Bryn Williams-Jones argues that identifying the right ethical problem is only half the challenge; we must also determine who is responsible for addressing it.
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I recently gave a talk on conflicts of interest (COI) to a group of psychiatrists, researchers, and clinical ethics colleagues. After a brief presentation of the key concepts, we opened up for questions and discussion — and the resulting conversation had almost nothing to do with COI.
After more than twenty years working on COI, I have become very good, even too good, at identifying them. Give me a problematic situation, and I can usually find an interest that risks influencing professional judgment. But a useful concept can also become the wrong analytic lens. As I explained to my audience, not every uncomfortable professional situation is a COI. Some involve conflicting roles, obligations, values, or loyalties. Others arise because individuals are being asked to manage problems created by the organizations and systems in which they work.
But this concept should not become a catch-all for every professional tension. We should not, as I’ve found myself doing, imagine that COI are everywhere
A clinician can occupy two roles that generate different responsibilities. Two colleagues may disagree because they hold different views about what constitutes a patient’s welfare. A professional may feel competing obligations toward a patient, a team, an institution, and a professional association.
These situations can overlap, but treating them all as COI can obscure rather than clarify what is actually problematic.
Before asking what the ethical solution could be, we often need to ask a more basic question: have we identified the right problem, and are we looking for it at the right level?
Naming a problem matters because different problems call for different responses. Disclosure or recusal may help manage a COI. But they do little to resolve a disagreement about personal or professional values. A conflict of roles may require clarifying responsibilities, and sometimes separating the roles, although that isn’t always possible. Competing obligations may require negotiation, compromise, or accepting that no single option satisfies everything we owe to everyone involved. This can leave a moral residue, the sense that something important remains unsatisfied.
An AI-generated photo of a diverse group of healthcare workers sitting around a table, discussing an issue.
The professional responsibility of the clinician is directed toward the patient sitting in front of them. But that patient is rarely the only one waiting for care. Spending an additional 30 minutes with one patient may mean delaying care for many others. While this looks like a bedside ethical problem because that is where the decision occurs, the conditions producing it may have little to do with the individual clinician.
If someone has only five minutes to see a patient because the service is chronically understaffed, exhorting them to exercise better ethical judgment misses the point. The immediate decision is individual, but the problem is organizational — and shifting the framing can help us understand the situation differently.
At the micro level, ethics concerns relationships and decisions involving patients, families, colleagues, and teams. At the meso level, questions concern institutional policies, allocation mechanisms, staffing, organizational culture, and responsibility. At the macro level, we encounter health policy, financing, regulation, and broader social choices.
These levels interact, but they are not interchangeable. The level at which action is possible may also differ from the level at which the problem first becomes visible.
A clinician may be asked to make difficult decisions within systems characterized by inadequate staffing or poorly designed policies. Institutions may have procedures, codes, and risk-management mechanisms showing that appropriate processes exist, yet when a difficult decision goes badly, they may unfairly download responsibility onto the individual who had to make the decision.
Professionals remain accountable for their judgments, but accountability should not become a mechanism for avoiding institutional responsibility. Some decisions should also be deliberately moved away from the individual.
Organ transplantation provides a familiar example. We do not normally ask the treating physician, whose responsibility it is to advocate for a particular patient, to decide independently who should receive a scarce organ. Allocation systems create criteria, committees, and procedures precisely because asking one clinician to reconcile obligations to an individual patient with distributive justice creates an unreasonable burden.
Recognizing these limits of individual responsibility also changes how we approach difficult decisions. Clinicians may feel exposed when institutional responsibility and individual accountability diverge. My response is simple: don’t do it alone.
This is not an argument for hiding responsibility inside a committee. Collective decision-making can become a way of ensuring that nobody is accountable for anything. But good collective processes can do something different.
Interdisciplinary teams bring different forms of knowledge, professional responsibilities, and ways of seeing a problem. Families, patients, community members, ethics consultants, and other trusted participants may add perspectives that professional teams cannot supply themselves.
Collective reasoning also makes patterns visible. Five clinicians struggling with the same problem can each believe they are confronting an individual failure. Put them in the same room, ideally with a bioethicist helping to mediate and translate across professional languages, and the problem may look very different. Instead of a conflict between differing professional values, the team may recognize that they’re all living with the same organizational problems, even if they experience them differently.
Sometimes the most important contribution of bioethics is to change the level at which the problem is understood.
Bioethics is good at identifying values, clarifying concepts, and evaluating competing arguments. We need to become better at asking what kind of ethical problem we are dealing with and where it belongs. Is this really a COI? Is the apparent clinical dilemma being generated by an organizational failure? Are professionals being asked to assume responsibilities that belong to institutions? Is an individual intervention appropriate, or does the problem require a collective response?
Not every difficult situation has an elegant solution; sometimes the available choices are bad, even tragic. But before asking people to choose among them, we should make sure we have not handed the ethical problem to the wrong person.
Sometimes the first ethical intervention is simply to move the problem to the level where something can actually be done about it.
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Bryn Williams-Jones is professor and director of the Department of Social and Preventive Medicine, School of Public Health, Université de Montréal. He also writes about bioethics, academic life, and leadership at BrynStorming.
