequently, the SPCA mandated that better housing and husbandry conditions be instituted for the remaining animals at the sanctuary.

This case represents a number of ethical challenges that can occur in veterinary practice. Junior veterinary associates in a clinical practice may not be comfortable with the ethics of certain medical decisions made by colleagues but may feel unable to speak up because of respect for the opinion of more senior veterinarians, because of fear of reprisal and loss of income if they express a minority opinion and are subsequently fired and because of insufficient confidence with their own knowledge and skill set to know whether proceeding in a certain way with a case can or should be done. Pride and overconfidence can also adversely impact patient welfare and result in permanent harm or death [ 72 ]. Knowledge of orthopedic surgery in companion animals does not necessarily translate to adequate knowledge of orthopedic surgery in less familiar species, such as nonhuman primates. In this case, the veterinarians elected not to pursue reasoning with the aggrieved client and profited from the situation, resulting in a very poor welfare outcome for the lemur. Using a virtue ethics framework ( Table 1 ), the veterinarians would have been able to articulate the limitations in their own skillset and knowledge, as well as the potential conflict of interest for significant financial gain and sought further outside advice and support before proceeding with the surgeries. Peer interactions and clear communications of possible outcomes, welfare concerns and an optimal course of action are important to discuss with the client. As a last resort, veterinarians can also invoke legal reporting requirements if there are significant client conflicts that create major animal welfare risks.

4.6. Example 6: Failure to Provide Timely Veterinary Care Follow-Up

A dairy farm with 60 milking Holsteins experienced a serious and sudden barn fire. All cows, including milking and dry cows and pregnant replacement heifers were removed from the burning structure, although this occurred under extreme circumstances. The barn was completely destroyed in the fire and a press release issued afterwards indicated that no human or animal lives had been lost in the blaze. The herd veterinarian was called to the farm and provided fluids and several doses of nonsteroidal anti-inflammatory drugs to a pregnant heifer that had been injured in the blaze, although because of the detritus clinging to the heifer’s hair coat, the true extent of the injuries may not have been immediately obvious. The milking cows were moved to a neighbouring farm for the next month and the remaining dry cows and replacement heifers were moved to a distant pasture on the property, with minimal daily attention, while the devastated farmer and family focused on rebuilding the barn. Almost four weeks after the event, the herd veterinarian revisited the farm and found the previously treated heifer with severe burns on the dorsum. The cow was administered a nonsteroidal anti-inflammatory drug and was shipped to a nearby veterinary referral centre. Upon arrival, the receiving veterinarian ordered immediate euthanasia of the heifer on the truck because of significant concerns about poor welfare and unrelieved pain and distress. At post-mortem, the heifer was noted to have extensive third degree burns and eschar covering approximately 60% of the dorsum ( Figure 7 ).

Holstein heifer with third degree burns to dorsum one month following a barn fire.

In this case, the veterinarian admitted to forgetting about the cows in the back pasture, in part, because they were not convenient to access and because of the overall busyness of their practice. The client had also largely ignored these animals in the aftermath of the fire, because of their shock surrounding the incident, severe economic straits until insurance money was available and their ongoing attention to rebuilding their barn and several other outbuildings. The lack of attention and follow-up in this case led to severe suffering of the affected animal. The veterinarian subsequently referred the animal as a teaching donation to minimize any costs to the client associated with deadstock removal as well as the difficulty that would have arisen to remove the carcass from the remote pasture. This was a very difficult case because of the complexity of circumstances. From a utilitarian point of view ( Table 1 ), the heifer should have been euthanized at the original visit, because of the extent of the injuries suffered and because it was known at that time that medical care of the animal could not be managed intensively. Conversely, from a consequentialist approach, the heifer was originally kept because she was carrying a genetically valuable foetus and if she had survived, the end may have justified the means. For this approach to be justifiable, the heifer would have needed to be monitored carefully and treated intensively. Poor decisions for animal welfare were made in this case because of the veterinarian’s sympathy for and assumptions about client circumstances and because of inattention to their ethical duty to the animal and an inability to speak up and advocate for the heifer’s welfare. It is unknown whether the veterinarian delayed conducting a revisit sooner because of concerns about the client’s ability to pay for the call. The receiving veterinarian immediately recognized the severe and adverse welfare state of the heifer and acted promptly to relieve further animal suffering.

5. Applying Ethics to Veterinary Practice

Veterinary decision-making will always be complex and messy and the ethical reasoning underpinning a course of action cannot be simply addressed by turning to an algorithm or flowchart, as often one or more courses of action may be reasonable for a given situation. Additionally, the fact that there is no clear metric to aim for may make the concept of ‘ethical veterinary practice’ seem like a nebulous goal. The value of emphasizing ethics in everyday clinical practice is that it helps the clinician to reflect on their course of action, it empowers clinicians to advocate for their patients and it is critical for informing policy—policy for the profession and for animal welfare [ 73 ]. Ultimately, veterinarians have an ethical obligation to provide good care for their patients and clinics and universities must provide initial training in ethical decision-making and then nurture a culture that enables veterinary students and practitioners to speak up. Without this, there is a gap between the theory of ethical veterinary practice and its actual application, which, as has been discussed, can lead to significant moral conflict and burn-out as well as significant animal welfare issues, as per the examples provided. Kong describes the creation of an ethics community in human medicine to nurture ethical reasoning and moral imagination [ 73 ]. An ethics community is created when academics and clinicians are sensitive to ethical issues and encourage ongoing dialogue in a safe environment in which practitioners can speak openly about their clinical ethical concerns [ 73 ]. In veterinary medicine, this could include nonjudgmental and peer-to-peer discussions with like-minded colleagues, as well as veterinary ethicists and academic researchers.

Moore describes a “common-morality theory” in bioethics characterized by pre-theoretical common-sense ethical judgment that acts as starting point of view for most ethical frameworks [ 74 ]. This background in ethics knowledge and knowledge of veterinary ethics frameworks and approaches during veterinary medical education will nurture ethical reasoning for future practitioners. For those already practicing veterinary medicine, continuing education focusing on medical skills and ethical decision-making as well as peer-to-peer discussions can facilitate higher levels of moral reasoning in complex cases and in determining the most appropriate course of action [ 75 ]. In the end, ethical medical reasoning is a highly reflective process characterized by a continuous assessment of the advantages and disadvantages of each framework over time [ 73 , 74 ].

6. Conclusions

Ethical and moral issues arise commonly in all spheres of veterinary practice. Ethics education during veterinary training may help to improve ethical sensitivity and equip veterinarians with frameworks and approaches that support ethical decision-making. These also provide clear justifications for “speaking up” in ethically challenging situations. Good communication skills lie at the heart of the veterinary-client relationship and veterinarians must not assume a passive role when serious welfare matters are at hand. Advocating for animal welfare may not be comfortable and may, at times, require courage but is necessary to advance the veterinary medical profession and to improve human regard for animals as sentient beings. Further research and discourse on veterinary ethical issues may improve veterinary teaching and translation of ethics theory and reasoning into applied practice.

Acknowledgments

Elein Hernandez would like to thank the Science and Technology Council of Mexico (Consejo Nacional de Ciencia y Tecnología, CONACYT) for its financial support during her DVSc program. Anne Fawcett would like to thank her supervisors, Paul McGreevy and Siobhan Mullan, for their support.

Author Contributions

Patricia V. Turner and Elein Hernandez conceived of the paper and Elein Hernandez, Anne Fawcett, Jeff Rau, Emily Brouwer, and Patricia V. Turner co-wrote and edited the paper.

Conflicts of Interest

The authors declare no conflict of interest.

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Post Office executives played a leading role in publicly defending their organisation over the hundreds of prosecutions it brought against the sub-postmasters who ran its branches, based on the flawed Horizon accounting system.

But, behind the scenes, it was in-house lawyers who took on the task of briefing senior executives on the robustness of its Horizon software. They were also responsible for commissioning relevant audits and setting out the UK state-owned organisation’s approach to litigation. 

More than 900 people were convicted of a range of offences, including theft and false accounting, in cases involving data from Fujitsu’s flawed Horizon system, which was introduced in 1999. More than 700 prosecutions were brought by the Post Office itself.

However, it was another lawyer — James Hartley, partner and head of dispute resolution at law firm Freeths — who represented 555 of the sub-postmasters in a landmark 2019 High Court case in which the extent of the IT scandal emerged. The judge ruled that several “bugs, errors and defects” meant there was a “material risk” that the Horizon system was to blame for faulty data used in the Post Office prosecutions.

“It’s quite a complex web of obligation, responsibility and culpability,” says Hartley, reflecting on the reach of the affair into the legal profession. “Somewhere along the way, lawyers have stepped over the red line.”

Now, a public inquiry into the scandal is gaining momentum as it takes evidence from senior Post Office executives, government ministers and figures from Fujitsu, ahead of its conclusion this summer.

In the coming months, the inquiry will hear testimony from several former general counsel at the Post Office, each of whom will give evidence against the backdrop of a debate about whether the role of an in-house lawyer needs to be more strictly regulated.

Susan Crichton, the Post Office’s general counsel between 2010 and 2013, will appear today at Aldwych House in London to respond to claims that, under her watch, the business brought prosecutions against sub-postmasters despite concerns surrounding Horizon.

Audio recordings shared with the inquiry, of conversations between Crichton and forensic accountants Second Sight in 2013, suggest she briefed the company’s chief executive that claims made by accused sub-postmasters about the Horizon system were, in fact, true.

Their discussions include the detail, long denied by the Post Office, that third parties could access systems remotely and alter transaction data. Sub-postmasters successfully argued in court that they could not be held solely responsible for any shortfalls because of this third-party access.

Crichton’s evidence is also expected to spell out some of the difficulties that existed for general counsel in raising concerns, particularly when executives fail to act in response.

Chris Aujard, Crichton’s successor, is scheduled to appear at the inquiry tomorrow. Jane MacLeod, who succeeded Aujard, is due to appear in June, shortly after current counsel Ben Foat takes the stand.

Somewhere along the way, lawyers have stepped over the red line James Hartley, Freeths

Contemporaneous documents suggest that there may have been opportunities for the Post Office to prevent litigation.

The Post Office’s general counsel were involved in commissioning half a dozen reports and reviews by external auditors and consultants, including BAE Systems, Deloitte, EY, and Second Sight, in the decade leading up to the 2019 High Court case.

Some of these reports found faults with internal systems and how they were managed. External lawyers in 2013 warned the Post Office that the business was at risk of breaching its obligations as a prosecutor over improper practices, if any decision were made to shred documents, which prevented disclosure.

Richard Moorhead, a professor of law and professional ethics at the University of Exeter, says matters should be reported “up the ladder” and that general counsel need to act as a “moral compass” within an organisation. “They need to speak up if they think things are being done which are improper and ensure the client hears those things,” he says.

Moorhead, who sits on the government-appointed Horizon Compensation Advisory Board, is a vocal critic of the lawyers involved in the Post Office Horizon scandal.

He adds that there were occasions when in-house lawyers at the Post Office should have sought to “blow the whistle” once it became obvious that errors in the Horizon system could account for shortfalls.

General counsel play a prominent role in shaping the legal strategy of a company or organisation and advising executives on the best approach to compliance and handling legal risk. But there is sometimes tension between serving the business and acting in the public’s interest. 

In the aftermath of the Enron and WorldCom fraud scandals in the early 2000s, US regulators introduced new security laws that required general counsel to report adverse information to audit committees, directors and other officials when senior leadership was unresponsive.

[GCs] need to speak up if they think things are being done which are improper and ensure the client hears those things Richard Moorhead, University of Exeter

Brian Cheffins, a professor of corporate law at the University of Cambridge, says the new rules produced a playbook for in-house lawyers who had been “stonewalled internally”, particularly as these individuals could find themselves in “deep water” when misgovernance became evident.

But Cheffins is opposed to plans to set out general counsel’s obligations formally, and warns that doing so risks duplicating duties that already exist elsewhere.

General counsel in the UK operate under the same rules as any solicitor or barrister advising a client, which stipulate acting with integrity in ensuring that senior figures are briefed on unpalatable information. The Horizon affair has reminded lawyers of their duties when advising executives.

Hartley says: “In-house lawyers need to recalibrate their thinking on where that red line is so they know when to turn around to the person they’re advising and say, ‘No, we cannot do that’.”

Post Office general counsel: in the spotlight

Susan Crichton In 2012-2013 she was involved in instructing Second Sight to conduct an independent investigation into Horizon. The forensic accountants raised concerns but these were not actioned by the business despite executives being briefed. Crichton left the Post Office to take on a similar role at TSB Bank in 2013; she retired in 2018.

Chris Aujard After becoming general counsel in 2013, he was tasked with winding down a mediation scheme set up for affected sub-postmasters and removing Second Sight from its role investigating the Post Office. Meeting minutes from 2014 showed he was present when executives discussed setting aside £1mn in “token payments” to mitigate any reputational damage.

Jane MacLeod In position as general counsel when 555 sub-postmasters brought a suit against the Post Office, MacLeod was responsible for overseeing the business’s initial response. The public inquiry will explore her handling of disclosure and response to litigation when she gives evidence in June. She resigned from the Post Office in 2019.

Ben Foat Appointed to general counsel in 2019, Foat previously served as the business’s legal director. He appeared at the inquiry in the middle of last year after widespread disclosure failures resulted in weeks of delays to evidence. Sir Wyn Williams, chair of the inquiry, has since threatened officials with criminal penalties if such problems recur.

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Boeing failures are a case study of America’s manufacturing “dark age”

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Boeing released its first-quarter financial results Wednesday, and, despite the disastrous Alaska Airlines flight earlier this year and the ensuing public scrutiny the plane manufacturer has faced, the report was not as bad as expected . Revenue came in slightly higher than forecast, but still down 8% from the year before.

Boeing has a storied history that reaches back well over a century. Its current problems raise the question of how we got here — and magnify worries about American manufacturing at large.

Jerry Useem, a contributor to The Atlantic, joined “Marketplace” host Kimberly Adams to talk about Boeing and what he calls the dark age of American manufacturing . An edited transcript of their conversation is below.

Kimberly Adams:  You open your piece with a pretty stark comparison of Boeing of the past and Boeing of more recent days. Can you lay that out for me?

Jerry Useem:  Well, the comparison is a stark one in that early in Boeing’s existence, it paid very close attention to the process of manufacturing. And the original founder, Bill Boeing, had his office right in the building adjacent to the shop floor and would often stroll over and inspect individual pieces. And what we’ve arrived at now is a situation where the management of Boeing is very much detached from the actual building of its planes.

Adams:  Can you briefly sort of take me through the timeline of Boeing, of how they went from this superprestigious company that was doing everything in-house, had all of its engineers very plugged into what was going on, to what we’re learning as these investigations continue about such a disparate chain of events that led to, you know, the door blowing out on the plane and things like that.

Useem:  The timeline is kind of a long one. I think it was in the early 2000s that a lot of the key decisions were made. And airplanes are that kind of business where the errors of yesterday take a long time to show up. But around 2005, they really got serious about what they called offloading. And this meant doing less and less of the work in-house. You know, for some of its planes, having the wings built elsewhere, having the entire tail section built elsewhere. But they took this further and further. And I’d say, prior to the accident, it was beginning to recognize that it had taken this too far and was beginning to sort of reintegrate and try to make some steps to bring itself back to kind of its engineering-manufacturing roots.

Adams:  How common is what Boeing has done in the rest of American manufacturing?

Useem:  I think it’s actually not uncommon. It’s a very visible case for what I think has been a fairly pervasive phenomenon. I mean, as recently as the early 2000s, Intel was seen as the absolute last word in manufacturing prowess, and its CEO frankly admitted that it lost its edge on the shop floor. And they’ve pronounced what he’s called a “death march” to get back to leadership and the actual process of making things better, ensuring quality, etc.

Adams:  Yeah, one of the issues you point to in American manufacturing is that power in these companies like Boeing moved from engineers to financial managers. How did that happen, and what’s been the consequence?

Useem:  The engineers who first were sort of in charge of the executive suite when the American corporation came to be. Henry Ford and Bill Boeing, these were people who arose from the shop floor. And over time, it’s been pretty well documented that the CEO class came to be populated by people out of the finance function, which meant they spoke the language of numbers and accounting, they didn’t speak the language of engineering. And so those best equipped to understand how to put things together were no longer in charge. And I think that’s a process that’s now gone too long, gone too far.

Adams:  What’s the lesson for other American manufacturers to take from this situation? Not just, you know, what Boeing is doing right now, but how Boeing got to this point?

Useem:  I think the lesson is ignore the process of making at your peril. You know, a lot of people have set up the Boeing story as sort of a case of a company that’s put costs in front of quality. But the thing is, really what they’ve done is actually made it more expensive for themselves. I mean, they’ve had their production lines shut down. This is extremely costly. So you’ve got to find sustainable ways to keep on driving costs down, keep on improving quality. So it’s a matter of: Are you going to do it bluntly, by getting rid of your experienced workers, your advanced machine tools, and the managerial attention required to make those continual improvements? Or are you going to lean into it?

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