"Whistleblowing" a health issue.

                           By K.Jean Lennane

Abstract

Objective-To examine the response of organisations

to "whistleblowing" and the effects on

individual whistleblowers.

Design-Questionnaire survey of whistleblowers

who contacted Whistleblowers Australia after its

publicity campaign.

Setting-Australia.

Subjects-25 men and 10 women from various

occupations who had exposed corruption or danger

to the public, or both, from a few months to over 20

years before.

Results-All subjects in this non-random sample

had suffered adverse consequences. For 29 victimisation

had started immediately after their first,

internal, complaint. Only 17 approached the media.

Victimisation at work was extensive: dismissal (eight

subjects), demotion (10), and resignation or early

retirement because of ill health related to victimisation

(10) were common. Only 10 had a full time job.

Long term relationships broke up in seven cases, and

60 of the 77 children of 30 subjects were adversely

affected. Twenty nine subjects had a mean of 5 3

stress related symptoms initially, with a mean of 3 6

still present. Fifteen were prescribed long term

treatment with drugs which they had not been

prescribed before. Seventeen had considered

suicide. Income had been reduced by three quarters

or more for 14 subjects. Total financial loss was

estimated in hundreds of thousands of Australian

dollars in 17. Whistleblowers received little or no

help from statutory authorities and only a modest

amount from workmates. In most cases the corruption

and malpractice continued unchanged.

Conclusion-Although whistleblowing is important

in protecting society, the typical organisational

response causes severe and longlasting health,

financial, and personal problems for whistleblowers

and their families.

9 Rowntree Street,

Balmain, New South Wales

2041, Australia

 

Introduction

"Whistleblowing" is defined in the American

Whistleblower Protection Act 1989 as occurring when

a present or former employee discloses information

"which the employee reasonably believes evidences a

violation of any law, rule, or regulation, or gross

mismanagement, a gross waste of funds, an abuse of

authority, or a substantial and specific danger to public

health or safety." Recently it has become an important

issue in Britain: health professionals who have spoken

out about changes to the NHS that adversely affect

patient care have been dismissed or otherwise disciplined.'

4 There have been similar reports from New

Zealand5 and Australia,6 and in the United States

nursing journals have extensively covered the longstanding

issues of incompetent or impaired surgeons,

corrupt hospital administration, and maltreatment of

patients.78 As in the McBride case,9 the exposure of

fraudulent research depends largely on whistleblowers.

Other important public health issues are environmental

contamination; the safety of roads, trains, and

aeroplanes; and protection from disease. To prevent

disasters we depend on the conscientiousness,

efficiency, and incorruptibility of the responsible

institutions and, if things have slipped, on individual

whistleblowers to raise the alarm. But however desirable

whistleblowing may be for the public good, people

who expose corruption and malpractice, even in a

democracy, do so at considerable personal risk.

A support group, Whistleblowers Australia, was

founded in July 1991 because of concern about cases of

victimisation of whistleblowers. After a publicity

campaign many previously unknown whistleblowers

made contact, and it rapidly became obvious that they

were seriously traumatised with appreciable health

problems. Although the protective legislation recognises

that whistleblowers are likely to suffer, there are

no published medical reports on their suffering, and,

although most whistleblowers seek medical help, there

is no guidance on how best to care for them. I

conducted a questionnaire survey late in 1992 of

whistleblowers who had contacted Whistleblowers

Australia during the previous 12 months.

Subjects and methods

A questionnaire was developed in consultation with

Whistleblowers Australia. This covered problems

which seemed common, including items from a less

detailed survey in the United States.'0 One hundred

and fifty seven people who had contacted the support

group were asked if they would agree to receive the

questionnaire. Ninety two questionnaires were sent

out to those who agreed, with a reminder two months

later. Thirty five were returned in time for this

analysis. Although the questionnaires were anonymous,

suspicion of Whistleblowers Australia, then an

unknown quantity, seemed a major factor for failing to

respond; reluctance to reopen old wounds was another.

The sample was not random in any way. Subjects

made contact because they were dissatisfied.

There were 25 men and 10 women from several

states. Only two were under 35 years of age; 22 were

between 35 and 50; and the rest were over 50. Ten had

exposed the corruption or malpractice less than two

years before; 11, 2-4 years before; five 5-10 years

before; five 11-20 years before; and four more than

20 years before.

Eight were public servants; four each were in health,

transport, or teaching; three each were in banking or

finance, law enforcement, or local government; and the

remaining six worked in other disciplines, including

four who had not worked for the organisation they had

confronted.

Subjects classified the type of problem they sought

to expose predominantly as corruption (often coupled

with waste and mismanagement) and danger to the

public (table I). Some cases entailed both.

Results

All subjects had started by making a complaint

internally, through what they considered were the

proper channels. Three had not made a complaint but

submitted a report during the normal course of their

duties. Three subjects had not progressed beyond

making an internal complaint. The remaining 32 had

subsequently complained to some official external

body-for example, ombudsmen, members of parlia-

BMJ VOLUME 307 1 1 SEPTEMBER 1993 667

TABLE I-Comrption and malpractice exposed by 35 w}

Corruption

Estimated cost to taxpayer (SA):

100 million

1 million-30 million

100 000-900 000

Thousands

Danger or damage to public

Disease/contamination

Unsafe:

Hospital equipment

Aircraft

Railway signals

Work conditions

Licensing of incompetent drivers

Child sexual abuse

Arson-sabotage

Wrongful eviction

Insider trading

Immigration rackets

ment, their union, the Independent 4

Against Corruption, the auditor general.'

of external bodies appealed to ranged fror

Only 17 subjects had approached the mec

only after exhausting internal and external ,

Fifty external bodies were mentione

several states, so the numbers for each

Only three were rated as helpful by mo

person. Unions scored two helpful ratings

harmful, seven neither helpful nor harmi

hopeless. Only six bodies scored any helpf

while there were 22 harmful and 51 neithe

harmful mentions.

The problem complained of continued

or increased in 25 cases, decreased in fo

unknown in the remaining six. No actic

taken against those responsible or the

promoted in 30 cases, and in five cases thi

ible had received minor disciplinary action

case were all those responsible discipline

promoted.

Thirty four of the 35 subjects had been '

a result of exposing the misconduct; the oi

had not been working for the organisatior

In three cases victimisation started

complaint-for example, when they refuse

26 it started immediately after their first c

five it was delayed (range 3 weeks to 8 m

form of victimisation is detailed in table I

people originally working for the bodz

TABLE II-Types of victimisation expeienced by 31 whi

Major change to job

Dismissal

Pressured to resign

Position abolished

Transferred to another town

Pressed to take redundancy

Informal tactics

Personal isolation

Removal of normal work

Abuse/denigration

Forced psychiatric referral

Under scrutiny/regular inspections

Impossible demands

Physical isolation

Threat of:

Defamation action

Disciplinary action

Demotion

Accusations

Other harassment*

*For example, performance of menial duties, denial of

from site, removal of files, death threats, adverse report

inquiries, falsification of records, unrelated charges, adver

from previous supervisors.

histleblowers fronted, only three were still employed by the organisation

at the same level. Five others had been demoted,

No of subjects with three more having taken prolonged sick leave or

workers' compensation. Eight had been dismissed.

Three had retired at the expected time; another nine

3 had retired early or resigned because of ill health

9 related to victimisation.

5 Ten of the whole sample were currently unemployed,

two were working part time for a new employer, and

2 two were receiving an invalid's pension. Only 10 of the

35 were currently working full time in any job.

I Fewer than 18 subjects received support from

I workmates; 26 of them were ostracised, actively

1 victimised, and betrayed to some extent.

1 Twenty seven had been in a long term relationship at 2l

the time they exposed the corruption or malpractice.

Twenty were still in that relationship, which had been

negatively affected in 10 and positively affected in one;

the effect was neutral in nine, but most subjects citing a

neutral effect made it clear that there had been both

Commission positive and negative components. Five of the remain-

The number ing seven said that the whistleblowing was wholly

n one to 13. responsible for the breakdown of the relationship; two na and then said that it was partly responsible. Five had never

avenues, married, two saying that their whistleblowing made

d, covering finding a partner difficult.

were small The 30 subjects with children had a total of 77. Of ,re than one these, 60 had been adversely affected by divorce and

but also six forced separation of their parents; disrupted educa-

[u1l and one tion, anxiety, insecurity, and stress; poverty; public

ul mentions attacks on the parent's image; anger and loss of faith;

r helpful nor and the parent giving a role model of constant conflict,

being preoccupied, absent, unable to relate, and in

unchanged poor physical or mental health and having little time

our, and was for or interest in the children's activities. Three cases

)n had been involved organised crime: one family was unable to go

y had been out because the father was under police protection with

Lose respons- a contract on his life; a 6 year old girl received a

In only one personal death threat letter; and a teenage boy's pets

:d and none were killed.

Loss of income occurred in 25 cases. In 11 the

victimised as decrease was half or less; in 14 it was three quarters or

ne exception more. Other costs were predominantly legal and

concerned. medical. Total estimated financial loss was thousands

before any of Australian dollars in six, tens of thousands in eight,

d a bribe. In hundreds of thousands in 16, and one million in one

omplaint. In long running case.

tonths). The Twenty nine subjects experienced symptoms they

I. Of the 31 attributed to stress. The most common were difficulty

y they con- in sleeping, anxiety, panic attacks, depression, suicidal

thoughts, and feelings of guilt and worthlessness.

Other symptoms included nervous diarrhoea, trouble

istleblowers in breathing, stomach problems, loss of appetite, loss

of weight, high blood pressure, palpitations, hair loss,

No of subjects grinding of teeth, nightmares, headaches, tiredness,

weeping, tremor, frequency of urination, and feeling

stressed. In addition, one subject developed diabetes

8 and another stomach cancer, which both attributed to 153

the stress but were probably not related to it. Those

5 with symptoms had an average of 5-3 when under the

greatest stress and an average of 3-6 currently. Fifteen

were prescribed drugs that they had not been taking

17 before for depression, hypertension, and peptic ulcers.

15 Two had attempted suicide, one twice; 17 had con-

13 sidered suicide, 10 seriously. Eighteen subjects were

192 non-drinkers at the time they blew the whistle. Of the

8 19 current drinkers., five considered that drinkingy was

7 now a problem. Six were smokers. All had increased

7 their intake.

5 Thirteen subjects (10 men, three women) were

18 forced by their employer to see a psychiatrist, under

threat of disciplinary action. Subjects saw a median of

benefits, barring three (range 1 to 6) psychiatrists. Four found the

ts, fines, intemal experience helpful or neutral and nine found it uihelpful

or distressing. In three more cases the employer

668 BMJ VOLUME 307 11 SEPTEMBER 1993

tried to insist on a consultation with a psychiatrist but

was successfully resisted.

The most upsetting aspects of the experience were

classed as lies, deceit, and corruption in high places

(15); attacks or harassment (five); effects on health or

career (four); destruction of family and distress to

family and friends (four); the guilty not being brought

to account (three); and isolation, loneliness, and loss of

friends (three).

Nineteen subjects said that they still thought about

the whistleblowing and its aftermath daily, 18 of them

for an hour or more. This occurred regardless of how

long ago it happened.

Fifteen subjects thought that they had been

damaged as a person by the experience, 13 felt

strengthened, and six felt both damaged and strengthened.

In an estimate of personality type with a rough

adaptation of the Myer Briggs system, 21 subjects were

introverted and 14 extraverted." On the remaining

three axes the sensing, thinking, perceiving combination

occurred in 16.

Twenty one subjects classed themselves as Christian

and 14 as having no formal belief.

The motives behind their action were described by

31 subjects as duty, justice, concern for others, and a

desire to stop the wrongdoing; two gave no reason and

two more personal reasons.

Despite what had happened, 23 subjects said that

they would to it again because, "Deep down I know I

did the right thing, and by my doing it, it may help

others to do the right thing." Six said that they would

not and six were unsure. Twelve, however, advised

others not to expose corruption or to think hard or

twice about it. Other advice was to be thoroughly

prepared: get outside help or advice first, research legal

and other aspects, document everything, including by

audio tape and videotape, and go straight to an outside

agency rather than expose oneself to the employer.

When they were asked who or what had helped them

most four responded "nothing"; 10 nominated family

members or a helping professional; and 12 other

whistleblowers.

Discussion

This non-random sample cannot be said to be typical

of everyone who blows the whistle. Whistleblowers

who had been fairly treated would not have contacted

Whistleblowers Australia. Those who contacted the

support group may not be typical either, perhaps being

more assertive or less thoroughly crushed than others

who did not. Nevertheless, in this small and essentially

anecdotal study the similarity of the treatment meted

out by different management staff, in different

organisations, and even in different countries'2-'4 is

striking. "They all seem to be following the same

handbook," as one subject put it. Some techniques,

such as putting the whistleblower in a bare office with

no telephone, seem almost diagnostic.

SHOOTING THE MESSENGER

In their response organisations can use any number

of staff, for as long as it takes, to wear the lone

whistleblower down. Their aim seems to be to isolate

whistleblowers as incompetent, disloyal, troublesome,

mentally unbalanced, or ill; to force them to leave; to

frighten and alienate workmates and other supporters;

and to avoid examining the issues they are complaining

about. In the survey this had mostly been achieved: the

wrongdoing continued, while the whistleblowers were

left discredited and in poor health and poverty with

their careers in ruins.

Whistleblowing is a type of "principled organisational

dissent,"" highlighting parallels with heresy,

mutiny, political dissent under totalitarian regimes,

and intellectual dissent.'6 Principled dissenters challenge

immediate and accepted authority because of

conflict with what they regard as a higher authoritytruth,

justice, the public interest, or God.

Whistleblowers, however, may not always realise

they are dissenting as the stated principles of organisations

usually outlaw malpractice. It is often shattering

for them to find deviance supported while they are

savagely victimised.

It is disappointing that statutory authorities so often

fail to help, seeming, like most workmates, to side with

employers as part of the authority system. Obedience

to authority and group conformity seem to be central to

this. In the agentic state described by Milgram most

people seem willing to do almost anything to others,

disregarding personal morality, as long as some

authority figure seems to be ultimately responsible.'7

Forcing whistleblowers to see psychiatrists in order

to discredit them, usually as having a personality

disorder that could account for their irrational obsession

with malpractice, is reminiscent of Soviet misuse

of psychiatry."I If the first psychiatrist's report is

unhelpful the subject can be forced to see another until

the desired result is achieved. This practice is clearly

unethical: coercion invalidates consent. (The personalities

of the subjects in this study were not unusual,

but nearly half were of the sensing, thinking, perceiving

type (about 12% of the population), which is

considered to be particularly suited to quality control

or accountancy."')

CARING FORTHE MESSENGER

Doctors whose help whistleblowers seek voluntarily

should aim at avoiding the common end result of lonely

and bitter obsession, chronic anxiety, and other stress

related illness in someone who is often unemployable

and whose family is suffering or gone.

The victims must be reassured that what they are

experiencing is a recognised phenomenon, occurring

not because of their inadequacy but because of the

organisation's failure to deal with the issues they have

raised. Attacks on their credibility, competence,

personality, and worth are "shooting the messenger"

and to be understood as part of the process rather than

taken personally. Intense guilt, anger, and mistrust are

normal responses, and victims need safe opportunities

to express these emotions to the doctor while not

allowing them to increase the painful isolation they are

already feeling.

The doctor also needs to advise on priorities.

Intensely preoccupied with the injustice of the

employer's reaction, and often incapacitated by

anxiety and depression, whistleblowers tend to expend

all their energy trying to get action on the malpractice.

But this may take many years, and four priorities must

apply.

(1) Look after the whistleblowers' physical and

mental health. Victims have to be convinced of the

need for regular excercise, relaxation, and time off

from the stress. Support will reduce the need for

symptomatic relief, but antidepressants may become

necessary. Patients should be warned of the risks of

dependence on alcohol, smoking, and benzodiazepines,

which should be used only sparingly. Previous

vulnerability-for example, from abuse in childhood

-may be reactivated and will usually require psychiatric

referral.

(2) Provide support for spouse and family. The

doctor can help by seeing the spouse, arranging

appropriate referral, and helping the couple to overcome

the feelings of guilt and shame that may be

inhibiting their enlisting help from family, church, and

community.

(3) Seek the best possible exit from what is happen-

BMJ VOLUME 307 11 SEPTEMBER 1993 669

ing at work. Transfer to another department or leaving

with the best possible financial settlement may be

possible. Periods of sick leave are often needed to give

breathing space from victimisation in order to consider

options adequately.

(4) After all of these are in place start tackling the

malpractice.

The doctor may be able to advise on external sources

of help and support. But what helped many whistleblowers

in this study most was the opportunity to meet

others in the same situation. Most did so for the first

time through Whistleblowers Australia. If there is no

such contact point available it would be worth considering

setting one up by advertising locally.

PREVENTION

Prevention of the problem, rather than its management,

is obviously preferable. Given the importance of

the issues, preventing whistleblowing itself is not really

an option. Prevention of the workplace reaction is

essential, which the legislation tries to do. Unfortunately,

the reaction nearly always starts immediately

after the first (internal) complaint. By the time whistleblowers

realise that the complaint is not being handled

appropriately it is already too late-the employer has

victimised (possibly dismissed) them and is unable to

withdraw without losing face and possibly being liable

for damages.

Educating managers is essential-on group

dynamics, the damage done to whistleblowers, their

families, and the community, and the damage that

failure to correct malpractice will in due course do to

the organisation their denial tries to protect. More

research, including both managers and staff, is

urgently needed to find ways of changing this important

and potentially devastating aspect of human

behaviour.

I thank Ingrid Reynolds for help in designing the questionnaire

and for reviewing the manuscript.

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(Accepted 20Jsdy 1993)

Economic Evaluation and Health Care

What does it mean?

Ray Robinson

This is thefirst in a series of

articles that describe the ways

in which methods ofeconomic

evaluation may be used to

assess the economic costs and

consequences associated with

differentforms ofhealth care

intervention.

Institute for Health Policy

Studies, University of

Southampton,

Southampton S09 SNH

Ray Robinson, professor of

health policy

BMJ 1993;307:670-3

Ever since the concept of value for money in health

care was introduced into the NHS, economic terms

and jargon have become part of our everyday livesbut

do we understand what the different types of

economic evaluation all mean, particularly those

that sound similar to the uninintiated? This article

introduces readers to the purpose of economic

evaluation, and briefly explains the differences

between cost-minimisation analysis (used when the

outcomes of the procedures being compared are the

same); cost-effectiveness analysis (used when

the outcomes may vary, but can be expressed in

common natural units, such asmmHgfor treatments

of hypertension); cost-utility analysis (used when

outcomes do vary-for example, quality of life

scales); and cost-benefit analysis (used when a

monetary value is being placed on services received).

Further articles will deal with each one in more

detail.

Economic evaluation is a technique that was developed

by economists to assist decision making when choices

have to be made between several courses of action. In

essence, it entails drawing up a balance sheet of the

advantages (benefits) and disadvantages (costs)

associated with each option so that choices can be

made. Although the precise forms of economic

evaluation may vary, the "cost-benefit" framework is

common to all of them and constitutes the distinctive

feature of this approach.

Origins

The most widely known form of economic evaluation,

cost-benefit analysis, was developed over 50 years

ago to assist public sector investment planning. Unlike

the private sector, where costs, prices, and profits can

be used as a guide to decisions about investment, goods

and services provided by the public sector are often

provided free (or at least substantially below their costs

of production) or the prices charged to the consumer

do not reflect the full social benefit of the service. In

such cases there is a need for an alternative to private

sector profit and loss accounting.

Early applications of cost-benefit analysis were

undertaken in the United States during the 1930s in

connection with flood control programmes. In Britain,

it started to be applied widely during the 1960s to

transport investment projects (for example, the MI

motorway, the Victoria underground line, and the

proposed third London airport). Since then it has been

applied in various forms and contexts, including

education, town planning, and health care.

670 BMJ VOLUME 307 ilsEPrEmBER 1993