Hide Behind the Protocol

This morning I read a strange piece of news from Tennessee. The state had tried to execute a woman by lethal injection. Two doses of pentobarbital had been administered, yet she was still alive. Eventually the execution was abandoned and she was taken to hospital.

My first reaction was not particularly philosophical. It was simply: How can you possibly fail at this?

Whatever one thinks about capital punishment, human beings have been remarkably successful at killing one another for thousands of years. There are certainly simpler ways of doing it. Yet somewhere along the way we decided that a modern state should not merely execute a person. It should execute a procedure.

That distinction is more important than it first appears.

An execution by firing squad makes the nature of the act rather difficult to misunderstand. People aim weapons at another person and kill them. Lethal injection transforms the same intention into something resembling a medical procedure. There is a bed, an intravenous line, chemicals, dosages, monitoring and a protocol. The violence has not disappeared. It has acquired administration.

This creates a peculiar problem. Procedures work wonderfully until reality does something that was not anticipated by the person who wrote them.

In Tennessee, the prescribed doses were administered, but the prisoner remained alive. At some point the protocol simply ran out of instructions. The procedure had reached its end. The person had not.

There is something almost philosophical about this.

The protocol had been executed. The execution had not.

It would be easy to regard this as one of those bizarre problems peculiar to capital punishment. I do not think it is. The extremity of the example merely makes visible something we do everywhere.

Modern societies love protocols, and for good reasons. Procedures create consistency. They protect against arbitrary decisions. They preserve institutional knowledge. They allow thousands of people who do not know one another to coordinate their actions. Nobody would want an air traffic controller, a surgeon or the operator of a nuclear power station to improvise everything according to mood.

But protocols have another, less discussed attraction.

They are wonderful places to hide.

The more unpleasant a decision is, the more tempting it becomes to move that decision into a procedure. Once this has been accomplished, something curious happens to responsibility. Nobody quite seems to be doing anything anymore.

A person is not rejected. The criteria were not met.

Someone is not denied assistance. The case falls outside the mandate.

An employee is not dismissed by another human being. The position is eliminated as part of a restructuring process.

A prisoner is not killed by people. A sentence is carried out according to protocol.

The grammar changes first. Then, almost unnoticed, our understanding of the action changes with it.

This is not necessarily deliberate deception. Nobody needs to sit in an office and devise language intended to conceal responsibility. In fact, that is what makes the phenomenon interesting. Institutions gradually develop ways of speaking and acting that allow difficult decisions to appear as consequences of processes rather than choices made by people.

And once a decision has been converted into a procedure, the procedure itself becomes its justification.

We followed the protocol.

It is a remarkably powerful sentence. It can mean that the rules were followed carefully and responsibly. But it can also mean something quite different: Do not ask me whether what happened made sense. That was no longer my department.

I have seen this often in social work. A person has a problem, and somewhere there is a procedure designed for that category of problem. Forms are completed, criteria checked, assessments conducted and the appropriate steps followed. Usually this is sensible.

Then a human being arrives who has neglected to fit the category.

His situation almost meets the criteria, but not quite. He needs assistance, but fails one technical requirement. Or everyone involved can see that the prescribed intervention makes little sense in this particular case. Nevertheless, the procedure says step one, step two, step three.

At that moment the procedure can stop being a tool and become a substitute for thought.

The absurdity is sometimes visible to everyone involved. The social worker may see it. The client certainly sees it. Even the person who wrote the report may privately agree. Yet nobody wants to be the person who steps outside the procedure, because stepping outside it creates something that following it conveniently removes: personal responsibility.

If I follow the protocol and something goes wrong, I can explain myself.

If I depart from the protocol and something goes wrong, I have to explain my judgement.

That difference is enormous.

Years ago, while working in security, I encountered another version of the same phenomenon. Security organisations adore scenarios. People sit in rooms imagining emergencies and constructing sequences of responses. If this happens, do that. If that happens, call this person. If the alarm reaches this level, proceed to the next stage.

On paper it is beautiful.

Then something actually happens.

Unfortunately, reality has not attended the briefing.

The alarm is real, but not quite the kind anticipated. Two things happen simultaneously that were supposed to happen separately. The person designated to make the decision cannot be reached. The threat comes from the wrong direction. Suddenly the beautifully designed procedure resembles a map of a country one is no longer in.

The obvious response would be judgement.

But judgement is precisely what elaborate systems often try to eliminate. Judgement is unpredictable. It cannot be completely standardised. Most importantly, judgement requires a judge.

Someone has to say: I understand what the rule says. I understand why it says it. But this situation is different, and I am going to do something else.

The final part of that sentence is the difficult one.

I am going to do something else.

There is an “I” again.

There is someone who can be questioned. Someone who can be wrong. Someone who may later have to explain why he did what he did.

The protocol offers an escape from this discomfort. It allows us to replace the dangerous sentence I decided with the reassuring sentence the procedure was followed.

This may explain why institutions so often respond to failed procedures by creating more procedures. Something goes wrong. There is an investigation. The investigation produces recommendations. The recommendations produce additional rules. Another box is added to the form and another branch to the flowchart. Everyone feels that the system has learned something.

Perhaps it has.

But there is a point at which the attempt to anticipate every possible reality becomes absurd. Human situations contain too many variables. The more complicated the world becomes, the more elaborate our procedures become, and the more elaborate our procedures become, the more tempting it is to confuse compliance with competence.

Eventually we arrive at one of the stranger achievements of modern civilisation: a system in which everyone can perform his assigned task correctly and the overall result can still be ridiculous.

No individual necessarily made the absurd decision.

The absurd decision emerged from the process.

This is why hiding behind the protocol is so seductive. It does more than distribute responsibility. It can make responsibility almost disappear. Each person performs one legitimate step. Each person can point to the rule authorising that step. Nobody needs to own the final result.

The procedure becomes a kind of invisible hand, except that there is nothing invisible about the people operating it. They are all there. What disappears is the moment at which any one of them has to say: Yes. This is what we are doing.

There is a paradox here. We create procedures partly because we want institutions to behave more responsibly. Yet the same procedures can make it easier for individuals within those institutions to avoid responsibility.

Perhaps that is the deeper lesson in the strange story from Tennessee.

It is not really about lethal injection, and it is certainly not an argument against protocols. A civilisation without procedures would quickly become arbitrary and chaotic. The problem begins when the protocol ceases to guide judgement and starts replacing it.

We tell ourselves that enough rules can remove uncertainty from human affairs. Enough boxes, enough criteria, enough predetermined steps, and eventually nobody will have to make the uncomfortable decision.

But reality has an irritating habit of producing cases that were not invited to the planning meeting.

Sooner or later, the alarm comes from the wrong direction. The client does not fit the category. The exception is not listed in the manual.

Or the person is still alive after step three.

And then the protocol has nothing left to say.

Someone does.