Accept Respirator Evaluation Request (Action 1) → Valve Flaw Discovered (Event 1)
National Society of Professional Engineers
NSPE Code — Faithful Agent or Trustee Obligation
Agent-Trustee Loyalty Obligation Standard
the fundamental conflict between the obligation to hold paramount the public health and safety and some another key provision of the NSPE Code of Ethics—here the obligation to act for each employer or client as 'faithful agent or trustee'
NSPE Board of Ethical Review in characterizing the ethical dilemma
The obligation to act as a faithful agent or trustee for the employer is identified as a key competing provision of the NSPE Code that must be balanced against the paramount public safety duty; frames the core ethical tension Engineer A faces
BER 76-4 Client-Suppressed Findings at Public Hearing
From XYZ Corporation's termination of Engineer Doe's contract through the public hearing at which contradictory data was presented
the corporation terminated the contract with Engineer Doe with full payment for services performed and instructed Engineer Doe not to render a written report
Client-Suppressed Findings at Public Hearing State
Engineer Doe's findings suppressed by XYZ Corporation while corporation presents contradictory data at public regulatory hearing
Board's conclusion that Engineer Doe had an ethical obligation to report his findings to the authority upon learning of the hearing
the XYZ Corporation had presented data to support its view that the present discharge met minimum standards
XYZ Corporation instructed Engineer Doe not to render a written report, then presented data to the authority supporting its view that discharge met minimum standards
BER 76-4 Public Hearing Triggering Condition Factual Distinguishability from Engineer A MedTech
Engineer A considered whether BER Case No. 76-4 (Engineer Doe/XYZ Corporation public hearing) required him to immediately report the infant respirator concern to governmental authorities, but the Board found the cases factually distinguishable.
Precedent Factual Distinguishability Non-Automatic Application Constraint
Engineer A was constrained from automatically applying the BER Case No. 76-4 escalation mandate because the triggering conditions of that precedent — a scheduled public hearing, personal involvement in the engineering decision, domain expertise, and completed findings — were all absent from his situation, requiring calibrated rather than automatic application of the precedent.
NSPE BER Case No. 76-4 comparative analysis; NSPE Code of Ethics
In the present case, unlike the facts in BER Case No. 76-4, Engineer A is not faced with a scheduled public hearing at which he believed he had an obligation to correctly report information that was within his personal knowledge
At the time Engineer A assessed his escalation obligations regarding the infant respirator safety concern
Engineer A was not personally involved in the engineering decision-making process and did not have any particular expertise in the technical area involved
unlike the facts and circumstances involved in BER Case No. 76-4
NSPE Board of Ethical Review Case No. 76-4
Among one of the earlier cases of this type was BER Case No. 76-4.
unlike the facts and circumstances involved in BER Case No. 76-4, Engineer A was not personally involved in the engineering decision-making process and did not have any particular expertise in the technical area involved.
NSPE Board of Ethical Review to frame and distinguish the current case
Cited as a directly analogous precedent involving an engineer (Doe) who discovered environmental discharge violations and faced the question of whether to report findings to a public authority at a scheduled hearing; used to distinguish Engineer A's situation by contrasting the presence of a public hearing and direct personal involvement
Benevolent Motive Does Not Cure Ethical Violation Applied to Engineer A's Threat
Engineer A's threat to report to governmental authorities before exhausting internal mechanisms
Graduated Internal Escalation Before External Reporting Obligation
Engineer A's good faith and well-intentioned motivation for threatening external reporting did not render that threat ethically appropriate — the Board holds that the premature external threat was not a reasonable or ethical response regardless of Engineer A's praiseworthy concern for public safety.
Good intentions and genuine safety concern are ethically relevant mitigating factors but do not transform a procedurally inappropriate escalation action into an ethically permissible one.
Engineer A Medical Device Safety Review Engineer
Benevolent Motive Does Not Cure Ethical Violation
Although an experienced professional engineer and by all indications a well-intended individual acting in good faith, as is sometimes the case in matters of this type, Engineer A may not be in possession of all of the necessary information to make an informed judgment. Engineer A's statement—which essentially amounted to a threat to the manager—was not a reasonable or ethical response to the circumstances in question.
The Board acknowledges Engineer A's good faith while still holding that the form of his escalation was ethically inappropriate.
Although an experienced professional engineer and by all indications a well-intended individual acting in good faith
Engineer A's statement—which essentially amounted to a threat to the manager—was not a reasonable or ethical response to the circumstances in question.
CausalLink_Accept Respirator Evaluation R
CausalLink_Defer to Internal Resolution P
CausalLink_Identify and Report Valve Flaw
CausalLink_Threaten Regulatory Agency Rep
NSPE Ethics Framework — Employer Loyalty vs. Public Safety Balancing
Client Confidentiality vs. Public Safety Balancing Framework
sometimes mitigating factors and circumstances impact upon one's understanding of this conflict (e.g., the knowledge held by the engineer, the risks involved, level of personal involvement, actions taken and not taken by individual the engineer/employer, and other factors)
those concerns should be balanced with other legitimate factors, including the objective consideration of the concerns, the level of potential risk involved, and a review of appropriate 'next steps' to address the issue
NSPE Board of Ethical Review in analyzing the competing obligations
The Board applies a balancing framework weighing Engineer A's loyalty to MedTech against his paramount public safety obligation, incorporating mitigating factors such as the engineer's level of personal involvement, technical expertise, completeness of information, and the risk level involved
Client Report Suppression Prohibition Applied to XYZ Corporation Instruction to Engineer Doe
XYZ Corporation's instruction not to render a written report
XYZ Corporation's presentation of contrary data at the public hearing
Faithful Agent Obligation Within Ethical Limits
XYZ Corporation's instruction to Engineer Doe not to render a written report after terminating his contract — combined with the corporation's subsequent presentation of contrary data at the public hearing — constituted a paradigm case of client report suppression that Engineer Doe's professional obligations required him to overcome by reporting to the regulatory authority.
The client's authority to terminate the engagement and instruct against a written report did not extinguish Engineer Doe's professional obligation to ensure that his safety-relevant findings reached the regulatory authority, particularly when the client was actively misrepresenting the situation.
Engineer Doe Consulting Engineer Discovering Regulatory Violation
the corporation terminated the contract with Engineer Doe with full payment for services performed and instructed Engineer Doe not to render a written report to the corporation.
Client report suppression instruction is overridden by public welfare paramount when the suppressed findings are material to public health and the client is actively presenting contrary information to regulators.
Thereafter, Engineer Doe learned that the authority had called a public hearing and that the XYZ Corporation had presented data to support its view that the present discharge met minimum standards.
Comparative Case Precedent Distinguishing Obligation Applied to BER 76-4 vs Present Case
Board's ethical analysis comparing Engineer A's situation to BER Case No. 76-4
The Board explicitly distinguishes the present case from BER 76-4 by identifying three material factual differences — absence of a public hearing, Engineer A's lack of personal involvement in the engineering decision, and Engineer A's lack of specialized expertise — and uses those distinctions to derive a different (though related) set of obligations for Engineer A.
The Board's analogical reasoning from BER 76-4 illustrates how professional ethics gains operational meaning through case precedents — the prior case establishes the principle, and the present case refines it by identifying the conditions under which a different application is required.
Comparative Case Precedent Distinguishing Obligation
In the present case, unlike the facts in BER Case No. 76-4, Engineer A is not faced with a scheduled public hearing at which he believed he had an obligation to correctly report information that was within his personal knowledge and for which the failure to report could result in a direct and demonstrable harm to the public.
Material factual distinctions justify a different obligation profile while preserving the underlying principle that public welfare is paramount.
In the present case, unlike the facts in BER Case No. 76-4, Engineer A is not faced with a scheduled public hearing
unlike the facts and circumstances involved in BER Case No. 76-4, Engineer A was not personally involved in the engineering decision-making process and did not have any particular expertise in the technical area involved
It was not ethical for Engineer A to indicate that if prompt measures are not taken to correct the problem, he will be compelled to report the matter to an appropriate federal regulatory agency.
Beyond the Board's finding that Engineer A's external reporting threat was premature, the analysis reveals a structural gap in the Board's reasoning: it does not specify what internal escalation steps would have been sufficient before such a threat became ethically permissible. In a medical device manufacturing context like MedTech, internal mechanisms available to Engineer A would plausibly include escalation to senior engineering leadership above the non-engineer manager, referral to a formal product safety committee, engagement with legal or regulatory compliance counsel, or invocation of an internal ethics reporting channel. The Board's conclusion that Engineer A had not exhausted internal mechanisms carries limited practical guidance unless these pathways are enumerated. A non-engineer manager's continued inaction does not, by itself, constitute organizational inaction when a design team investigation is actively underway—but neither does an active investigation constitute a blanket justification for indefinite delay when hundreds of potentially defective devices are already in hospital use. The Board should have articulated a clearer threshold: Engineer A's next ethical obligation was to escalate vertically within MedTech's engineering hierarchy, not to threaten external reporting, and only after that vertical escalation failed would the external threat have been proportionate.
The Board's conclusion that Engineer A's threat was premature does not adequately reckon with the compounding moral weight introduced by the proliferation of hundreds of potentially defective infant respirators into hospital settings. The Board appears to treat the graduated escalation obligation as a fixed procedural sequence insensitive to the rate at which risk accumulates in the external environment. However, a proportionality-sensitive reading of the public welfare paramount principle suggests that the ethical permissibility of escalation steps is not static—it contracts as the population of vulnerable patients exposed to an unresolved defect grows. Infants on respirators represent a maximally vulnerable patient population incapable of self-advocacy, and the absence of reported incidents does not diminish the actuarial significance of hundreds of deployed devices with a potentially misplaced relief valve. The Board's conclusion would have been strengthened had it acknowledged that while Engineer A's threat was procedurally premature given the active internal investigation, the growing device circulation created a legitimate urgency that meaningfully compressed—though did not eliminate—the normal graduated escalation timeline. Failing to acknowledge this compression risks implying that procedural compliance with escalation sequences is ethically sufficient regardless of how rapidly external risk accumulates, a conclusion that sits in tension with the paramount public safety obligation.
The Board's distinction between this case and BER Case 76-4—where Engineer Doe faced active client suppression of findings at a public regulatory hearing—reveals an implicit but underexamined asymmetry in the ethical standards applied to engineers depending on whether their employer engages in active suppression versus passive delay. In BER 76-4, the triggering condition for permissible external action was the employer's affirmative act of presenting contradictory data at a public hearing, a clear and observable ethical violation. In the present case, MedTech's conduct is characterized by organizational inertia and delegation to an ongoing investigation rather than active concealment. The Board's stricter standard applied to Engineer A in the passive-delay scenario may inadvertently create a perverse incentive structure: employers who actively suppress findings cross a bright ethical line that liberates the engineer to act, while employers who engage in prolonged but nominally active internal review can forestall engineer escalation indefinitely without triggering the same ethical permission. A more complete analysis would have addressed this asymmetry by specifying that passive organizational delay, when combined with growing external risk exposure and the absence of meaningful progress indicators, can become functionally equivalent to active suppression for purposes of the engineer's escalation obligation—and that the Board's graduated escalation framework must include a temporal limit beyond which continued deference to an 'ongoing investigation' is no longer ethically distinguishable from acquiescence to inaction.
The Board's conclusion does not adequately address the ethical significance of Engineer A's acknowledged non-expert status in respirator design, and how that epistemic limitation should modulate—but not nullify—his escalation obligations. Engineer A's concern is grounded in good faith observation rather than confirmed technical violation: he identified a potentially misplaced relief valve without the domain expertise to certify that the placement is definitively dangerous. This epistemic limitation has two competing ethical implications that the Board leaves unresolved. On one hand, epistemic humility counsels deference to the design team's ongoing investigation, since the team possesses the domain competence Engineer A lacks and may determine that the valve placement is within acceptable safety parameters. On the other hand, the non-expert status does not extinguish Engineer A's obligation to raise and re-raise a good faith safety concern—it merely affects the confidence level at which he can assert that a violation exists. The Board should have clarified that Engineer A's non-expert status makes the external reporting threat premature not only because internal mechanisms were unexhausted, but also because the factual predicate for external reporting—a confirmed or highly probable safety defect—had not yet been established by competent evaluation. This framing would have provided a more principled basis for the Board's conclusion than the procedural escalation argument alone, and would have better guided engineers in analogous situations where they identify concerns outside their primary domain of expertise.
In response to Q101, Engineer A's acknowledged non-expert status in respirator design meaningfully constrains the ethical weight his safety assessment can carry when justifying an escalation to external regulatory threat. Because his concern rests on good-faith observation rather than confirmed technical violation—no incidents had been reported and no applicable safety standard had been demonstrably breached—the epistemic foundation for bypassing remaining internal channels is weaker than it would be for a domain expert. This does not nullify his obligation to act; the NSPE Code's public safety paramount principle applies regardless of specialization. However, proportionality requires that the strength of the escalation response be calibrated to the certainty of the underlying risk assessment. A non-expert's good-faith concern, while ethically cognizable and worthy of vigorous internal advocacy, does not by itself generate sufficient epistemic warrant to compress the graduated escalation timeline to the point of immediately threatening federal regulatory reporting after only a single month of organizational delay. The proportionality of Engineer A's response was therefore diminished, not eliminated, by his competence limitation.
In response to Q102, the fact that MedTech's design team was actively investigating the concern at the time Engineer A issued his regulatory reporting threat constitutes a meaningful mitigating factor that the Board should have weighed more explicitly, though it does not fully exonerate Engineer A's procedural choice. The ethical distinction between genuine organizational inaction and a legitimate ongoing investigation is critical: inaction warrants accelerated escalation, while active investigation warrants monitored deference with a defined deadline. An engineer in Engineer A's position should assess whether the investigation is staffed by competent personnel, whether it has a defined timeline, and whether the organizational response is proportionate to the risk profile. Here, the design team's involvement by domain-competent engineers suggests the matter was not being ignored but was being processed through appropriate channels. Engineer A's failure to distinguish between these two states—and his issuance of an external threat while an internal investigation was underway—reflects a lapse in practical judgment. The ethically appropriate response upon learning of the active investigation would have been to demand a specific resolution deadline from the manager and escalate internally to senior engineering leadership if that deadline was not honored, rather than immediately threatening federal regulatory reporting.
In response to Q103, the Board's conclusion that Engineer A had not exhausted internal mechanisms before threatening external reporting would be substantially strengthened by specifying what those mechanisms entail in a medical device manufacturing context. In a company like MedTech, internal escalation pathways reasonably include: (1) escalation beyond the non-engineer manager to senior engineering leadership or a chief engineer; (2) referral to a formal product safety committee or quality assurance function; (3) consultation with in-house legal counsel regarding regulatory obligations under FDA medical device frameworks; and (4) use of any internal ethics hotline or compliance reporting channel. Engineer A's escalation path—reporting to a non-engineer manager, waiting one month, and then threatening external reporting upon learning of an active design team review—skipped multiple of these intermediate steps. The non-engineer manager's authority limitation is itself a signal that Engineer A should have escalated laterally or upward within the engineering hierarchy rather than treating the manager's continued uncertainty as organizational finality. The Board's conclusion implicitly rests on this reasoning but would carry greater practical guidance if it enumerated these pathways explicitly.
In response to Q104, the proliferation of hundreds of potentially defective infant respirators into hospitals does create a heightened urgency that compresses the normal graduated escalation timeline, but it does not compress it to zero. The vulnerability of the patient population—infants on respiratory support—and the growing market exposure are morally relevant factors that shift the proportionality calculus in Engineer A's favor. However, urgency calibrated to patient vulnerability does not automatically justify skipping intermediate internal escalation steps; it justifies accelerating them. The ethical response to growing circulation risk is to escalate more rapidly and more forcefully within the organization—demanding immediate access to senior engineering leadership, invoking formal safety committee review, and setting explicit short deadlines—before resorting to an external regulatory threat. The Board's conclusion that Engineer A's threat was premature remains defensible even accounting for infant vulnerability, because the internal escalation pathway had not been fully traversed. What the vulnerability factor does establish is that Engineer A's ultimate obligation to report externally, if internal mechanisms fail, is stronger and arises sooner than it would in a case involving less vulnerable end users.
In response to Q201, the tension between the public safety paramount principle and the faithful agent obligation to MedTech is not resolved by the Board's conclusion in a way that fully accounts for the intermediate nature of Engineer A's conduct. The Board correctly identifies that Engineer A had not yet exhausted internal mechanisms, which means the faithful agent obligation had not yet been overridden by the public safety paramount principle. However, the Board's reasoning implies a sequential model: faithful agent obligations persist until internal mechanisms are genuinely exhausted, at which point public safety paramount takes precedence and external reporting becomes not only permissible but obligatory. Under this model, Engineer A's error was one of timing and sequencing, not of ultimate direction. The NSPE Code resolves the tension by treating public safety as lexically superior but procedurally conditioned: the engineer must first demonstrate that the employer has been given a genuine and complete opportunity to self-correct before the faithful agent obligation yields. Because MedTech was neither actively suppressing findings nor demonstrably ignoring them—the design team was actively investigating—the faithful agent obligation had not yet been fully discharged, and the external threat was therefore premature.
In response to Q202, the conflict between epistemic humility—requiring deference to domain experts given Engineer A's non-expert status—and the principle of non-acquiescence to employer safety inaction reaches its ethical inflection point when deference to an ongoing investigation becomes functionally indistinguishable from passive acquiescence to organizational delay. That inflection point is not reached merely by the passage of one month, particularly when a design team of domain-competent engineers is actively reviewing the concern. Deference becomes ethically impermissible acquiescence when: (1) the investigation lacks a defined timeline or has exceeded a reasonable one; (2) the investigation is staffed by personnel without relevant competence; (3) the organizational response is demonstrably disproportionate to the risk profile; or (4) the employer has explicitly rejected the safety concern on non-technical grounds such as cost. None of these conditions were clearly established in the present case at the time Engineer A issued his threat. Epistemic humility therefore counseled continued monitored deference with escalating internal pressure, not an immediate external reporting threat. The non-acquiescence principle would have been properly invoked only after the investigation concluded without remediation or was abandoned.
In response to Q203, it is analytically possible for Engineer A's external reporting threat to be simultaneously procedurally premature and substantively proportionate, and the Board's conclusion does not fully resolve this duality. The benevolent motive principle—that good intentions do not cure an ethical violation—addresses the procedural dimension: Engineer A's concern for infant safety does not excuse his failure to exhaust internal escalation pathways. However, the substantive proportionality question—whether the magnitude of the risk, given hundreds of potentially defective respirators in use with vulnerable infant patients, warranted a response of the intensity Engineer A chose—is a separate inquiry. The Board's conclusion is best understood as addressing procedural ethics rather than substantive proportionality. A complete analysis would acknowledge that Engineer A's instinct about the appropriate ultimate response was not wrong, but his timing was. This distinction matters for practical guidance: engineers facing similar circumstances should understand that the Board's conclusion does not counsel passivity in the face of growing risk, but rather demands that the urgency of the risk be channeled into accelerated internal escalation before external threats are issued.
In response to Q204, the Board's comparative reasoning distinguishing BER Case 76-4 from the present case does create a structural asymmetry that could inadvertently reward employers who engage in passive delay rather than active suppression. In BER 76-4, Engineer Doe faced a client actively presenting contradictory data at a public regulatory hearing—a condition of active deception that triggered an immediate and unambiguous obligation to correct the record. The present case involves neither active suppression nor public deception, only organizational delay during an internal investigation. The Board's stricter graduated escalation standard applied to Engineer A is logically defensible on the facts, but it produces a troubling implication: an employer that actively suppresses findings triggers Engineer A's external reporting obligation immediately, while an employer that passively delays investigation can extend the internal escalation timeline indefinitely. To avoid this perverse incentive, the Board's framework should be supplemented with a principle that passive delay beyond a reasonable, risk-calibrated deadline is ethically equivalent to active suppression for purposes of triggering the external reporting obligation. Without this supplement, the graduated escalation standard may be exploited by employers who understand that appearing to investigate is sufficient to forestall external reporting.
In response to Q301, from a deontological perspective, the duty to hold public safety paramount does not generate an absolute obligation to threaten external reporting the moment internal inaction is confirmed, even under a strict Kantian framework. The categorical imperative requires that the engineer's maxim be universalizable: if every engineer threatened external regulatory reporting after one month of organizational delay during an active internal investigation, the result would be a systematic undermining of the internal safety governance structures that organizations depend upon to function. A universalizable maxim would instead require engineers to exhaust all available internal escalation pathways before resorting to external threats, reserving external reporting for cases of genuine organizational failure rather than organizational delay. Furthermore, the duty of non-maleficence—avoiding unnecessary harm to the employer through premature regulatory intervention—is itself a deontological constraint that must be weighed against the duty to protect public safety. The deontological resolution therefore supports the Board's conclusion: Engineer A's duty was to escalate internally with greater urgency and specificity before issuing an external threat.
In response to Q303, from a consequentialist perspective, the growing circulation of hundreds of potentially defective infant respirators does shift the moral calculus in a direction that partially favors Engineer A's conduct, but does not fully vindicate it. The expected harm calculation must account for: (1) the probability that the relief valve placement actually causes overpressure events; (2) the severity of harm to infant patients if it does; (3) the probability that Engineer A's external reporting threat accelerates remediation versus triggering defensive organizational responses that slow it; and (4) the systemic consequences of normalizing external reporting threats before internal mechanisms are exhausted. On factors (1) and (2), the calculus favors urgency given infant vulnerability and the potential for catastrophic harm. On factors (3) and (4), the calculus is less clear: an external reporting threat may prompt faster action, but it may also cause MedTech to shift resources toward regulatory defense rather than engineering remediation, and it may erode the trust relationships that make internal safety escalation effective across the industry. A consequentialist analysis therefore does not straightforwardly vindicate Engineer A's threat; it suggests that the expected value of accelerated internal escalation—demanding a specific deadline from senior engineering leadership—likely exceeded the expected value of an immediate external reporting threat.
In response to Q304, from a virtue ethics perspective, Engineer A's decision to threaten external regulatory reporting reflects a genuine expression of professional courage and integrity—virtues that the NSPE Code explicitly endorses through its public safety paramount principle—but falls short of the virtue of practical wisdom, or phronesis, that a fully competent professional engineer would exercise. Practical wisdom requires not merely the courage to act on one's convictions but the judgment to act in the right way, at the right time, through the right means, and to the right degree. A practically wise engineer in Engineer A's position would have recognized that the active design team investigation represented a meaningful organizational response, that his own non-expert status counseled epistemic humility about the certainty of the defect, and that the internal escalation pathway had not been fully traversed. The virtuous response would have been to escalate with urgency and specificity to senior engineering leadership, set a clear remediation deadline, and reserve the external reporting threat as a final lever after those steps failed. Engineer A's conduct reflects the virtue of moral seriousness but the vice of impatience—a failure to calibrate the intensity of his response to the actual state of organizational engagement with the problem.
In response to Q401, if Engineer A had immediately escalated beyond the non-engineer manager to senior engineering leadership or a formal internal safety committee upon first learning of the one-month inaction, the Board would very likely have found his conduct fully ethical. This counterfactual reveals that the Board's conclusion rests primarily on a sequencing failure rather than a substantive one: Engineer A's ultimate goal—ensuring the respirator defect was corrected—was ethically correct, but his chosen pathway skipped intermediate internal escalation steps that were both available and appropriate. The counterfactual also suggests that the public safety risk would likely have been more effectively mitigated through internal escalation to engineering-competent senior leadership, because such escalation would have placed the concern before personnel with both the technical authority to evaluate it and the organizational authority to mandate remediation, without triggering the defensive dynamics that an external regulatory threat can produce. The Board's conclusion therefore implicitly endorses a model in which the non-engineer manager's authority limitation is itself a signal to escalate laterally within the engineering hierarchy, not a signal to escalate externally.
In response to Q402, if the facts of this case had included an active public regulatory hearing at which MedTech was presenting data contradicting Engineer A's safety findings—mirroring the circumstances of BER Case 76-4—the Board would almost certainly have reached the opposite conclusion and found Engineer A's external reporting threat not only ethical but obligatory. The critical distinguishing factor in BER 76-4 is not merely the existence of external regulatory proceedings, but the active deception of a regulatory body through the presentation of contradictory data. This condition transforms the ethical calculus entirely: the engineer's obligation to correct misleading information presented to a regulatory authority is immediate and non-negotiable, because the regulatory process itself—the mechanism society relies upon to protect public safety—is being corrupted. In the present case, no such corruption of regulatory process was occurring; MedTech was conducting an internal investigation without any external regulatory engagement. The Board's comparative reasoning is therefore sound, and this counterfactual confirms that the BER 76-4 precedent is factually distinguishable on the most morally relevant dimension: the presence or absence of active deception of a public regulatory body.
In response to Q403, if Engineer A had been a recognized expert in respirator design rather than a non-expert evaluator, the Board would likely have applied a lower threshold for permitting the external reporting threat, though it would not necessarily have found the threat fully ethical without some additional internal escalation. Expert status would have substantially altered the epistemic foundation of Engineer A's concern: a confirmed technical violation identified by a domain expert, combined with one month of organizational inaction and hundreds of devices in circulation, would have created a much stronger case for compressing the graduated escalation timeline. The epistemic humility constraint that the Board implicitly applied to Engineer A—requiring deference to the design team's ongoing investigation precisely because Engineer A was not a respirator expert—would have been significantly weakened or eliminated. However, even an expert engineer would retain a faithful agent obligation to MedTech that requires genuine exhaustion of internal mechanisms before external threats, particularly when an internal investigation by competent personnel is underway. Expert status therefore lowers the threshold for external escalation but does not eliminate the procedural requirement of internal exhaustion.
In response to Q404, if Engineer A had made no threat of external reporting but instead simply filed a report with the federal regulatory agency without warning, the Board would almost certainly have judged that conduct less ethical than the conditional threat he actually issued, and this comparison reveals an important dimension of the Board's underlying theory of graduated escalation. The conditional threat—'if prompt measures are not taken, I will report'—preserves the employer's opportunity to self-correct and thereby honors the faithful agent obligation while simultaneously signaling the seriousness of Engineer A's concern. Silent, unannounced external reporting would have denied MedTech any final opportunity to remediate, would have been a more severe breach of the faithful agent obligation, and would have bypassed the internal escalation process entirely. The Board's conclusion that the threat was premature therefore implies a hierarchy: silent external reporting without warning is least ethical, conditional external threat before internal exhaustion is moderately problematic, and conditional external threat after genuine internal exhaustion is not only ethical but potentially obligatory. This hierarchy reveals that the Board's graduated escalation theory is not merely about sequencing but about preserving the employer's meaningful opportunity to self-correct at each stage before the next escalation level is triggered.
The Board resolved the tension between the faithful agent obligation and the public safety paramount principle not by declaring one categorically superior to the other, but by imposing a sequencing requirement: public safety ultimately prevails, but only after internal escalation pathways have been meaningfully exhausted. In this case, Engineer A had escalated once to a non-engineer manager, waited one month, and then re-escalated to the same manager before issuing his external reporting threat. The Board found this sequence insufficient—not because public safety was subordinated to employer loyalty, but because Engineer A had not yet engaged the full range of internal mechanisms available to him, such as senior engineering leadership, a safety officer, or formal internal safety channels. The case thus teaches that the faithful agent obligation does not dissolve upon first confirmed inaction; rather, it persists as a procedural constraint that shapes how and when the public safety paramount principle may be invoked to justify external escalation. The two principles are not in direct conflict so much as they are temporally sequenced, with faithful agency governing the process and public safety governing the ultimate outcome.
The principle of epistemic humility—requiring Engineer A to acknowledge his non-expert status in respirator design—interacted with the principle of non-acquiescence to employer safety inaction in a way the Board did not fully resolve. On one hand, Engineer A's acknowledged competence limitation counseled deference to MedTech's ongoing internal design team investigation, since domain-competent engineers were actively reviewing the concern. On the other hand, the non-acquiescence principle demands that an engineer not passively accept organizational delay that allows a potentially dangerous product to proliferate. The Board's conclusion implicitly weighted epistemic humility more heavily than non-acquiescence at the moment Engineer A issued his threat, treating the active internal investigation as a meaningful mitigating factor that reduced the urgency justifying external escalation. However, this resolution creates a structural problem: the longer an internal investigation continues without resolution while defective devices circulate, the more the epistemic humility constraint functions as a mechanism for organizational delay rather than a genuine safeguard against premature escalation. The case teaches that epistemic humility must be time-bounded—deference to an ongoing investigation is ethically appropriate only for a reasonable period, after which continued deference becomes indistinguishable from acquiescence to inaction, regardless of the engineer's non-expert status.
The principle of proportional escalation calibrated to growing device circulation and infant vulnerability existed in unresolved tension with the principle that benevolent motive does not cure an ethical violation. The Board acknowledged that Engineer A's concern was genuine and that the proliferation of hundreds of potentially defective infant respirators into hospitals represented a real and growing risk. Yet the Board nonetheless found his external reporting threat premature, implying that procedural correctness in escalation is not waived by the substantive seriousness of the underlying risk. This resolution reveals a deeper principle prioritization embedded in the Board's reasoning: the integrity of the graduated escalation process is treated as a near-independent ethical value, not merely an instrumental means to the end of public safety. The case thus teaches that proportionality of response to risk severity does not automatically override procedural obligations, but it also leaves open a critical threshold question—at what point does the accumulation of risk factors (vulnerable patient population, growing device circulation, non-engineer manager authority, one month of inaction) collectively satisfy the internal exhaustion requirement and render external escalation not merely understandable but obligatory? The Board's conclusion would have been substantially strengthened by specifying that threshold explicitly, rather than leaving it implicit in the comparison to BER Case 76-4.
Standards development organizations; medical device industry bodies
Consumer Product Safety Testing Standard
a relief valve intended to protect against overpressure being applied to the infant's lungs may have been incorrectly placed so that under certain circumstances, an infant could potentially experience dangerously high pressure levels
Engineer A when assessing whether the relief valve placement creates a dangerous condition for infant patients
Provides the technical baseline against which the misplaced relief valve in the infant respirator is evaluated, establishing what constitutes acceptable overpressure protection in life-critical medical equipment.
Contextual Calibration of Reporting Obligation Applied to No-Incident No-Standard Respirator Case
Engineer A's non-expert status in respirators
Identified relief valve placement concern
Good Faith Safety Concern Threshold for External Reporting
Engineer A's reporting obligation is calibrated by the contextual factors: no confirmed incidents, no applicable regulatory standards, non-expert assessment, but vulnerable infant population and identified design defect — resulting in an obligation to report to federal agency for further investigation rather than as a confirmed defect finding
The contextual calibration produces a genuine but appropriately framed reporting obligation: Engineer A should report to the federal agency as a professional concern requiring regulatory investigation, acknowledging uncertainty while fulfilling the reporting duty
Contextual Calibration of Public Safety Reporting Obligation
although not an expert on respirators, Engineer A determines that a relief valve intended to protect against overpressure being applied to the infant's lungs may have been incorrectly placed
Contextual factors reduce certainty but do not eliminate the reporting obligation; the appropriate response is a calibrated report framed as a professional concern requiring regulatory review
although no incidents have been reported
an infant could potentially experience dangerously high pressure levels
he will be compelled to report the matter to an appropriate federal regulatory agency
Should Engineer A threaten to report the infant respirator safety concern to a federal regulatory agency upon re-escalating to the non-engineer manager, or should he first exhaust additional internal escalation pathways within MedTech before issuing any external reporting threat?
After learning that a month has passed with no corrective action and that hundreds of potentially defective infant respirators are now in circulation, Engineer A must decide whether to immediately threaten external regulatory reporting to the manager or instead pursue additional internal escalation pathways before issuing any such threat.
Bypass the non-engineer manager's authority limitation by escalating urgently and directly to senior engineering leadership, a formal product safety committee, or legal/regulatory counsel within MedTech, setting an explicit short remediation deadline before considering any external reporting threat.
Inform the non-engineer manager that if prompt corrective measures are not taken, Engineer A will be compelled to report the matter to an appropriate federal regulatory agency, treating one month of inaction combined with hundreds of deployed devices as sufficient to trigger the external escalation threshold.
Re-escalate to the manager by formally demanding a specific resolution timeline and defined milestones from the design team investigation, deferring the external reporting threat unless and until that deadline passes without meaningful corrective action or engineering determination.
Should Engineer A treat his non-expert good-faith identification of the relief valve placement as sufficient epistemic basis to compress the graduated escalation timeline and threaten external reporting, or should his acknowledged competence limitation require him to defer to the domain-competent design team investigation while escalating internally with greater urgency?
Engineer A must determine how much ethical weight his non-expert safety assessment should carry when deciding the intensity and timing of his escalation response, given that his concern is grounded in cross-disciplinary good-faith observation rather than domain-specific expertise or confirmed technical violation.
Treat the active design team investigation by domain-competent engineers as a meaningful organizational response warranting monitored deference, while escalating internally with urgency to senior engineering leadership to demand a specific resolution timeline — reserving the external reporting threat for after domain-competent review concludes without remediation.
Treat Engineer A's cross-disciplinary engineering judgment as ethically sufficient to trigger the external reporting threat regardless of non-expert status, on the grounds that the public safety paramount principle applies without regard to specialization and that one month of inaction with hundreds of devices in circulation satisfies the escalation threshold.
Rather than threatening external reporting or deferring passively, seek direct engagement with the design team or a senior respirator engineer within MedTech to assess the technical validity of the valve placement concern, using that expert input to calibrate the appropriate intensity and timing of further escalation.
Should Engineer A treat MedTech's ongoing design team investigation as a legitimate internal process requiring monitored deference with a defined deadline, or should he treat the absence of any timeline, commitment, or engineering determination as functionally equivalent to organizational inaction that justifies immediate external escalation?
Engineer A must determine whether MedTech's active design team investigation constitutes a legitimate internal process warranting monitored deference or whether it is functionally equivalent to organizational inaction given the absence of any defined timeline, commitment, or engineering determination — and calibrate his escalation response accordingly.
Treat the design team investigation as a legitimate internal process, but demand a specific resolution deadline from the manager and escalate to senior engineering leadership if that deadline is not honored — treating the investigation as warranting monitored deference rather than either passive acceptance or immediate external threat.
Treat the manager's 'still being looked into' response — without any timeline, commitment, or engineering determination — as functionally equivalent to organizational inaction, and issue the conditional external reporting threat on the grounds that an indefinite investigation without milestones does not constitute a meaningful internal response.
Formally request a written status report from the design team or its supervisor — including scope, timeline, and interim findings — before determining whether the investigation constitutes a legitimate process warranting deference or an organizational delay justifying escalation, thereby gathering the information needed to make an informed proportionality judgment.
Should Engineer A treat his faithful agent obligation to MedTech as still operative and constraining — requiring further internal escalation before any external threat — or should he treat the public safety paramount principle as having already overridden that obligation given one month of inaction and hundreds of deployed devices?
Engineer A must resolve the tension between his faithful agent obligation to MedTech — which persists while internal mechanisms remain unexhausted — and his public safety paramount obligation triggered by the growing circulation of hundreds of potentially defective infant respirators, determining at what point the latter overrides the former.
Treat the faithful agent obligation as still operative because internal mechanisms — including senior engineering leadership, a safety committee, and formal recourse channels — have not been genuinely exhausted, and pursue those pathways urgently before issuing any external reporting threat, recognizing that public safety ultimately prevails but only after the employer has been given a complete opportunity to self-correct.
Treat one month of inaction combined with hundreds of deployed infant respirators as sufficient to discharge the faithful agent obligation and activate the public safety paramount principle, issuing the conditional external reporting threat on the grounds that the employer has had a reasonable opportunity to self-correct and has failed to do so.
Re-escalate to the manager with a formal written notice setting a specific short deadline — calibrated to the infant vulnerability and device circulation rate — for meaningful corrective action, explicitly stating that failure to meet the deadline will result in external regulatory reporting, thereby honoring the faithful agent obligation while signaling the imminent override of that obligation by the public safety paramount principle.
Should Engineer A treat the growing circulation of hundreds of potentially defective infant respirators as compressing the graduated escalation timeline to the point where his external reporting threat is proportionately calibrated, or should he treat that urgency as requiring accelerated internal escalation rather than a skip to external threat?
Engineer A must determine whether the proliferation of hundreds of potentially defective infant respirators into hospital settings — a maximally vulnerable patient population — compresses the normal graduated escalation timeline sufficiently to render his external reporting threat proportionate rather than premature, or whether urgency calibrated to infant vulnerability justifies accelerating internal escalation steps rather than skipping them.
Treat the growing device circulation and infant vulnerability as justifying a compressed but still sequential internal escalation — immediately escalating to senior engineering leadership and demanding a specific short remediation deadline calibrated to the risk profile, rather than skipping to an external reporting threat that bypasses remaining internal pathways.
Treat the combination of hundreds of deployed devices, a maximally vulnerable infant patient population, and one month of inaction as collectively sufficient to override the normal graduated escalation sequence, issuing the conditional external reporting threat on the grounds that the proportionality principle calibrated to imminent and widespread risk compresses the timeline to the point where the threat is not premature but obligatory.
Rather than threatening external reporting, escalate internally by formally requesting that MedTech halt further distribution of the respirator model pending the design team's engineering determination, treating the growing circulation as a basis for demanding an immediate interim protective measure rather than as a basis for compressing the external escalation threshold.
Should Engineer A issue a conditional external reporting threat that preserves MedTech's opportunity to self-correct, file an immediate unannounced report with the federal regulatory agency, or continue internal escalation without any external reporting threat at this stage?
Engineer A must determine whether the conditional framing of his external reporting threat — 'if prompt measures are not taken, I will report' — is ethically superior to either silent unannounced external reporting or continued passive deference, and whether the conditional structure of the threat preserves sufficient faithful agent obligation to be ethically permissible at this stage of escalation.
Refrain from issuing any external reporting threat at this stage and instead pursue additional internal escalation pathways — including senior engineering leadership, a safety committee, and formal recourse channels — reserving the conditional external threat for after those pathways have been genuinely exhausted and found insufficient.
Issue the conditional external reporting threat — 'if prompt measures are not taken, I will report to a federal regulatory agency' — on the grounds that the conditional framing honors the faithful agent obligation by preserving MedTech's opportunity to self-correct while signaling the seriousness of the concern and the engineer's ultimate public safety obligation.
Bypass the conditional threat entirely and file an immediate report with the appropriate federal regulatory agency without prior warning to MedTech, on the grounds that one month of inaction with hundreds of deployed infant respirators has already exhausted the employer's reasonable opportunity to self-correct and that further delay — even for a conditional threat — compounds the risk to a vulnerable patient population.
Defer to Internal Resolution Process (Action 3) + Management Inaction → Defective Respirators Distributed (Event 3)
Defer to Internal Resolution Process (Action 3) → Organizational Inaction Confirmed (Event 2)
Engineer Public Safety Escalation Standard
a month later Engineer A learns from Engineer B that nothing has been done to correct the issue
Engineer A indicates that if prompt measures are not taken to correct the problem, he will be compelled to report the matter to an appropriate federal regulatory agency
Hundreds of new respirators are now on the market, and Engineer A is concerned about the increasing likelihood of a tragic event
Engineer A when determining whether to report the defect to a federal regulatory agency after the manager fails to act
Directly governs Engineer A's duty to escalate the unresolved infant respirator defect beyond the non-engineer manager to a federal regulatory agency after a month of inaction, establishing the professional norm that internal failure to act triggers an obligation to notify external authorities.
Engineer Safety Recommendation Rejection Standard
Engineer A brings the issue and his proposed solution to the attention of the appropriate manager, who is not an engineer, and Engineer A assumes that the matter will be taken care of immediately
Engineer A again urges the manager to take immediate action
Engineer A after the manager declines to act on his safety recommendation for over a month
Governs Engineer A's obligations when the non-engineer manager fails to implement his safety recommendation to correct the misplaced relief valve, including documenting the concern, advising of risks, and determining whether escalation is required.
Engineer A Conditional External Regulatory Reporting Threat Proportionality Infant Respirator
After initial reporting, a month of inaction, and re-escalation, Engineer A issued a conditional threat to report to a federal regulatory agency if prompt measures were not taken — a proportionate response that preserved internal resolution while signaling the ultimate reporting obligation.
Conditional External Regulatory Reporting Threat Proportionality Obligation
Engineer A was obligated to issue his threat of external regulatory reporting only after exhausting internal escalation channels (initial report, one-month wait, re-escalation) and to frame it as conditional on MedTech's failure to take prompt corrective action, thereby preserving the possibility of internal resolution while fulfilling his public welfare obligation.
At the point of re-escalation to the manager after one month of inaction
if prompt measures are not taken to correct the problem, he will be compelled to report the matter to an appropriate federal regulatory agency
Engineer A Conditional External Regulatory Reporting Threat Proportionality MedTech Respirator
Conditional External Regulatory Reporting Threat Proportionality Capability
Engineer A possessed the capability to correctly calibrate the issuance of a conditional external regulatory reporting threat — issuing it only after exhausting internal escalation channels (initial report, one-month waiting period, re-escalation) and proportionate to the growing urgency of the safety concern.
Engineer A's conditional threat was issued at the appropriate stage of internal escalation exhaustion, making it ethically permissible
Issuing the conditional external reporting threat only after initial report, one month of inaction, and re-escalation — not prematurely at the outset
Engineer A Consumer Product Safety Concern Recognition MedTech Respirator
Consumer Product Inconsistent Performance Safety Concern Recognition Capability
Engineer A possessed the capability to recognize that the potential relief valve misplacement in the infant respirator represented a safety concern requiring escalation beyond normal product review, even in the absence of reported incidents.
Engineer A's recognition of the safety concern in the infant respirator triggered his escalation obligations
Identification of the relief valve misplacement as a safety concern and initiation of internal escalation
Engineer A determines that a relief valve intended to protect against overpressure being applied to the infant's lungs may have been incorrectly placed so that under certain circumstances, an infant could potentially experience dangerously high pressure levels
Engineer A Contextually Calibrated Reporting Obligation MedTech vs BER 76-4
The Board explicitly distinguished Engineer A's situation from BER Case No. 76-4 on the basis of three material contextual differences: absence of a public hearing, lack of personal involvement in the engineering decision-making, and absence of domain-specific expertise.
Contextually Calibrated Public Safety Reporting Obligation
Engineer A was obligated to calibrate his public safety reporting obligation to the specific contextual factors of his situation — no scheduled public hearing, no direct personal involvement in the design, no domain-specific expertise, no confirmed incidents, no applicable regulatory standards — recognizing that these factors generated a different (though still real) reporting obligation than the BER 76-4 situation, requiring a more graduated internal escalation approach rather than immediate external reporting.
Upon identifying the safety concern and assessing the appropriate reporting pathway
But unlike the facts and circumstances involved in BER Case No. 76-4, Engineer A was not personally involved in the engineering decision-making process and did not have any particular expertise in the technical area involved.
Engineer A Employer Active Investigation Deference MedTech Respirator Design Team
MedTech had initiated an internal investigation conducted by personnel competent in respirator design and manufacturing, which the Board identified as a material factor constraining Engineer A's authority to immediately escalate externally.
Employer Active Investigation Deference Pending Exhaustion Constraint
Engineer A was constrained from bypassing MedTech's active internal investigation — conducted by domain-competent respirator design and manufacturing personnel — by threatening or pursuing external regulatory reporting before making additional inquiries to determine whether meaningful action was being taken.
NSPE Code of Ethics; NSPE BER faithful agent and graduated escalation framework
MedTech was in the process of investigating the matter and determining whether a basis exists for those concerned
While MedTech's internal investigation into the infant respirator relief valve concern was active
If after making additional inquiries, Engineer A determines that no meaningful actions are being taken to address the issue, Engineer A should explore internal mechanisms within MedTech to seek further recourse
That investigation was presumably being conducted by individuals competent in the design and manufacturing of the respirator device in question
Engineer A Employer Cost-Rejection Non-Acquiescence Inaction Infant Respirator
The manager's failure to act for a month — despite the safety concern involving infant respirators — did not extinguish Engineer A's safety obligation; Engineer A correctly assessed that escalation to a federal regulatory agency was warranted if prompt action was not taken.
Employer Cost-Rejection Non-Acquiescence Safety Escalation Obligation
Engineer A was obligated not to treat the manager's month-long inaction and 'still being looked into' response as a discharge of the safety concern, and to assess whether the nature, probability, and severity of the identified risk required escalation beyond the employer relationship to a federal regulatory agency.
Upon learning of the month-long inaction and the manager's 'still being looked into' response
When the manager indicates that the matter is still being looked into by a design team
Engineer A Employer Cost Rejection Non-Acquiescence MedTech Respirator
Employer Cost-Schedule Rejection Non-Acquiescence Safety Escalation Capability
Engineer A possessed the capability to recognize that the employer's failure to act — implicitly driven by the cost of stopping the manufacturing process — did not discharge his professional safety obligation, and to escalate accordingly.
The cost of correcting the error (stopping manufacturing for part of a week) was a factor in the employer's inaction, and Engineer A did not acquiesce
Continuing to escalate despite the employer's implicit cost-driven inaction (stopping manufacturing for part of a week to correct the problem)
Correcting the error would involve stopping the manufacturing process for part of a week to correct problem
Engineer A Fact-Grounded Opinion Non-Expert Domain MedTech Respirator Escalation
Engineer A's safety concern was characterized by the Board as a personal opinion rather than a confirmed finding, limiting the weight it could bear as a basis for external escalation threats.
Engineer A was constrained from treating his personal opinion about the relief valve misplacement as an established professional finding sufficient to ground an external regulatory reporting threat, because his opinion was not founded on domain expertise, personal involvement in the design process, or completed technical analysis.
NSPE Code of Ethics; professional competence standards
Engineer A is faced with a situation where, in his personal opinion, a serious risk may exist
At the time Engineer A assessed and communicated his safety concern regarding the infant respirator
Engineer A may not be in possession of all of the necessary information to make an informed judgment
Engineer A Faithful Agent Boundary Public Safety Tension Resolution MedTech
The case presents the classical conflict between faithful agent duty and public safety paramount obligation, with the Board finding that Engineer A properly raised the concern internally but improperly jumped to external reporting threats before exhausting internal mechanisms.
Faithful Agent Boundary Within Public Safety Paramount Tension Resolution Obligation
Engineer A was obligated to resolve the tension between his faithful agent duty to MedTech and his public safety paramount obligation through a structured sequential process — first raising concerns internally (which he did), then monitoring the internal investigation, then escalating internally through additional mechanisms, and only then considering external reporting — rather than jumping prematurely to external reporting threats.
This case presents one of the classical ethical dilemmas faced by engineers, which is the fundamental conflict between the obligation to hold paramount the public health and safety and some another key provision of the NSPE Code of Ethics—here the obligation to act for each employer or client as 'faithful agent or trustee.'
Throughout the entire escalation process from initial concern identification through resolution
As is often the case with these types of situations, sometimes mitigating factors and circumstances impact upon one's understanding of this conflict.
This conclusion does not diminish, in any way, Engineer A's concern regarding his obligation to hold paramount public safety.
Engineer A Faithful Agent Obligation MedTech Respirator Investigation
Engineer A's threat to report to governmental authorities while MedTech's internal investigation was still ongoing represented a failure to honor the faithful agent obligation within its appropriate scope.
Engineer A was obligated to act as a faithful agent to MedTech by respecting the employer's ongoing internal investigation process and pursuing internal resolution channels before threatening external reporting, recognizing that the faithful agent duty operates within ethical limits but is not extinguished by the public safety paramount principle until internal mechanisms have been genuinely exhausted.
Throughout the internal escalation process while MedTech's investigation was ongoing
As the facts indicate, Engineer A has properly raised the public safety issue, and it appears that MedTech was in the process of investigating the matter and determining whether a basis exists for those concerned.
Engineer A Faithful Agent Public Safety Classical Dilemma Navigation
Faithful Agent Public Safety Paramount Classical Dilemma Recognition Capability
Engineer A demonstrated partial capability to recognize the classical faithful agent vs. public safety paramount dilemma — correctly identifying the safety concern and raising it internally — but did not fully exercise the capability to navigate the tension through graduated proportionate response, prematurely threatening external reporting before exhausting internal mechanisms.
Engineer A's navigation of the conflict between his faithful agent duty to MedTech and his public safety paramount obligation regarding the infant respirator
Engineer A's initial internal report of the safety concern (correct exercise of the capability) followed by premature external reporting threat (incomplete exercise of the navigation dimension of the capability)
Engineer A Faithful Agent vs. Public Safety Paramount Conflict
From Engineer A's identification of the potential respirator defect through resolution of the internal investigation
Engineer A's simultaneous obligations as faithful agent/trustee to MedTech and as engineer holding public health and safety paramount
Resolution of internal investigation with meaningful corrective action, or exhaustion of internal pathways triggering external reporting obligation
Engineer A has properly raised the public safety issue
Engineer A's identification of a potential safety defect in a product manufactured by his employer MedTech
Engineer A Good Faith Safety Concern No Incident No Standard MedTech Respirator
Engineer A's safety concern was based on professional judgment about potential overpressure risk, with no reported incidents and no specific standard violation confirmed, constraining the form and certainty of his escalation claims.
Good Faith Safety Concern Without Demonstrable Violation Escalation Boundary Constraint
Engineer A was constrained to calibrate his escalation to the fact that no incidents had been reported and no specific regulatory standard had been violated, requiring him to frame his concern as a good-faith professional judgment rather than a confirmed regulatory violation while still escalating appropriately.
NSPE Code of Ethics; BER graduated escalation framework; professional competence provisions
Engineer A Good Faith Safety Concern Without Confirmed Violation
From Engineer A's initial identification of the potential defect through the conclusion of MedTech's internal investigation
Good Faith Safety Concern Without Demonstrable Violation State
Engineer A's sincere but unconfirmed belief that a serious risk exists in the respirator device, without personal domain expertise or confirmed regulatory violation
Internal investigation conclusion confirming or refuting the safety concern
Engineer A's professional judgment that a serious risk may exist in the respirator device, absent domain expertise or confirmed violation
Engineer A Good Faith Safety Concern Without Demonstrable Violation Escalation Boundary MedTech Respirator
Engineer A's concern about the misplaced relief valve was based on personal opinion rather than confirmed findings, and no applicable governmental or industry standards specifically addressing the product were identified as violated.
Engineer A was constrained in the scope of permissible external escalation because his safety concern — while sincere and good-faith — was unconfirmed, lacked domain-expert grounding, and did not constitute a demonstrable violation of applicable standards, requiring that he distinguish between a confirmed safety violation (triggering mandatory external reporting) and a good-faith professional concern (permitting but not mandating external action).
Engineer A is faced with a situation where, in his personal opinion, a serious risk may exist and the failure to adequately address the risk could result in tragic consequences
Throughout Engineer A's assessment of his reporting obligations regarding the infant respirator
Engineer A Graduated Internal-to-External Escalation Obligation
From Engineer A's second escalation to the manager through the present; calibrated to the severity of infant safety risk and market proliferation
Graduated Escalation Obligation Calibrated to Danger Severity State
Engineer A's escalating obligation to move from internal advocacy to external regulatory reporting
Either organizational corrective action or Engineer A's external regulatory report
Engineer A's second escalation to the manager combined with the discovery that hundreds of units are on the market
Engineer A Graduated Internal Escalation Before External Reporting MedTech
After raising the safety concern to the non-engineer manager and waiting one month, Engineer A threatened external reporting rather than pursuing additional internal escalation channels available within MedTech.
Graduated Internal Escalation Obligation
Engineer A was obligated to proceed through graduated internal escalation channels within MedTech — including additional inquiries into the ongoing investigation, engagement with internal design teams, and pursuit of formal internal recourse mechanisms — before or in conjunction with any consideration of external escalation, acting advisedly, carefully, and sensitively while verifying all facts.
If after making additional inquiries, Engineer A determines that no meaningful actions are being taken to address the issue, Engineer A should explore internal mechanisms within MedTech to seek further recourse regarding this issue.
After initial internal reporting and before any external reporting threat
The Board believes that there were more reasonable and appropriate internal mechanisms within MedTech that could and should have been explored by Engineer A before threatening to report the matter to governmental authorities.
Engineer A Graduated Internal Escalation Exhaustion Before External Threat MedTech Respirator Discussion
The Board found that Engineer A's threat to report to governmental authorities was premature because internal mechanisms within MedTech had not been exhausted, and MedTech was actively investigating the matter.
Graduated Internal Escalation Exhaustion Before External Reporting Threat Constraint
Engineer A was constrained from threatening external regulatory reporting before exhausting all available internal escalation pathways within MedTech, including making additional inquiries into the ongoing investigation, exploring other internal mechanisms for recourse, and confirming that no meaningful action was being taken.
NSPE Code of Ethics; NSPE BER graduated escalation framework
there were more reasonable and appropriate internal mechanisms within MedTech that could and should have been explored by Engineer A before threatening to report the matter to governmental authorities
Throughout Engineer A's escalation process at MedTech
If after making additional inquiries, Engineer A determines that no meaningful actions are being taken to address the issue, Engineer A should explore internal mechanisms within MedTech to seek further recourse regarding this issue
Only if such efforts do not produce satisfactory results should Engineer A consider exploring external avenue for action
Engineer A Graduated Internal Escalation Exhaustion MedTech Respirator
Engineer A's regulatory reporting threat was issued only after a two-step internal escalation process spanning one month, satisfying the internal exhaustion prerequisite.
Engineer A was constrained from threatening external regulatory reporting before exhausting internal escalation pathways; the case record shows he satisfied this constraint by making an initial report, allowing a month for response, and re-escalating before issuing the regulatory reporting threat.
NSPE Code of Ethics; BER Case No. 76-4 precedent; graduated escalation framework
Engineer A brings the issue and his proposed solution to the attention of the appropriate manager
Throughout the escalation sequence from initial report to regulatory reporting threat
Engineer A Graduated Internal Escalation Infant Respirator MedTech
Engineer A first reported the safety concern to the appropriate manager, waited a month, learned from Engineer B that nothing had been done, and then re-escalated to the manager before threatening external reporting.
Engineer A was obligated to exhaust internal escalation channels — including initial reporting to the appropriate manager, allowing time for internal response, and re-escalating after learning of inaction — before threatening external regulatory reporting.
From initial identification of the defect through the month-long waiting period and re-escalation
Engineer A Gray Area Public Welfare Threshold Judgment MedTech Respirator
Gray Area Public Welfare Threshold Judgment Capability
Engineer A demonstrated the capability to exercise professional judgment in a gray area situation — where the safety concern was based on potential misplacement without confirmed incidents or specific standards — and to determine that the concern merited escalation based on the magnitude of potential harm to vulnerable infant patients.
Engineer A's threshold judgment that the concern merited escalation despite uncertainty reflects gray area public welfare threshold judgment
Determining that the potential relief valve misplacement warranted internal escalation despite the absence of incidents, specific standards, or domain-specific expertise
Engineer A Growing Circulation Proportional Urgency Calibration MedTech Respirator
Growing Circulation Proportional Urgency Calibration Capability
Engineer A possessed the capability to recognize that hundreds of potentially defective respirators now in circulation among vulnerable infant patients proportionally increased the urgency of his escalation obligation.
Engineer A calibrated his urgency to the hundreds of new respirators now on the market when re-escalating to management
Recognition that the growing number of respirators on the market increased the likelihood of a tragic event, motivating re-escalation
Engineer A Growing Circulation Proportional Urgency Escalation Infant Respirator
After learning that hundreds of new respirators were on the market and that no corrective action had been taken for a month, Engineer A escalated urgently and threatened external reporting.
Growing Vulnerable Population Circulation Proportional Urgency Escalation Obligation
Engineer A was obligated to calibrate the urgency of his escalation to the growing number of potentially defective infant respirators in circulation, recognizing that hundreds of units on the market with a vulnerable infant population elevated the reporting obligation to near-mandatory urgency.
Upon learning that hundreds of potentially defective respirators were in circulation with no corrective action taken
Engineer A Imminent vs Non-Imminent Risk Escalation Calibration MedTech Respirator
Imminent vs Non-Imminent Risk Escalation Calibration Capability
Engineer A demonstrated the capability to calibrate his escalation response to the growing but not yet incident-confirmed risk — pursuing graduated internal escalation rather than immediately contacting external regulatory authorities, while recognizing that the growing circulation volume was increasing urgency.
Engineer A's escalation was proportionate to the risk level — real and growing but not yet incident-confirmed — consistent with graduated escalation rather than full-bore multi-authority campaign
Choosing graduated internal escalation (initial report → re-escalation → conditional external threat) rather than immediate external reporting, calibrated to the non-imminent but growing risk
Engineer A Interdisciplinary Competence Threshold Non-Expert Respirator Review
Engineer A, not a respirator expert, nonetheless applied his general engineering judgment to identify a potentially dangerous relief valve placement and escalated the concern, demonstrating that cross-disciplinary competence can be sufficient to trigger the safety reporting obligation.
Interdisciplinary Competence Threshold Recognition for Specialized Referral Obligation
Engineer A was obligated to recognize that his general engineering competence — though not respirator-specific — was sufficient to identify that the relief valve placement raised a credible safety concern warranting escalation, and to act on that recognition rather than deferring entirely to domain experts.
Upon completion of the respirator review
Engineer A Interdisciplinary Threshold Competence Respirator MedTech
Engineer A was asked to evaluate a respirator outside his specialty; his threshold competence was sufficient to identify the potential defect and trigger escalation, even though full technical resolution required domain expertise.
Interdisciplinary Threshold Competence Referral Constraint
Engineer A's non-expert status in respirator design constrained the depth of his independent technical analysis but did not bar him from identifying the threshold safety concern and recommending specialist review — his general engineering competence was sufficient to trigger the escalation obligation.
NSPE Code of Ethics — competence provisions; professional judgment standard
At the time of Engineer A's initial review of the infant respirator
Engineer A Internal Design Team Non-Acquiescence Infant Respirator
When the manager indicated the matter was still under internal review by a design team, Engineer A did not accept this as a final answer and instead issued a conditional threat of external regulatory reporting.
Internal Design Team Ongoing Review Non-Acquiescence Obligation
Engineer A was obligated to refuse to accept the manager's representation that the matter was 'still being looked into' by a design team as a sufficient resolution, and to press for concrete corrective action by conditioning his forbearance on prompt measures being taken.
When the manager indicates that the matter is still being looked into by a design team, Engineer A indicates that if prompt measures are not taken to correct the problem, he will be compelled to report the matter to an appropriate federal regulatory agency
Upon the manager's response that the matter was still being looked into
Engineer A Internal Design Team Non-Acquiescence MedTech Respirator
Internal Design Team Review Non-Acquiescence Capability
Engineer A possessed the capability to recognize that the manager's representation that the matter was 'still being looked into' by a design team was insufficient, and to refuse to treat ongoing internal review as a discharge of the safety obligation.
Engineer A refused to accept 'still being looked into' as a sufficient response and escalated with a conditional external reporting threat
Issuing a conditional external reporting threat when the manager indicated the matter was still under internal review, rather than accepting the assurance and waiting further
Engineer A Internal Escalation Near-Exhaustion
From Engineer A's second escalation to the manager (after one month of inaction) through the present
Engineer A's internal escalation pathway within MedTech
One month of managerial inaction following Engineer A's initial report, followed by a second escalation that yielded only a vague reference to an ongoing design team review
Engineer A Internal Escalation Pathway Assessment
From the Board's determination that Engineer A's threat was premature through Engineer A's completion of all available internal escalation steps
Internal Escalation Pathway Exhaustion Assessment State
Engineer A's obligation to assess whether all internal MedTech mechanisms have been genuinely exhausted before considering external regulatory reporting
Engineer A's exhaustion of all internal mechanisms without satisfactory result, or satisfactory internal resolution
Board's finding that Engineer A's threat to report to governmental authorities was not a reasonable or ethical response because internal mechanisms had not been fully explored
Engineer A Internal Mechanism Exhaustion Before External Threat MedTech Respirator
Engineer A, not personally involved in the respirator design and lacking domain-specific expertise, threatened to report to a governmental agency after a month of employer inaction, while MedTech's internal investigation was still ongoing.
Internal Mechanism Exhaustion Before External Reporting Threat Obligation
Engineer A was obligated to exhaust all reasonable internal mechanisms within MedTech — including inquiry into the ongoing internal investigation, engagement with internal design teams, and pursuit of formal internal recourse channels — before threatening to report the infant respirator safety concern to governmental authorities.
At the time Engineer A issued the external reporting threat to the non-engineer manager
Engineer A Internal Mechanism Exhaustion Sequencing Before External Threat
Internal Mechanism Exhaustion Sequencing Before External Regulatory Threat Capability
Engineer A needed — but did not fully exercise — the capability to identify and exhaust all available internal escalation mechanisms within MedTech, including making additional inquiries into the ongoing internal investigation and exploring further internal recourse pathways, before issuing a threat to report the matter to governmental authorities.
Engineer A's escalation of infant respirator safety concern at MedTech after one month of managerial inaction
The BER's finding that Engineer A's statement amounting to a threat to the manager was not a reasonable or ethical response because more reasonable and appropriate internal mechanisms within MedTech could and should have been explored first
Only if such efforts do not produce satisfactory results should Engineer A consider exploring external avenue for action.
{'license': 'Professional Engineer', 'specialty': 'General engineering (not a respirator expert)', 'employer': 'MedTech', 'experience_level': 'Experienced'}
Experienced PE employed by MedTech who, at a colleague's request, evaluates an infant respirator, identifies a potentially dangerous relief valve placement defect, escalates internally to a non-engineer manager, follows up a month later upon learning no action was taken, and threatens to report to a federal regulatory agency if corrective action is not promptly taken.
{'type': 'employer', 'target': 'MedTech'}
{'type': 'peer', 'target': 'Engineer B Peer Safety Evaluation Requesting Engineer'}
{'type': 'reports_to', 'target': 'MedTech Non-Engineer Manager'}
Engineer A, an experienced professional engineer, is employed by MedTech
Engineer A determines that a relief valve intended to protect against overpressure may have been incorrectly placed
Engineer A Mitigating Circumstance Balanced Assessment MedTech Respirator
Engineer A, acting in good faith, identified a potential safety concern in an infant respirator but may not have been in possession of all necessary information to make an informed judgment, and did not adequately weigh the mitigating factors before threatening external reporting.
Mitigating Circumstance Balanced Safety Obligation Assessment Obligation
Engineer A was obligated to identify and weigh all relevant mitigating factors — including his level of personal knowledge, the risks involved, his lack of personal involvement in the engineering decision-making, the actions taken and not taken by himself and MedTech, and other contextual factors — before determining the appropriate form and urgency of his safety reporting obligation.
As is often the case with these types of situations, sometimes mitigating factors and circumstances impact upon one's understanding of this conflict (e.g., the knowledge held by the engineer, the risks involved, level of personal involvement, actions taken and not taken by individual the engineer/employer, and other factors).
Upon identifying the safety concern and before determining the appropriate escalation pathway
While Engineer A may have had legitimate concerns, those concerns should be balanced with other legitimate factors, including the objective consideration of the concerns, the level of potential risk involved, and a review of appropriate 'next steps' to address the issue.
Engineer A Mitigating Factor Balanced Escalation Scope MedTech Infant Respirator
Engineer A identified a potential relief valve misplacement in infant respirators and needed to calibrate his escalation response against multiple mitigating factors identified by the Board.
Mitigating Factor Balanced Safety Escalation Scope Constraint
Engineer A was constrained from treating his good-faith safety concern as automatically triggering maximum escalation, and was required to weigh mitigating factors — including his lack of domain expertise, non-involvement in the design decision, the ongoing employer investigation, and the unconfirmed nature of the risk — before determining the appropriate escalation scope.
NSPE Code of Ethics; NSPE BER analysis of mitigating circumstances
Throughout Engineer A's assessment of his escalation obligations at MedTech
Engineer A Month-Delay Inaction Re-Escalation MedTech Respirator
Month-Delay Inaction Re-Escalation Capability
Engineer A possessed the capability to recognize that one month of managerial inaction was insufficient discharge of the safety concern and to re-escalate with a conditional threat of external regulatory reporting.
After a month of inaction, Engineer A re-escalated and threatened external regulatory reporting if prompt corrective action was not taken
Re-escalation to the manager after learning from Engineer B that nothing had been done, and issuance of a conditional external reporting threat
Engineer A Multi-Case BER Precedent Synthesis Consumer Product Safety MedTech Respirator
Multi-Case BER Precedent Synthesis for Consumer Product Safety Reporting Calibration Capability
Engineer A's actions were consistent with the calibrated framework established by BER precedent cases for consumer product safety reporting — exhausting internal channels before threatening external reporting — demonstrating implicit application of the synthesized precedent framework.
Engineer A's escalation sequence aligned with the BER precedent framework for consumer product safety reporting calibration
Sequential escalation pattern: initial internal report → waiting period → re-escalation → conditional external reporting threat, consistent with BER 08-10 framework
a month later Engineer A learns from Engineer B that nothing has been done
Engineer A No-Incident Good Faith External Reporting Threshold Infant Respirator
No incidents had been reported and no specific regulatory standard governed the relief valve placement, yet Engineer A's professional judgment identified a credible risk to infants, which he determined warranted external reporting if MedTech failed to act.
No-Incident No-Standard Safety Concern Good Faith External Reporting Threshold Obligation
Engineer A was obligated to recognize that his good-faith professional judgment that the relief valve was incorrectly placed — even without confirmed incidents or applicable regulatory standards — was sufficient to trigger the obligation to report to a federal regulatory agency if internal escalation failed.
Upon re-escalation to the manager after learning of month-long inaction
although not an expert on respirators, Engineer A determines that a relief valve... may have been incorrectly placed so that under certain circumstances, an infant could potentially experience dangerously high pressure levels
Engineer A No-Incident No-Standard Good Faith Safety Reporting Threshold MedTech Respirator
No-Incident No-Standard Good Faith Safety Reporting Threshold Recognition Capability
Engineer A possessed the capability to recognize that the absence of reported incidents and the absence of a specific regulatory standard did not extinguish his professional obligation to escalate the safety concern based on good-faith engineering judgment.
Engineer A acted on good-faith professional judgment despite the absence of incidents or specific standards
Proceeding with internal escalation and conditional external reporting threat despite no prior incidents and no specific standard governing the relief valve placement
Engineer A determines that a relief valve intended to protect against overpressure being applied to the infant's lungs may have been incorrectly placed
Engineer A Non-Engineer Manager Safety Finality Prohibition MedTech
Engineer A reported the safety concern to a non-engineer manager and assumed it would be handled, but a month later learned nothing had been done, requiring re-escalation.
Non-Engineer Manager Safety Decision Finality Prohibition Constraint
Engineer A was constrained from treating the non-engineer manager's initial acceptance of the safety concern as a final engineering resolution, and was required to continue escalating when no corrective action was taken.
NSPE Code of Ethics — public safety paramount; non-engineer authority limitation principle
the appropriate manager, who is not an engineer, and Engineer A assumes that the matter will be taken care of immediately
From Engineer A's initial report to the manager through the one-month period of inaction
Engineer A Non-Expert Medical Device Safety Concern Identification MedTech Respirator
Non-Expert Medical Device Safety Concern Identification Capability
Engineer A possessed the capability to identify a potentially dangerous relief valve misplacement in an infant respirator despite not being a respirator domain expert, applying general engineering principles to recognize a safety concern requiring internal escalation.
Engineer A evaluated the infant respirator at Engineer B's request and identified the safety concern using general engineering competence
Identification of potential relief valve misplacement that could cause dangerously high pressure in infant lungs, despite having no prior respirator-specific expertise
Engineer A Non-Expert Non-Involved Proportionality Calibration MedTech Respirator
Engineer A, an experienced PE but not a respirator expert and not personally involved in the design, identified a potential relief valve placement concern and threatened external reporting after one month of employer inaction.
Non-Expert Non-Involved Engineer Internal Escalation Proportionality Obligation
Engineer A was obligated to calibrate the scope and urgency of his escalation proportionally to his epistemic limitations — including his lack of direct involvement in the respirator design process and absence of domain-specific expertise — by making additional inquiries, engaging internal mechanisms, and allowing competent internal personnel to investigate before threatening external escalation.
Engineer A was not personally involved in the engineering decision-making process and did not have any particular expertise in the technical area involved.
Upon identifying the safety concern and throughout the internal escalation process
Although an experienced professional engineer and by all indications a well-intended individual acting in good faith, as is sometimes the case in matters of this type, Engineer A may not be in possession of all of the necessary information to make an informed judgment.
Engineer A Non-Expert Respirator Safety Evaluation
From the moment Engineer B asks Engineer A to evaluate the respirator through Engineer A's identification of the relief valve placement concern
Non-Expert Safety Evaluation Triggering Competence Boundary State
Engineer A's competence relative to respirator design evaluation
Not yet terminated; persists as Engineer A continues to advocate on the finding
Engineer B's request for Engineer A to evaluate the infant respirator despite Engineer A not being a respirator expert
Engineer A Non-Expert Respirator Safety Identification Permissibility MedTech
Engineer A, not a respirator specialist, identified a potentially dangerous relief valve misplacement in an infant respirator and was obligated to escalate despite his non-expert status.
Non-Expert Domain Threshold Safety Identification Permissibility Constraint
Engineer A was constrained to identify and escalate the potential relief valve misplacement based on general engineering principles, notwithstanding his non-expert status in respirator design, while being limited in the depth of independent technical analysis he could provide.
NSPE Code of Ethics — public safety paramount obligation; professional competence provisions
At the time of Engineer A's initial review of the infant respirator design
Engineer A Non-Expert Safety Concern Identification Infant Respirator
Engineer A, not a respirator expert, reviewed an infant respirator at Engineer B's request and identified a potentially dangerous relief valve placement that could expose infants to dangerously high pressure levels.
Non-Expert Safety Concern Identification and Internal Escalation Obligation
Engineer A was obligated to identify and internally escalate the potential relief valve misplacement in the infant respirator, notwithstanding his non-expert status in respirator design, because his general engineering competence was sufficient to recognize a credible safety risk to a vulnerable population.
Upon completion of the respirator review and identification of the potential defect
Engineer A Non-Involved Non-Expert Epistemic Humility Escalation Calibration
Non-Involved Non-Expert Engineer Epistemic Humility Safety Escalation Calibration Capability
Engineer A needed — but initially failed to fully exercise — the capability to recognize that his lack of personal involvement in the respirator engineering decision-making process and his absence of domain-specific respirator expertise meant he may not have possessed all necessary information to make an informed judgment, and that this epistemic limitation required calibrating his escalation to internal mechanisms before threatening external regulatory reporting.
Engineer A's evaluation of infant respirator relief valve placement at MedTech, where he was not involved in the original engineering decision-making and lacked respirator-specific expertise
The BER's finding that Engineer A's threat to report to governmental authorities was not a reasonable or ethical response given his non-involvement and non-expertise, and that he should have recognized his epistemic limitations as a calibrating factor
Engineer A Non-Involved Non-Expert Premature External Threat Prohibition MedTech Respirator
Engineer A, an experienced PE but not a respirator expert and not involved in the original design, threatened to report to governmental authorities after only one month of internal escalation, which the Board found unreasonable and unethical.
Non-Involved Non-Expert Engineer Premature External Threat Prohibition Constraint
Engineer A was prohibited from issuing a threat to report the infant respirator safety concern to governmental authorities because he was not personally involved in the engineering decision-making process, did not have domain expertise in respirator design, and had not exhausted available internal escalation mechanisms within MedTech.
At the time Engineer A issued his threat to the MedTech manager
Engineer A's statement—which essentially amounted to a threat to the manager—was not a reasonable or ethical response to the circumstances in question
Engineer A Ongoing Investigation Deference and Monitoring MedTech Respirator
MedTech was in the process of investigating the infant respirator safety concern when Engineer A threatened external reporting, with the investigation being conducted by individuals competent in the relevant domain.
Ongoing Internal Investigation Deference and Monitoring Obligation
Engineer A was obligated to defer to MedTech's ongoing internal investigation — conducted by personnel competent in respirator design and manufacturing — while actively monitoring its progress through additional inquiries, rather than treating the investigation as either a final resolution or as a justification for immediate external escalation.
During the period when MedTech's internal investigation was ongoing
That investigation was presumably being conducted by individuals competent in the design and manufacturing of the respirator device in question.
Engineer A Ongoing Investigation Non-Discharge MedTech Respirator
After one month of inaction and hundreds of potentially defective respirators in circulation, the manager's open-ended 'still being investigated' response was insufficient to discharge Engineer A's escalation obligation.
Ongoing Internal Investigation Non-Discharge of Safety Escalation Constraint
Engineer A was constrained from treating the manager's representation that the matter was 'still being looked into by a design team' as a sufficient discharge of his safety escalation obligation, given the absence of any timeline, commitment, or engineering determination.
NSPE Code of Ethics — public safety paramount; BER graduated escalation framework
At the second escalation meeting, one month after the initial report
Engineer A Post-Internal-Exhaustion Conditional External Reporting MedTech Future Obligation
The Board affirmed that Engineer A's public safety paramount obligation is not extinguished, but is conditional on exhaustion of internal mechanisms — if internal efforts do not produce satisfactory results, external reporting becomes appropriate.
Post-Internal-Exhaustion Conditional External Reporting Obligation
Engineer A will be obligated to pursue external reporting to appropriate governmental or regulatory authorities if, after exhausting all available internal mechanisms within MedTech — including additional inquiries, engagement with internal design teams, and formal internal recourse channels — he determines that no meaningful corrective action is being taken to address the infant respirator safety concern.
After exhaustion of all internal escalation mechanisms and determination that no meaningful corrective action is being taken
Engineer A Post-Internal-Exhaustion Conditional External Reporting Pathway
Engineer A will need to exercise the capability to correctly calibrate any future conditional threat of external regulatory reporting — issuing such a threat only after exhausting all internal escalation mechanisms within MedTech, including additional inquiries and further internal recourse pathways, and only if those efforts produce unsatisfactory results.
Engineer A's future escalation pathway for the infant respirator safety concern at MedTech if internal mechanisms prove unsatisfactory
BER's prospective direction that external reporting should be considered only after internal mechanisms have been fully exhausted and found unsatisfactory
Engineer A Precedent-Based BER 76-4 Analogical Reasoning
Precedent-Based Ethical Reasoning Capability
Engineer A needed the capability to apply BER 76-4 precedent reasoning to his own situation — recognizing both the analogical similarities (safety concern, faithful agent tension) and the critical factual distinctions (no public hearing, no personal involvement, no domain expertise) that differentiate his obligations from those of Engineer Doe in BER 76-4.
Engineer A's ethical reasoning about his obligations regarding the infant respirator safety concern at MedTech
The BER's analysis comparing Engineer A's situation to BER 76-4 and finding that the factual distinctions materially altered the applicable obligations
Engineer A Precedent-Distinguishable Reporting Obligation
From the Board's comparative analysis of BER 76-4 and the present case through the Board's determination of the appropriate ethical response
In the present case, unlike the facts in BER Case No. 76-4, Engineer A is not faced with a scheduled public hearing at which he believed he had an obligation to correctly report information
Precedent-Distinguishable Safety Reporting Obligation State
Engineer A's situation as materially distinguishable from BER Case No. 76-4, requiring calibrated rather than automatic application of the precedent's external reporting conclusion
Board's issuance of its conclusion distinguishing the cases and prescribing a graduated internal-first response
Board's recognition that BER 76-4 appears analogous but differs materially on personal involvement, domain expertise, absence of public hearing, and absence of confirmed regulatory violation
Engineer A Premature External Reporting Threat Assessment Infant Respirator
Engineer A did not immediately threaten external reporting upon identifying the defect; he first reported internally, waited a month, re-escalated, and only then issued a conditional external reporting threat — satisfying the prohibition on premature external threats.
Premature External Reporting Threat Prohibition Obligation
Engineer A was obligated to refrain from threatening external regulatory reporting before exhausting internal escalation channels; the case record shows he complied with this obligation by first reporting internally, waiting a month, and re-escalating before issuing the conditional external reporting threat.
Throughout the escalation sequence from initial identification through the conditional external reporting threat
Engineer A Premature External Reporting Threat Prohibition MedTech Manager
Engineer A threatened to report to a governmental agency after one month of employer inaction, while MedTech was still in the process of internally investigating the matter through personnel competent in respirator design.
Engineer A was obligated to refrain from threatening to report the infant respirator safety concern to governmental authorities before exhausting internal escalation channels at MedTech, recognizing that issuing such a threat to the non-engineer manager — while MedTech's internal investigation was still ongoing — was ethically impermissible even though the underlying safety concern was legitimate.
Engineer A Premature External Threat Engineer
{'license': 'Professional Engineer', 'employer': 'MedTech', 'specialty': 'General engineering (not specialized in respirator design/manufacturing)', 'good_faith': True}
An experienced professional engineer at MedTech who, in good faith, identified a potential safety risk in a respirator device, but threatened to report to governmental authorities before exhausting internal escalation mechanisms, without direct involvement in the engineering decision-making process and without specialized expertise in the technical area. The Board found this response unreasonable and directed Engineer A to first exhaust internal mechanisms.
{'type': 'employed_by', 'target': 'MedTech'}
{'type': 'escalation_target', 'target': 'Non-Engineer Manufacturing Safety Decision Authority'}
{'type': 'peer_of', 'target': 'Peer Safety Evaluation Requesting Engineer'}
If after making additional inquiries, Engineer A determines that no meaningful actions are being taken to address the issue, Engineer A should explore internal mechanisms within MedTech
Engineer A Proliferating Defect Proportional Urgency MedTech Respirator
Hundreds of potentially defective infant respirators were distributed to hospitals while the defect remained uncorrected, requiring Engineer A to escalate with proportionally greater urgency.
Proliferating Unresolved Defect Proportional Urgency Escalation Constraint
Engineer A was constrained to calibrate the urgency of his escalation to the growing number of potentially defective infant respirators in circulation, intensifying his escalation posture as hundreds of units reached hospitals without correction.
NSPE Code of Ethics — public safety paramount; graduated escalation proportionality principle
From the initial report through the one-month period during which hundreds of additional respirators entered the market
Engineer A Public Safety Paramount Faithful Agent Tension MedTech Respirator
The Board identified the faithful agent vs. public safety paramount tension as the classical ethical dilemma at the core of this case, with the resolution depending on exhaustion of internal mechanisms before external escalation.
Client Loyalty vs. Public Safety Priority Constraint
Engineer A was constrained by the priority relationship between his faithful agent duty to MedTech and his paramount public safety obligation — with public safety taking precedence if internal mechanisms failed to produce meaningful action, but the faithful agent duty constraining the form and timing of escalation while internal mechanisms remained available.
NSPE Code of Ethics Section I.1 (public safety paramount); Section IV.1 (faithful agent duty)
Throughout Engineer A's handling of the infant respirator safety concern at MedTech
The NSPE Code requires that his duty to the public to be paramount.
Engineer A Regulatory Reporting Threat Proportionality Internal Exhaustion MedTech Respirator
Engineer A threatened to report to governmental authorities after only one month and without exploring other internal mechanisms, which the Board found premature and ethically impermissible.
Regulatory Reporting Threat Proportionality to Internal Exhaustion Constraint
Engineer A's threat to report the infant respirator safety concern to governmental authorities was constrained to be ethically permissible only after exhausting internal escalation channels — including initial reporting, allowing reasonable time for response, making additional inquiries, and exploring other internal mechanisms — which had not yet occurred at the time he issued the threat.
At the time Engineer A issued his threat to the MedTech manager, approximately one month after initial escalation
Engineer A Regulatory Reporting Threat Proportionality MedTech Respirator
Engineer A threatened to report to a federal regulatory agency only after making an initial report, waiting a month, learning of continued inaction, and re-escalating — satisfying the internal exhaustion prerequisite for a permissible regulatory reporting threat.
Engineer A was constrained to issue his threat of external regulatory reporting only after exhausting internal escalation channels — initial report, one-month wait, re-escalation — and was ethically permitted to make the threat upon receiving only an open-ended non-committal response from the non-engineer manager.
NSPE Code of Ethics; BER graduated escalation framework; Graduated Internal Escalation Exhaustion Before External Reporting Threat Constraint
At the second escalation meeting, after one month of inaction and hundreds of defective units in circulation
Engineer A Regulatory Reporting Threat as Final Internal Lever
From Engineer A's explicit statement of intent to report externally through either organizational action or actual external report
Regulatory Reporting Threat as Internal Escalation Lever State
Engineer A's explicit threat to report to a federal regulatory agency if MedTech does not act promptly
MedTech takes corrective action, or Engineer A files external regulatory report
Engineer A's statement that he will be compelled to report to an appropriate federal regulatory agency if prompt measures are not taken
Engineer A Resource Constraint Manufacturing Stoppage Cost MedTech
Correcting the relief valve error required halting manufacturing for part of a week — a resource constraint that appeared to influence management's delay in acting, but which could not ethically override the safety obligation.
The cost and operational disruption of stopping the manufacturing process for part of a week to correct the relief valve placement constituted a resource constraint that MedTech management weighed against corrective action, but which Engineer A was constrained from treating as a justification for inaction on a safety-critical defect.
NSPE Code of Ethics — public safety paramount over economic considerations
Engineer A's additional internal inquiries before Engineer A considering external reporting
Engineer A's initial report to manager before Engineer A learning nothing had been done
Engineer A's initial report to manager before hundreds of respirators reaching the market
Engineer A's second urging of the manager after Engineer A's initial report to manager
Engineer A's threat to report to federal agency after Engineer A's second urging of the manager
Engineer B Peer Safety Evaluation Requesting Engineer
{'employer': 'MedTech', 'relationship_to_engineer_a': 'Company colleague'}
MedTech colleague who requests Engineer A's safety evaluation of the infant respirator and later informs Engineer A that no corrective action has been taken by management.
{'type': 'peer', 'target': 'Engineer A Medical Device Safety Review Engineer'}
Peer Safety Evaluation Requesting Engineer
Engineer B, a company colleague of Engineer A, asks Engineer A to evaluate a respirator designed by MedTech for infant use
Engineer A learns from Engineer B that nothing has been done to correct the issue
Engineer Doe BER-76-4 Public Hearing Trigger Recognition
BER Precedent Factual Distinction Public Hearing Trigger Recognition Capability
Engineer Doe demonstrated the capability to recognize that the scheduled public hearing at which XYZ Corporation was presenting data he knew to be inconsistent with established environmental standards created a direct and mandatory obligation to report his contrary findings to the State Pollution Control Authority.
BER 76-4 — Engineer Doe retained by XYZ Corporation for environmental consulting, concluded discharge would violate standards, was instructed not to render written report, then learned of public hearing
Recognition that the public hearing — at which false or misleading data was being presented — created a direct demonstrable harm to the public if his contrary findings were not reported, triggering the public safety paramount obligation over the faithful agent duty to XYZ Corporation
In concluding that Engineer Doe had an ethical obligation to report his findings to the authority upon learning of the hearing, the Board concluded that upon learning of the hearing, Engineer Doe was squarely confronted with his obligations to the public concerning its safety, health, and welfare.
Engineer Doe BER 76-4 Client-Suppressed Findings Public Hearing Correction Obligation
BER Case No. 76-4 precedent cited in the Discussion: Engineer Doe discovered plant discharge would violate environmental standards, was instructed not to render a written report, and then learned XYZ Corporation presented contradictory data at a public hearing.
Client-Suppressed Findings Public Hearing Correction Constraint
Engineer Doe was constrained to report his findings to the State Pollution Control Authority upon learning that XYZ Corporation had presented contradictory data at the public hearing, because his completed findings directly contradicted the corporation's public presentation and silence would have created a materially false impression before a regulatory authority.
NSPE BER Case No. 76-4; NSPE Code of Ethics
Engineer Doe learned that the authority had called a public hearing and that the XYZ Corporation had presented data to support its view that the present discharge met minimum standards
Upon Engineer Doe learning that XYZ Corporation had presented contradictory data at the public regulatory hearing
The NSPE Code requires that his duty to the public to be paramount. In this case, it is presumed that a failure to meet the minimum standards established by law is detrimental to the public health and safety.
upon learning of the hearing, Engineer Doe was squarely confronted with his obligations to the public concerning its safety, health, and welfare
Engineer Doe Client Report Suppression Resistance BER 76-4
After Engineer Doe verbally advised XYZ Corporation that its discharge would violate environmental standards, the corporation terminated the contract with full payment and instructed him not to render a written report.
Client Report Suppression Resistance Obligation
Engineer Doe was obligated to resist XYZ Corporation's instruction not to render a written report of his findings that plant discharge would violate established environmental standards, recognizing that the corporation's payment of fees and termination of the contract did not extinguish his obligation to ensure that public authorities had accurate information.
Subsequently, the corporation terminated the contract with Engineer Doe with full payment for services performed and instructed Engineer Doe not to render a written report to the corporation.
Upon receiving XYZ Corporation's instruction not to render a written report after contract termination
{'license': 'Professional Engineer (implied)', 'specialty': 'Environmental/water quality consulting', 'case_reference': 'BER Case No. 76-4'}
Retained by XYZ Corporation to perform consulting engineering services; concluded that plant discharge would violate established environmental standards; was terminated and instructed not to produce a written report; upon learning of a public hearing at which XYZ misrepresented data, bore an ethical obligation to report findings to the State Pollution Control Authority.
{'type': 'client', 'target': 'XYZ Corporation'}
{'type': 'reports_to', 'target': 'State Pollution Control Authority'}
Consulting Engineer Discovering Regulatory Violation
the corporation employed Engineer Doe to perform consulting engineering services and submit a detailed report
Engineer Doe concluded that the discharge from the plant would lower the quality of the receiving body of water below established standards
Engineer Doe had an ethical obligation to report his findings to the authority upon learning of the hearing
the corporation terminated the contract with Engineer Doe
Engineer Doe Public Hearing Triggering Condition External Reporting BER 76-4
Engineer Doe, retained by XYZ Corporation, concluded that plant discharge would violate environmental standards, was instructed not to render a written report, and then learned that XYZ Corporation was presenting contrary data at a public hearing before the State Pollution Control Authority.
Public Hearing Triggering Condition Distinguishing Obligation
Engineer Doe was obligated to recognize that the scheduled public hearing — at which XYZ Corporation was presenting data that he knew to be inconsistent with his findings — constituted a heightened triggering condition that generated an immediate and direct external reporting obligation to the State Pollution Control Authority.
Upon learning that the State Pollution Control Authority had called a public hearing at which XYZ Corporation was presenting data contrary to his findings
Engineer Doe's completion of studies before Engineer Doe's verbal advisement to XYZ Corporation
Engineer Doe's verbal advisement to XYZ Corporation before XYZ Corporation terminating Engineer Doe's contract
NSPE Code — Graduated Public Safety Escalation Obligation
If after making additional inquiries, Engineer A determines that no meaningful actions are being taken to address the issue, Engineer A should explore internal mechanisms within MedTech to seek further recourse regarding this issue. Only if such efforts do not produce satisfactory results should Engineer A consider exploring external avenue for action.
NSPE Board of Ethical Review in prescribing Engineer A's appropriate course of action
The Board applies a graduated escalation framework: Engineer A should first exhaust internal mechanisms within MedTech before threatening or pursuing external reporting to governmental authorities; only if internal efforts fail should external avenues be explored
Epistemic Humility Constraint Applied to Engineer A's Premature Threat
Engineer A's evaluation of the infant respirator relief valve
Engineer A's threat to report to governmental authorities
Engineer A's lack of direct involvement in the respirator design process, absence of specialized expertise in the technical area, and possible incomplete knowledge of ongoing corrective actions required him to make additional internal inquiries before threatening external reporting — his epistemic position counseled internal dialogue rather than immediate external escalation threats.
An engineer who identifies a potential safety concern through peer review, without direct design involvement or domain specialization, must honestly assess the limits of their own knowledge before choosing the form of escalation — the epistemic gap between personal opinion and demonstrated professional finding is ethically relevant.
Epistemic Humility Constraint on Escalation Urgency
Engineer A was not personally involved in the engineering decision-making process and did not have any particular expertise in the technical area involved. Although an experienced professional engineer and by all indications a well-intended individual acting in good faith, as is sometimes the case in matters of this type, Engineer A may not be in possession of all of the necessary information to make an informed judgment.
Epistemic humility does not eliminate the safety obligation but shapes its appropriate form — internal inquiry to fill knowledge gaps before external threats.
Engineer A may not be in possession of all of the necessary information to make an informed judgment.
those concerns should be balanced with other legitimate factors, including the objective consideration of the concerns, the level of potential risk involved
U.S. Food and Drug Administration / U.S. Congress
Federal Medical Device Safety Regulatory Framework (e.g., FDA 21 CFR Part 803 Medical Device Reporting)
Medical Device Safety Regulatory Framework
Engineer A as the external reporting authority he will invoke if the manager does not act promptly
Provides the legal mechanism and authority to which Engineer A threatens to report the unresolved infant respirator defect, establishing the external regulatory accountability that compels manufacturer action when internal escalation fails.
Faithful Agent Obligation Invoked Against Engineer A External Threat
Engineer A's obligation to act as a faithful agent to MedTech — including respecting the employer's ongoing internal investigation process and pursuing internal channels before threatening external reporting — is the counterweight principle that the Board uses to evaluate Engineer A's premature external threat.
The faithful agent obligation in this context requires Engineer A to work within MedTech's legitimate internal processes before threatening external escalation, particularly when MedTech was actively investigating the concern.
the obligation to act for each employer or client as 'faithful agent or trustee'
The Board holds that faithful agent obligations counsel internal escalation first; the public safety obligation overrides only when internal mechanisms are exhausted or demonstrably inadequate.
Good Faith Safety Concern Threshold Applied to Engineer A Respirator Concern
Infant respirator relief valve safety concern
Engineer A's good faith professional belief that the infant respirator relief valve posed a serious safety risk — even without confirmed incidents or applicable regulatory standards — was sufficient to generate a real reporting obligation, but the Board holds that this obligation is properly discharged through internal escalation first rather than immediate external threat.
Good faith safety concern is necessary but not sufficient to justify immediate external reporting threats; the form and urgency of the response must also be calibrated to the engineer's epistemic position and the availability of internal mechanisms.
Engineer A is faced with a situation where, in his personal opinion, a serious risk may exist and the failure to adequately address the risk could result in tragic consequences.
Good faith concern triggers an obligation to pursue resolution, but the appropriate form of that pursuit is internal escalation when internal mechanisms are available and active.
Good Faith Safety Concern Threshold Invoked By Engineer A Without Confirmed Incidents
Absence of confirmed incidents as potential barrier to reporting
Infant respirator potential overpressure defect
Engineer A's professional judgment that the relief valve may have been incorrectly placed — even without any reported incidents — constitutes a sufficient good faith basis to justify and ultimately require reporting to a federal regulatory agency
The absence of confirmed incidents does not negate Engineer A's reporting obligation; his professional judgment that the design could cause harm to infants under certain circumstances is sufficient to trigger the good faith reporting threshold
Good faith professional belief in a genuine safety risk is sufficient to trigger reporting obligation even without confirmed incidents; the threshold is professional judgment, not certainty
an infant could potentially experience dangerously high pressure levels—although no incidents have been reported
Graduated Internal Escalation Invoked By Engineer A Before External Reporting Threat
Manager's failure to act on safety concern
MedTech internal safety reporting process
Non-Acquiescence to Employer Safety Testing Rejection
Engineer A first raised the safety concern internally to the appropriate manager, waited a month, then re-escalated internally before threatening external regulatory reporting — demonstrating the graduated escalation sequence
Engineer A correctly followed the graduated escalation sequence: internal report → reasonable wait → internal re-escalation → external reporting threat. However, the principle also requires that the external reporting threat be followed through if internal mechanisms continue to fail
Engineer A again urges the manager to take immediate action.
Graduated escalation is satisfied by Engineer A's sequence of actions; the remaining question is whether the external reporting threat was premature given that the design team was still investigating — the growing number of devices in circulation tips the balance toward the external threat being appropriate
Graduated Internal Escalation Obligation Applied to Engineer A
MedTech's ongoing internal investigation of the respirator safety concern
Engineer A was required to exhaust available internal escalation mechanisms at MedTech — including inquiry into the ongoing internal investigation, engagement with engineers competent in respirator design, and pursuit of internal recourse channels — before threatening external regulatory reporting.
The graduated escalation principle is particularly strong here because MedTech was actively investigating the concern, meaning internal mechanisms were not exhausted or demonstrably failed — making the external threat premature and ethically inappropriate.
Internal escalation is required first; external reporting becomes obligatory only if internal efforts do not produce satisfactory results.
Identify and Report Valve Flaw (Action 2) → Defer to Internal Resolution Process (Action 3)
Infant Respirator Potential Overpressure Safety Risk
From Engineer A's identification of the potential defect through the present; no incidents reported but risk is real
a relief valve intended to protect against overpressure being applied to the infant's lungs may have been incorrectly placed so that under certain circumstances, an infant could potentially experience dangerously high pressure levels—although no incidents have been reported
Potential Safety Risk Without Confirmed Imminent Harm State
MedTech infant respirators with potentially misplaced relief valve
Not yet terminated; persists until manufacturing defect is corrected and recalled units addressed
Engineer A's determination that the relief valve may have been incorrectly placed, potentially exposing infants to dangerously high pressure levels
Interdisciplinary Competence Threshold Invoked By Engineer A as Non-Expert Respirator Evaluator
Engineer A's evaluation of infant respirator design
Relief valve placement concern identification
Engineer A, despite not being a respirator expert, possesses sufficient cross-disciplinary engineering competence to identify a potential relief valve placement concern and escalate it for specialist review — satisfying the threshold obligation without overreaching into specialist certification
Engineer A's general PE competence is sufficient to identify the potential concern; the obligation is to escalate for specialist review (which the design team represents) rather than to personally certify the defect — but the escalation must actually occur and produce results
Interdisciplinary Competence Threshold for Specialized Referral
The interdisciplinary threshold is met by Engineer A's identification and escalation; the remaining obligation is to ensure the specialist review actually occurs and produces corrective action
Loyalty Tension Invoked in Engineer A's Internal Escalation Before External Threat
Internal escalation as expression of employer loyalty
Engineer A demonstrates loyalty to MedTech by first raising the safety concern internally and allowing time for internal resolution before threatening external reporting — but loyalty does not require indefinite silence when the employer fails to act on a public safety risk
Loyalty to MedTech is expressed through Engineer A's preference for internal resolution and his initial deference to the manager's handling of the concern; however, loyalty is bounded by the public safety obligation and cannot require indefinite silence
Engineer A brings the issue and his proposed solution to the attention of the appropriate manager, who is not an engineer, and Engineer A assumes that the matter will be taken care of immediately.
After a month of inaction, loyalty has been sufficiently honored through internal escalation; the public safety obligation now overrides the loyalty preference for internal resolution
Matter Still Under Review (Event 4) → Threaten Regulatory Agency Report (Action 5)
MedTech Employer Safety Investigation Active
From MedTech's initiation of the investigation through its conclusion with or without corrective action
Employer Safety Investigation Active State
MedTech's ongoing internal investigation into the respirator safety concern raised by Engineer A, conducted by domain-competent personnel
Conclusion of investigation with corrective action, or abandonment of investigation without resolution triggering Engineer A's external escalation obligation
Engineer A's escalation of the safety concern to MedTech management, prompting MedTech to begin investigating
MedTech Manufacturing Employer Safety Investigator
{'entity_type': 'Medical device manufacturing company', 'response': 'Internal investigation underway', 'product': 'Respirator device'}
The manufacturing employer of Engineer A that, upon receiving safety concerns about a respirator device, was in the process of internally investigating the matter through individuals competent in respirator design and manufacturing — distinguishing it from a purely safety-rejecting employer, though it bears the structural role of organizational authority over the safety response.
{'type': 'employs', 'target': 'Engineer A'}
{'type': 'employs', 'target': 'Non-Engineer Manufacturing Safety Decision Authority'}
there were more reasonable and appropriate internal mechanisms within MedTech that could and should have been explored
{'license': 'None (non-engineer)', 'employer': 'MedTech', 'authority': 'Production and safety decision authority'}
Non-engineer manager at MedTech who receives Engineer A's safety findings and proposed solution, fails to act for over a month, and when pressed again indicates the matter is still under review by a design team — triggering Engineer A's threat to escalate to federal regulators.
{'type': 'employer_representative', 'target': 'MedTech Safety-Rejecting Manufacturing Employer'}
{'type': 'supervises', 'target': 'Engineer A Medical Device Safety Review Engineer'}
Non-Engineer Manufacturing Safety Decision Authority
Engineer A brings the issue and his proposed solution to the attention of the appropriate manager, who is not an engineer
A month later Engineer A learns from Engineer B that nothing has been done to correct the issue
The manager indicates that the matter is still being looked into by a design team
MedTech Non-Engineer Manager Safety Authority Boundary Recognition MedTech Respirator
Non-Engineer Manager Safety Authority Boundary Recognition Capability
The MedTech non-engineer manager lacked or failed to exercise the capability to recognize the limits of non-engineering authority over safety-critical engineering determinations, resulting in a month of inaction on Engineer A's safety findings.
The non-engineer manager's failure to act on the safety concern illustrates the absence or non-exercise of this capability
Failure to act on Engineer A's safety findings for over a month, and characterizing the matter as 'still being looked into' rather than facilitating prompt corrective action
MedTech Non-Engineer Manager Safety Decision Authority Limitation Infant Respirator
The non-engineer manager received Engineer A's safety findings and proposed solution but failed to act for over a month, and when pressed again indicated the matter was 'still being looked into' — a failure to exercise appropriate authority over a safety-critical engineering matter.
The non-engineer MedTech manager was obligated to recognize the limits of non-engineering authority over safety-critical engineering determinations and to ensure that Engineer A's safety concern received timely engineering review and corrective action, rather than allowing a month of inaction.
From receipt of Engineer A's initial safety report through the month-long period of inaction
MedTech Non-Engineer Manager Safety Decision Authority Limitation Respirator
The non-engineer manager's failure to act for a month and subsequent 'still being looked into' response did not constitute a valid engineering resolution of the safety concern.
The non-engineer MedTech manager was constrained from treating his managerial authority as sufficient to finally resolve or indefinitely defer a safety-critical engineering determination raised by a licensed professional engineer.
NSPE Code of Ethics — non-engineer authority limitation principle; public safety paramount
the appropriate manager, who is not an engineer
From Engineer A's initial report through the one-month period of inaction and the second escalation meeting
MedTech Non-Engineer Manager Safety Inaction
From Engineer A's first report to the manager through the present; manager still 'looking into it' after one month
Non-Engineer Manager Safety Inaction State
MedTech manager's failure to act on Engineer A's safety escalation over a one-month period
Not yet terminated; manager still deferring to a design team review
Engineer A's initial report to the manager followed by discovery one month later that no corrective action had been taken
MedTech Ongoing Investigation Deference Active Monitoring
Ongoing Employer Investigation Deference With Active Monitoring Capability
Engineer A needed — and was directed by the BER to exercise — the capability to defer to MedTech's ongoing internal investigation conducted by competent respirator design and manufacturing personnel, while actively monitoring its progress through additional inquiries, and recognizing that such deference was conditional on the investigation producing meaningful results within a reasonable timeframe.
Engineer A's response to MedTech's ongoing internal investigation of the infant respirator relief valve safety concern
BER's direction that Engineer A should make additional inquiries into the ongoing internal investigation before concluding that no meaningful action was being taken, and should explore further internal recourse only if those inquiries revealed insufficient progress
MedTech Proliferating Defective Respirator Market Exposure
From the point at which Engineer A learns hundreds of units are on the market through the present
Proliferating Defective Product Market Exposure State
Hundreds of potentially defective infant respirators distributed to hospitals while defect remains uncorrected
Manufacturing halt, recall, or correction of the defect
Discovery that hundreds of new respirators with the unresolved defect are now on the market
MedTech Safety-Rejecting Manufacturing Employer
{'industry': 'Medical equipment manufacturing', 'product': 'Infant respirators', 'safety_response': 'Delayed/failed to act on identified defect'}
Medical equipment manufacturer that employs Engineers A and B, manufactures infant respirators, and through its management fails to act on an identified safety defect for over a month while hundreds of potentially defective units enter the market — prioritizing production continuity over public safety correction.
{'type': 'employs', 'target': 'Engineer A Medical Device Safety Review Engineer'}
{'type': 'employs', 'target': 'Engineer B Peer Safety Evaluation Requesting Engineer'}
Engineer A is employed by MedTech, a company that manufactures medical equipment
A key company product is respirators that are used in hospitals
Correcting the error would involve stopping the manufacturing process for part of a week
Hundreds of new respirators are now on the market
Misleading Data Correction Obligation Applied to Engineer Doe BER 76-4
State Pollution Control Authority public hearing
XYZ Corporation's presentation of data at the public hearing claiming discharge met minimum standards
Engineer Doe, having completed his technical study and concluded that XYZ Corporation's discharge would violate environmental standards, had an obligation to report his findings to the pollution control authority upon learning that XYZ Corporation was presenting contrary data at the public hearing.
When an engineer possesses completed technical findings that directly contradict data being presented to a regulatory authority, and the uncorrected data would result in regulatory approval of an environmentally harmful project, the engineer's public safety obligation requires correcting the record.
Misleading Data Correction Obligation at Regulatory Hearing
Public welfare paramount overrides the client's instruction not to render a written report when the client is actively presenting false data to a regulatory authority at a public hearing.
Engineer Doe learned that the authority had called a public hearing and that the XYZ Corporation had presented data to support its view that the present discharge met minimum standards.
National Society of Professional Engineers (NSPE)
Engineer A determines that a relief valve... may have been incorrectly placed so that under certain circumstances, an infant could potentially experience dangerously high pressure levels
Engineer A in evaluating his ethical obligations regarding the unresolved respirator defect
Grounds Engineer A's fundamental obligation to hold public safety paramount and to escalate an unresolved safety defect in infant respirators beyond the non-engineer manager to a federal regulatory agency when internal action is not taken.
NSPE BER BER-76-4 Public Hearing Trigger Factual Distinction Recognition
The BER demonstrated the capability to recognize the critical factual distinction between BER 76-4 — where a scheduled public hearing created a direct mandatory reporting obligation — and the present case involving Engineer A, where no public hearing was scheduled and the safety concern was based on personal opinion rather than personal knowledge of contrary data being presented publicly.
NSPE BER analysis of Engineer A's infant respirator safety concern at MedTech, comparing to BER 76-4 (Engineer Doe / XYZ Corporation environmental discharge case)
Explicit comparison of BER 76-4 facts (public hearing, personal knowledge, direct demonstrable harm) against Engineer A's situation (no hearing, personal opinion, speculative risk) to determine that the BER 76-4 mandatory reporting trigger was not activated in Engineer A's case
NSPE BER Engineer A Mitigating Factor Weighted Assessment
Mitigating Factor Weighted Safety Obligation Scope Determination Capability
The BER demonstrated the capability to identify and weigh multiple mitigating factors — including Engineer A's level of personal knowledge, the risks involved, his level of personal involvement in the engineering decision-making process, and actions taken and not taken by Engineer A and MedTech — to determine that these factors collectively calibrated Engineer A's safety obligation toward internal escalation rather than immediate external reporting.
NSPE BER analysis of Engineer A's infant respirator safety concern at MedTech
Explicit enumeration of mitigating factors (knowledge held, risks involved, level of personal involvement, actions taken/not taken) and their application to determine that Engineer A's obligation was to exhaust internal mechanisms before threatening external reporting
NSPE BER Faithful Agent Public Safety Classical Dilemma Recognition
The BER demonstrated the capability to recognize and correctly frame the classical NSPE Code ethical dilemma between the faithful agent/trustee obligation and the public safety paramount obligation, identifying it as a fundamental structural tension that must be navigated through graduated, proportionate response rather than immediate override of one obligation by the other.
Opening framing of the case as presenting 'one of the classical ethical dilemmas faced by engineers' and the subsequent analysis showing how mitigating factors and graduated escalation allow both obligations to be respected to the extent possible
NSPE Board of Ethical Review in analyzing Engineer A's obligations
Cited as the primary normative authority establishing both the paramount duty to hold public health and safety and the obligation to act as faithful agent or trustee for the employer/client — the two competing obligations at the heart of the case
Non-Acquiescence to Employer Safety Inaction Invoked By Engineer A
Design team's ongoing investigation as substitute for corrective action
MedTech manager's failure to act on safety concern for over one month
Engineer A refuses to accept the non-engineer manager's month-long inaction and the 'still being looked into' response as a discharge of his professional safety obligation, threatening external regulatory reporting if prompt corrective action is not taken
The employer's failure to act for a month, and the manager's response that the matter is 'still being looked into,' does not discharge Engineer A's professional obligation — he must not acquiesce to employer inaction when public safety is at risk
When the manager indicates that the matter is still being looked into by a design team, Engineer A indicates that if prompt measures are not taken to correct the problem, he will be compelled to report the matter to an appropriate federal regulatory agency.
After a month of inaction and a second internal escalation, Engineer A's non-acquiescence is appropriate; the employer's ongoing investigation does not justify indefinite deferral of corrective action when hundreds of devices are in circulation
Non-Acquiescence to Employer Safety Testing Rejection Applied to Engineer A Post-Exhaustion Obligation
MedTech's failure to act for over a month after receiving Engineer A's safety findings
Potential future failure of MedTech's internal investigation to produce corrective action
If MedTech's internal investigation concludes without meaningful corrective action, Engineer A's professional obligation is not discharged by MedTech's inaction — he must continue to pursue internal recourse and ultimately consider external reporting if internal mechanisms fail.
The employer's business decision not to act on safety concerns does not discharge the engineer's professional obligation; the engineer must continue escalating through available channels until the concern is genuinely resolved or external reporting becomes necessary.
Non-acquiescence is the endpoint of the graduated escalation sequence — if internal mechanisms fail, external reporting becomes obligatory.
Non-Engineer Supervisor Authority Limitation Standard
Engineer A in assessing the legitimacy of the manager's inaction on his safety recommendation
Establishes the limits of the non-engineer manager's authority to delay or override Engineer A's professional safety judgment regarding the respirator defect, reinforcing that the manager cannot legitimately suppress the engineer's safety findings.
Non-Engineer Safety Decision Authority Limitation Applied to MedTech Manager
MedTech Non-Engineer Manager's inaction on safety concern
Non-engineer manager as final decision authority on safety matter
The non-engineer MedTech manager's failure to act on Engineer A's safety concern for over a month does not constitute a professional engineering determination that the concern is unfounded — Engineer A's professional obligation persists and requires escalation beyond non-engineer management
The non-engineer manager lacks the professional authority to make a final determination on the safety adequacy of the respirator design; his inaction and 'still being looked into' response cannot discharge Engineer A's professional obligation, requiring Engineer A to escalate beyond non-engineer management
Non-Engineer Safety Decision Authority Limitation Principle
The non-engineer manager's structural incapacity to make professional engineering safety determinations means that Engineer A cannot treat the manager's inaction as a professional safety clearance, justifying escalation to external regulatory authority
Organizational Inaction Confirmed (Event 2) → Second Escalation to Manager (Action 4)
Engineer A when evaluating the respirator design despite not being a respirator specialist
Relevant to Engineer A's self-acknowledged limitation as 'not an expert on respirators' while still identifying a potentially dangerous defect, raising the question of whether his competence level is sufficient to ground the safety concern and whether specialist consultation is warranted.
Professional Competence Boundary Acknowledged By Engineer A in Non-Expert Respirator Review
Engineer A's self-assessment as non-expert in respirators
Engineer A acknowledges that he is not a respirator expert while still fulfilling his professional obligation to identify and escalate a potential safety concern — demonstrating appropriate competence boundary awareness
Professional competence requires Engineer A to be transparent about the limits of his expertise while not using those limits as an excuse to remain silent about an identified safety concern — the obligation is to escalate, not to personally certify
Competence limits inform how Engineer A frames his concern (as a potential issue requiring specialist review) but do not eliminate his obligation to identify and escalate the concern
Proportional Escalation Calibrated to Growing Device Circulation and Infant Vulnerability
Hundreds of infant respirators now on market
Infant population as vulnerable affected group
The growing number of potentially defective infant respirators in circulation (hundreds) and the vulnerability of the affected population (infants) calibrate Engineer A's escalation obligation upward, making the external reporting threat appropriate and urgent
As the number of devices in circulation grows and the affected population remains maximally vulnerable, the proportionality principle requires increasingly urgent and comprehensive escalation — the combination of breadth (hundreds of devices) and vulnerability (infants) places this at the high end of the escalation obligation spectrum
Proportional Escalation Obligation Calibrated to Imminence and Breadth of Risk
Hundreds of new respirators are now on the market, and Engineer A is concerned about the increasing likelihood of a tragic event.
The breadth and vulnerability factors override the preference for further internal escalation, making the external reporting threat not only permissible but obligatory
Proportional Escalation Obligation Applied to Engineer A vs BER 76-4 Contrast
BER 76-4 Engineer Doe's reporting obligation at public hearing
The Board's contrast between Engineer A's situation and BER 76-4 illustrates proportional escalation: Engineer Doe faced a public hearing with false data being presented (imminent, demonstrable harm requiring immediate external action), while Engineer A faced a general safety concern without confirmed incidents, personal involvement, or exhausted internal mechanisms (requiring measured internal escalation first).
The imminence, demonstrability, and breadth of the risk — combined with the engineer's epistemic position — determine the appropriate form and urgency of escalation; a scheduled public hearing with false data being presented demands immediate external action, while a general safety concern with active internal investigation demands internal escalation first.
Proportionality requires matching escalation form to risk characteristics; both cases honor public welfare paramount but through different appropriate responses calibrated to their specific facts.
In contrast, Engineer A is faced with a situation where, in his personal opinion, a serious risk may exist
Public Safety at Risk - Infant Respirator Defect
From Engineer A's initial finding through the present; escalating as more units enter the market
Infant patients in hospitals using MedTech respirators with unresolved relief valve defect
Correction of manufacturing defect and recall or remediation of distributed units
Identification of potentially misplaced relief valve in infant respirators now distributed to hospitals
Public Welfare Paramount Invoked By Engineer A Regarding Infant Respirator Risk
Infant respirator relief valve design defect
MedTech's failure to correct identified safety issue
Engineer A identifies a potentially dangerous relief valve placement in an infant respirator and, after employer inaction, threatens to report to a federal regulatory agency to protect infants from potential overpressure harm
Public welfare paramount requires Engineer A to escalate beyond employer inaction when hundreds of potentially defective infant respirators are in circulation and the employer has failed to act for over a month — the vulnerability of infants and the growing breadth of exposure make this a paradigmatic public welfare obligation
Public welfare paramount ultimately overrides employer loyalty and the preference for internal resolution when internal mechanisms have demonstrably failed over a month-long period and risk is growing
Public Welfare Paramount Invoked in Engineer A MedTech Respirator Case
Engineer A's decision about whether and how to escalate
The fundamental obligation to hold paramount public health and safety is the foundational principle generating Engineer A's concern about the infant respirator relief valve and the Board's analysis of his obligations — the entire case turns on how this paramount obligation interacts with other ethical duties.
In this context, the paramount public safety obligation does not automatically require immediate external reporting; it requires the engineer to pursue the most effective available path to actually securing public safety, which may mean exhausting internal mechanisms first when those mechanisms are actively engaged.
The Board holds that the paramount public safety obligation is preserved and honored through internal escalation when the employer is actively investigating; external reporting becomes obligatory only if internal mechanisms fail to produce satisfactory results.
This case presents one of the classical ethical dilemmas faced by engineers, which is the fundamental conflict between the obligation to hold paramount the public health and safety and some another key provision of the NSPE Code of Ethics
Was it ethical for Engineer A to indicate that if prompt measures are not taken to correct the problem, he will be compelled to report the matter to an appropriate federal regulatory agency?
Given that Engineer A is not an expert in respirator design, to what extent should his non-expert safety assessment carry ethical weight when deciding whether to escalate internally or threaten external regulatory reporting, and does his acknowledged competence limitation affect the proportionality of his response?
Does the fact that MedTech's design team was actively investigating the concern at the time Engineer A issued his regulatory reporting threat constitute a meaningful mitigating factor that the Board should have weighed more explicitly, and how should an engineer distinguish between genuine organizational inaction and a legitimate ongoing investigation?
What internal escalation pathways within MedTech—such as a safety officer, ethics hotline, legal counsel, or senior engineering leadership—should Engineer A have exhausted before either threatening external reporting or actually reporting, and does the Board's conclusion adequately specify what 'internal mechanisms' means in a medical device manufacturing context?
Should the Board have considered whether the proliferation of hundreds of potentially defective infant respirators into hospitals—a population of uniquely vulnerable patients—creates a sufficiently heightened urgency that compresses the normal graduated escalation timeline, effectively making Engineer A's threat not premature but proportionally calibrated?
Does the principle that engineers must hold public safety paramount conflict with the faithful agent obligation to MedTech when Engineer A—having already escalated internally once and waited a month—issues a conditional external reporting threat, and how should the NSPE Code resolve this tension when the employer is neither actively suppressing findings nor demonstrably ignoring them?
Does the principle of epistemic humility—requiring Engineer A to defer to domain experts given his non-expert status—conflict with the principle of non-acquiescence to employer safety inaction, and at what point does deference to an ongoing internal investigation become ethically indistinguishable from passive acquiescence to organizational delay?
Does the principle of proportional escalation calibrated to growing device circulation and infant vulnerability conflict with the principle that benevolent motive does not cure an ethical violation, and does the Board's conclusion adequately account for the possibility that Engineer A's threat was both procedurally premature and substantively proportionate at the same time?
Does the comparative case precedent distinguishing BER 76-4—where Engineer Doe faced active client suppression of findings at a public hearing—conflict with the graduated internal escalation obligation applied to Engineer A, in that the Board's stricter standard for Engineer A may inadvertently reward employers who engage in passive delay rather than active suppression, creating a perverse incentive structure?
From a deontological perspective, does Engineer A's duty to hold public safety paramount create an absolute obligation to threaten external reporting once internal inaction is confirmed, regardless of whether internal escalation pathways have been fully exhausted?
From a deontological perspective, does Engineer A's status as a non-expert in respirator design diminish the moral weight of his duty to escalate, given that his safety concern is grounded in good faith observation rather than confirmed technical violation?
From a consequentialist perspective, does the growing circulation of hundreds of potentially defective infant respirators shift the moral calculus such that Engineer A's premature external reporting threat, though procedurally improper, produces better expected outcomes than strict adherence to graduated internal escalation?
From a virtue ethics perspective, does Engineer A's decision to threaten external regulatory reporting reflect the virtue of professional courage and integrity, or does it instead reflect a failure of practical wisdom by bypassing the deliberate, measured judgment that a fully competent professional engineer would exercise in navigating the tension between employer loyalty and public safety?
If Engineer A had immediately escalated beyond the non-engineer manager to senior engineering leadership or a formal internal safety committee upon first learning of the one-month inaction, rather than issuing an external reporting threat, would the Board have found his conduct fully ethical, and would the public safety risk have been more effectively mitigated?
If the facts of this case had included an active public regulatory hearing at which MedTech was presenting data contradicting Engineer A's safety findings—mirroring the circumstances of BER Case 76-4—would the Board have reached the opposite conclusion and found Engineer A's external reporting threat not only ethical but obligatory?
If Engineer A had been a recognized expert in respirator design rather than a non-expert evaluator, would the Board have applied a lower threshold for permitting the external reporting threat, given that expert-grounded certainty about the defect would have substantially reduced the epistemic humility constraint on his escalation?
If Engineer A had made no threat of external reporting but instead simply filed a report with the federal regulatory agency without warning, would the Board have judged that conduct more or less ethical than the threat he actually issued, and what does that comparison reveal about the Board's underlying theory of graduated escalation?
State Pollution Control Authority Regulatory Body
{'entity_type': 'State regulatory agency', 'case_reference': 'BER Case No. 76-4', 'function': 'Environmental permit issuance and public hearing convening'}
Regulatory authority that advised XYZ Corporation of permit requirements and minimum discharge standards, and convened a public hearing at which XYZ Corporation misrepresented its compliance status — the hearing that triggered Engineer Doe's obligation to report.
{'type': 'receives_report_from', 'target': 'Engineer Doe'}
{'type': 'regulates', 'target': 'XYZ Corporation'}
the XYZ Corporation was advised by a State Pollution Control Authority that it had 60 days to apply for a permit to discharge manufacturing wastes
the authority had called a public hearing
XYZ Corporation Report-Suppressing Corporate Client
{'entity_type': 'Corporation', 'case_reference': 'BER Case No. 76-4', 'regulatory_context': 'Manufacturing waste discharge permit'}
Corporate client that retained Engineer Doe for environmental consulting, terminated the contract after receiving adverse verbal findings, instructed Engineer Doe not to produce a written report, and subsequently misrepresented data to the State Pollution Control Authority at a public hearing.
{'type': 'client_of', 'target': 'Engineer Doe'}
{'type': 'subject_to', 'target': 'State Pollution Control Authority'}
the XYZ Corporation was advised by a State Pollution Control Authority that it had 60 days to apply for a permit
XYZ Corporation terminating Engineer Doe's contract before Engineer Doe learning of the public hearing
design team review during one-month inaction period
hundreds of respirators reaching the market overlaps design team review period
internal escalation mechanisms exhausted before external reporting to federal regulatory agency