CalendarSource: IRB: Ethics and Human Research, Vol. 9, No. 5 (Sep. - Oct., 1987), p. 7Published by: The Hastings CenterStable URL: http://www.jstor.org/stable/3564258 .

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September/October 1987

be those followed by the institution in everyday business and personnel affairs.

It is the responsibility of managers of service organizations, public or private, to ensure that employees serve the clientele politely and efficiently. If sales people in a retail business are snippy, dishonest, lackadaisical, or inefficient, we look to management for a remedy, insisting it is their business to monitor and direct employee behavior. Staff members may not insist on an auton- omy that keeps customers waiting while they discuss last night's date; they willingly give up that right in accepting employment. Unenergetic managers will wait until an inordinate number of complaints indicates things aren't as they should be. More vigorous ones will train employees and ensure they are well-supervised in order to obviate behavior that offends the clientele. The norms for methods of supervision in hospitals differ from those of the department store, but not in terms of institutional responsibility for oversight of the services it provides. Such super- vision easily encompasses studies such as the one we are discussing.

Autonomy and Employment

Thus it is that Geller and Lidz and their "subjects" sensed, without being able to define, something wrong with the IRB's insistence upon obtaining informed consent. Failure to recognize that staff members had given up autonomy in the areas relevant to the research project leads to the perplexing list of questions that are the main body of the paper.

Geller and Lidz ask: "Does the subject have any options?" "Some of the staff asked us what

would happen if they all refused? "Did the staff have the power to

refuse?" "Did the researchers have the free-

dom to accept the refusal?" "Does requesting consent honor the

subject?" "Who were the subjects anyway?" They report further questions from

the staff, indicating that employees shared the authors' confusion about the relationship the IRB had mistakenly imposed on all:

"What difference does it make if we refuse?

"...what would happen if [we] all refused?

"Could we lose our jobs if we don't participate?"

All the questions disappear as soon as it is recognized that the unit staff, from psychiatrists to security guards

are, indeed, employees of the institution and subject to institutional supervision and direction. Unless the study involved procedures other than those implied by Geller and Lidz, there is no doubt that the hospital management was acting well within the accepted bounds of employer-employee expectations in authorizing the study and would have done better simply to direct unit staff to cooperate.

(If we consider the authors' case on its own terms - that is, with the mistaken premise they accepted in writing it - there is room for dissent from parts of their analysis, a matter to which I'll return.)

Few of us enjoy being supervised, and the higher up the ladder one goes the more distant supervision becomes. Yet, except for professionals in private practice and tenured members of college faculties, supervision of some kind remains the norm. Professionals in private practice avoid it because neg- ative reaction by clients, threatening their livelihood, is an adequate substi- tute; tenured professors avoid it because society believes meaningful supervison to be inconsistent with ensuring important scholarly freedom. But for the rest of us, from factory floor to the CEO's office, supervision and direction by the foreman or the board is taken for granted.

If supervision is the norm, the pos- sibility of criticism, negative or positive is implied, as is the risk of harm ranging from gentle rebuke to losing one's job. In recent years, it has become the practice to supervise as unobtrusively as possible. However, this is prompted not by any ethical mandate, but by modern managers' belief that a velvet glove produces better results than the abrupt interventions, denunciations, and/or firings that were the rule in the good old days when the "bull of the woods" reigned supreme.

It is easy to underestimate the loss of freedom involved in accepting employment, because autonomy is so highly valued that bosses and workers cooperate to disguise the loss. Yet, despite that charade, a principal motive for climbing the ladder is not money, as such, but achieving the increased autonomy money can bring. The higher reaches of any occupation typically allow incumbents much greater free- dom from supervision than do the humbler ones. In addition, accumulated wealth greatly expands one's latitude to resist unwelcome orders. When fed up with being bossed around, it is easy to quit.

Having thus gone on about the importance of "autonomy," I should acknowledge my suspicion that some students of ethics would reject that

7 CALENDAR

OCTOBER 26-27: Public Responsibility in Medicine & Research (PRIM&R) will sponsor The Economics of Health Care and Its Effect on Access at the Boston Park Plaza. The conference will examine the ethical, economic, social, and legal issues surrounding the allocation of health care both in this country, and in comparison with other industrialized nations. Issues to be addressed include the availability of health care for the uninsured and underinsured, the role of federal and state governments including current proposed legislation, the ethics vs. the economics of taking care of the sick--including the impact of DRGs, the role of responsibility of both for-profit and not-for-profit hospitals, and the effects of recent cutbacks and shifts in services on vulnerable groups. For more information contact Joan Rachlin, Executive Director, PRIM&R, 132 Boylston St., Boston, MA 02116; (617) 423-4112/1099. NOVEMBER 11: The second annual ARENA (Applied Research Ethics National Association) program will be held at the Park Plaza in Boston. The program will include both lectures and hands-on demonstrations of computer software available to IRBs and other hospital committees to help improve efficiency and effectiveness. NOVEMBER 12-13: Public Responsibility in Medicine & Research (PRIM&R) will sponsor IRBs: New Challenges and Problems at the Park Plaza in Boston. Issues to be examined include: AIDS, the Model NIH Policy, new FDA regulations, confidentiality, and the use of cell lines and tissues, among others. For information contact: Joan Rachlin, PRIM&R, 132 Boylston St., Boston, MA 02116; (617) 423-4112/1099. NOVEMBER 17: The Bioethics Committee of Overlook Hospital and the New Jersey Hospital Association's Council on Professional Ethics will sponsor a workshop on Creating and Maintaining a Hospital Bioethics Committee at Overlook Hospital in Summit, NJ. For information contact: Joseph C. d'Oronzio, Administrative Director, Dept. of Medical Education, Overlook Hospital, Summit, NJ 07901; (201) 522-3538.

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