Norm enforcement, learning and repair: three moral logics in organisational responses to unintended and unwanted healthcare outcomes.

Unintended and unwanted outcomes are an inherent aspect of healthcare practice, posing significant moral challenges for organisations on how to do justice to the situation and the people involved, aimed at strengthening safety and preventing future harm. How an organisation responds to these outcomes is crucial, as this affects the quality of care, public trust and can have a profound impact on both patients and healthcare professionals. This paper develops a conceptual framework delineating three distinct moral logics for responding to unintended and unwanted outcomes: norm enforcement (1), learning (2) and repair (3). Enforcement logic (1) emphasises safeguarding patients by dealing with unprofessional or unlawful actions; learning logic (2) seeks to prevent recurrence by improving systems and practices; and repair logic (3) focuses on addressing harm to patients and restoring trust. Our analysis reveals that, while analytically distinct and potentially complementary, these moral logics often overlap in practice and may generate tensions because they rely on different understandings of justice, accountability and appropriate organisational response. Our analysis underscores both the distinctions between these logics and a selected set of tensions that arise when they intersect, focusing on three central configurations of tension while recognising that other combinations are also possible. We identify three key causes of tension: first, norm enforcement (1) allows little room for doubt or reflection, which is essential for learning (2) and repair (3); second, current quality and regulatory systems pay relatively little attention to repair (3); and third, societal demands for publicity and transparency put pressure on learning (2) and repair processes (3). Our study's key contribution is recognising and understanding such moral logics and tensions. This can guide the development of more coherent and effective responses that ultimately enhance the quality of care and sustain trust in healthcare systems.