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speaking of obligations to account for one s performance, or to hold
others to account for their performance as second-order obligations,
we mean simply that these obligations refer to the relevant primary
obligations. The second-order obligations that make up a system of
accountability remain wholly indeterminate until primary obliga-
tions are specified. Putting matters quite generally, accountability is
achieved when obligation-bearers also have  and meet  second-
order obligations to account for their performance of their primary
obligations to others, who in turn have second-order obligations to
hold them to account for that performance. Accountability is always
second-order, and always presupposes that those who are to be held
to account have adequately specified, internally coherent and fea-
sible sets of primary obligations. (See the appendix to this chapter
for a more explicit and detailed exposition of the formal structure of
systems of accountability.)
In other respects systems of accountability vary greatly. They
may be democratic or corporate, bureaucratic or professional, colle-
giate or military, managerial or regulatory, and of many other sorts;
often accountability is multiple and hybrid. We shall not offer a
taxonomy of systems of accountability. However, we note that
accountability can have many purposes. Traditionally the most
common purposes were to ensure proper use of funds and proper
process. But systems of accountability are also often used for wider
purposes such as controlling others, censuring or sanctioning poor per-
formance, rewarding good performance, providing redress for those
short-changed by poor performance and ranking the performance
Trust, accountability and transparency 169
of different agents or institutions (the latter may be needed to
determine the allocation of scarce goods such as employment,
promotion or funding). However, behind this variety there is a
common structure and a common aim. Systems of accountability
establish second-order obligations (to render an account of perform-
ance; to hold to account for that performance) with the aim of
securing trustworthy performance. They may or may not have the
secondary aim of supporting the intelligent placing and refusal of
trust.
ACCOUNTABI LI TY, TRUSTWORTHI NESS AND TRUST
I N BI OMEDI CI NE
In the UK, as elsewhere, demands for accountability have mush-
roomed. Systems of accountability are more numerous, detailed,
intrusive, expensive and sophisticated than they were twenty or
thirty years ago.13 Nowhere is this more evident than in the
growth of accountability requirements for medicine and biomed-
ical research. If accountability supports rather than replaces trust-
worthiness and trust, we might expect these changes to have
increased levels of trustworthiness, of trust or of both. But this
has not happened. Trustworthiness is constantly questioned by
pointing to cases of actual, presumed or possible medical or
scientific dereliction.14 And trust is widely thought to have
13
Michael Moran, The British Regulatory State: High Modernism and Hyper-innovation
(Oxford: Oxford University Press, 2003).
14
There is a great deal of media coverage of untrustworthy action by individual
clinicians (from Shipman down to local hospital errors), and widespread suspicion
of the motivation and activity of researchers and those who fund and employ them.
Public debates about the proper remedies initially advocated greater public under-
standing of science, subsequently greater public engagement with science, and most
recently greater public engagement with science policy and science funding (so-called
 upstream engagement ). For a summary of the stages of this debate in the UK
and references to the relevant reports see references in note 12, p. 143 and http://
www.foundation.org.uk/pdf18/fst18_8.pdf.
170 Rethinking Informed Consent in Bioethics
declined.15 Although the decline in reported trust in GPs and
nurses is slight, decline in reported trust in  hospital doctors and
scientists, and in other professions, is larger. And there is consid-
erable reported public mistrust of genetics, and of the use, or
potential future use, of genetic information and genetic techno-
logies.16 The coincidence of supposedly rising standards for
accountability with supposed declines in trustworthiness and in
trust might have various causes. For example, it might reflect
reliance on inadequate conceptions of accountability, or inadequate
ways of providing evidence to those whose trust is sought.
Different approaches to accountability may be more or less useful
for different purposes. Some may be particularly well designed to
control the performance of those held to account; some to incentivise
maximal, or reliable, performance of primary tasks; some for penal-
ising inadequate performance or deterring risk-taking. Those who
hold others to account can have a wide range of purposes: they may
be concerned with the bottom line, with the quality of work done,
with avoiding failure, or with ranking performance.
We shall illustrate some of these differences by contrasting two [ Pobierz całość w formacie PDF ]