At first glance, Michael Swango's case may look more like a healthcare provider turned serial killer than a problem in organizational ethics. It's easy to interpret the moral story as one man's malevolence toward his patients and co-workers, not bureaucratic bumbling. Further moral analysis might seem pointless, in part because other moral issues are oblique and difficult to identify — there are many moral actors (doctors, nurses, administrators, and lawyers) and choices. Compared to poisoning and murder, other moral issues in this story seem like peccadilloes, hardly deserving serious critical attention and unrelated to the tragic outcomes.

The tragic events in the Swango case may well be extreme but they are as much the consequence of organizational failure as they are the actions of a deranged individual.

The New Yorker report captures the context of social interactions, most of them predictable and seemingly benign, that set the stage for Swango's misdeeds.

In fact, James Stewart's article highlights many of the problems of organizational ethics. First everyday mistake: fear of litigation becomes the excuse for inaction. Appropriately placed decision makers in the organization had enough evidence to move against Swango, but believed that legal inaction was the prudent course. While many organizational ethics problems do not have such untoward results, that this case had gotten to the brink of criminal investigation should have suggested to organization leaders that alternative grounds for action were mandated. Instead, after the internal investigation, two other suspicious but less well-documented incidents occurred and the chairman of the department nonetheless recommended that Swango be licensed to practice medicine in Ohio.

Second everyday mistake: subtle obstruction. The physicians and administrators resented the checks and balances provided by law enforcement, and they told investigators what they thought the investigators wanted to hear. Passive opposition and misleading information became deadly obstruction. An all too common problem of organizational ethics is the lack, evasion, or even obstruction of checks and balances. The division of labor required in complex organizations and the professional discretion afforded healthcare workers requires all organizations to have checks and balances. The internal professional regulation that served as the checks and balances in this case were insufficient for a complex organization; in fact the hospital group investigating Swango "failed to call the actual witnesses before them for statements." As healthcare organizations rapidly transform into even more complex sets of interactions, professional oversight will offer only one part of the needed checks and balances.

Third commonplace mistake: moral blindness. One physician who reviewed the case stated, "You don't come to a meeting thinking someone is a complicated psychopathic killer." Is this evidence of the personal trait of always wanting to presume the best about people? Is it a professional courtesy of expected reciprocity among professionals? Or, is it an understandable desire to avoid negative publicity for the organization? Certainly the simplest explanation of this blindness is to place the responsibility on the moral weakness of individuals or on the common practice of protection professionals afford each other. Yet about this blindness an investigator stated: "I can only arrive at one conclusion—they didn't want to know. They just wanted him out of the hospital." Pinning the blindness on the organization seems futile, except that it has a greater responsibility. Organizations gain their advantage by a division of labor. Dispersion and coordination of work characterize bureaucratic organization. By necessity, organizations must have oversight and be vigilant, especially where patient welfare is at stake.

It would be easy to miss the organizational ethics problems in this case. Those other than Swango could be exonerated; there was little or nothing they could do from their distance, and why should they be held responsible for the aggregation of infractions committed by a deranged individual? But organizational distance among moral actors and choices and a non-stick moral responsibility approach are features of organizations that must be addressed if there is to be movement in organizational ethics.