Sunday, March 15, 2009

The Problem with System Problems

You may have heard of Jennifer Thompson-Cannino and Ronald Cotton, authors of a recently published memoir "Picking Cotton," an accounting of Thompson-Cannino's mistaken identification of Cotton as her rapist and what happened in the aftermath of the tragic error. (Cotton served 11 years in prison before being exonerated by DNA evidence, an event that triggered Thompson-Cannino to experience near-stiffing guilt for her role in his conviction.) I've seen Jennifer and Ronald on 60 Minutes and caught them on several radio interviews, most movingly in a piece recorded for NPR's This I Believe series. (

They're sharing their story, a powerful testimony of love, forgiveness, and redemption. Jennifer and Ronald also champion a cause both hold dear: judicial reform, specifically the processes used to gather and present eyewitness testimony.

Thompson-Cannino and Cotton's journey is particularly remarkable because they have undertaken it together. When an accuser apologizes and a victim forgives, each experiences grace that only the other can offer. We are infrequently given a glimpse of healing like this, healing that comes from such a deeply personal place. But what may be easy to lose in the story of their personal triumphs is the role that system deficits played in the tragedy that befell them.

The problem with "system problems," I think, is that they often beg individual accountability, leaving us with the sensation of a debilitating ethical itch that simply cannot be scratched. Expressions like, "Lead, follow, or get out of the way," and "If not you, who? If not now, when?" suggest a general belief that things are under control, or can be brought under control. It's a matter of personal responsibility. Take me to your leader! If good people bring the good times, surely bad people must bring the bad.

So it's particularly interesting to me that Thompson-Cannino and Cotton, two people whose capacity for introspection and personal accountability are remarkably deep, are talking about system problems, looking past "the people" to focus on "the processes."

An analysis of events in the Cotton case reveals that the circumstances that led to Thompson-Cannino's initial identification of the perpetrator predisposed her to identify the most likely attacker, not the attacker. Cues and clues, erroneously, but not maliciously, offered by investigating officers further reinforced Jennifer's perception that she was right. The 60 Minutes piece was told, in part, by another person affected by this tragedy: the detective who investigated the case. A professional who, using the standard operating procedures employed at the time, helped to send an innocent man to prison for 11 years. If you're feeling the beginnings of an ethical itch, it may or may not be helpful to know that more than 75% of individuals convicted of crimes, then later exonerated because of DNA evidence, were convicted with eyewitness testimony that turned out to be erroneous.

DNA now offers us access to highly reliable evidence about what happened to who, under what circumstances, and where. When it's available, DNA evidence can corroborate or refute eyewitness testimony, making the likelihood of uncovering an objective truth far greater than it ever has been. Even without DNA evidence, the procedures used to identify perpetrators and preserve, but not influence, the memories of victims are now evidenced-based and should look different today than they did 25 years ago.

I think it would be fair, a word I use with great caution given what happened to Ronald Cotton, to say that it was not wrong to have used 'standard operating procedure' 25 years ago. But it would be wrong to use 25-year-old standard operating procedures today. It would be wrong to continue to do things in an unreliable way when someone's liberty or someone's life is at stake.

System level analysis offers a way to improve reliability in judicial processes, in aviation, in healthcare. It gives people who are very close to the action--like patients and clinicians--tools to see that everything may not be exactly as it appears on the surface.

That's what we're going to tease apart and talk about here at Florence dot com! I hope you'll come back again. Because it is not wrong to have used standard operating procedure 25 years ago, but it is wrong to use 25-year-old standard operating procedures today.

Next time: This picture paints a thousand words. (But I'm only going to use 500.)


Kristine said...


Anonymous said...

Great post, Barbara. We need more eloquent voices like yours waving the "systems flag". Please keep writing!

Tom Leifer

John G. Brenner said...

I have worked hundreds if not thousands of homicides, and as an investigator you must be very coherent of the inherent psychology of witness/victims statements but not to the point of disregarding them in whole. Experience is the key.

John G Brenner RN, MS.

Anonymous said...

There is a system problem with personal injury cases where heresay is admisable in the court hearing. Everyone has an expert and the public pay the price for lawyers and diagnostic test done only to impress the jury and not to heal the patient.

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