IN NORMAL circumstances I would be writing today about the President, Mrs Robinson - her extraordinary achievement in what had come to seem an unpromising office, and the enormous difficulty we shall have in finding someone able to maintain and develop the new Presidential role which she has created. But given the other major news event of the past week - the publication of the Report of the BTSB Inquiry - I know that she herself would prefer that I comment upon some of its implications.
For the events dealt with in that report represent the greatest human tragedy in Ireland since the foundation of the State - and one that uniquely affected women. And it has raised fundamental questions about the workings of parts of our public service.
At the outset it should be said that the women infected by the BTSB with hepatitis C have every right to be deeply angry about their fate - and every right to be incandescent with rage at the way they were treated by the board after this tragedy happened. The mistakes that led to their infection were intolerable - and the subsequent failure of the board to face up to its responsibility for the devastation it had created was quite unforgivable.
Why did all this happen? Basically, it would seem, because of a total inability on the part of those concerned to understand the very concept of public service. Not for the first time in Irish administrative history, the interests of a public institution, as perceived by its staff, were allowed to take precedence over the interests of those whom that institution was set up to serve.
It was quite astonishing that the staff of the BTSB ignored its own standards, which prohibit the use of blood or plasma from a person infected with hepatitis or jaundice. But the staff's reaction to the news that recipients of this plasma had suffered jaundice and/or hepatitis was grossly irresponsible.
For, instead of immediately sounding the alarm, those concerned failed even to report this appalling development either to their own board or to the National Drugs Advisory Council. And they failed to recall the contaminated batches which they had issued.
As the tribunal has now reported, one of the reasons for these failures was "a reluctance to admit the possibility of having been wrong and the possibility of a failure of anti-D, which would be involved in the recall of the product".
OW, none of us can honestly claim never to have refused to admit we have acted wrongly. And those of us who have held positions of responsibility as public servants and politicians have often been particularly reluctant to admit error. In these circumstances we should generally be slow to castigate others for a weakness to which all of us are in some degree prone.
But when lives are at stake nothing can forgive a failure to make such an admission. No consideration of pride, or fear of criticism, can ever be allowed to stand in the way of admitting an error when failure to make such an admission may pose a risk to the lives, or indeed health, of others.
Nor can one justify inaction in such a case by persuading oneself that there might be some other explanation for such an illness or death; the mere possibility that our action or inaction might contribute to a risk to health or life should be enough to compel such an admission of error.
That this did not happen in the present case was a clear betrayal of professional responsibility. This needs to be said without ambiguity - not so as to rub salt in any wounds, but for two quite compelling reasons.
First, because such an unambiguous admission is clearly necessary to help the victims, and those to whom they are dear, to bear their appalling pain and loss. And, second, because if such tragedies are to be avoided in future, it is necessary that everyone in posts of responsibility should have it borne in on them forcibly that the rewards that accompany such positions carry a commensurate moral responsibility.
This affair has, however, raised other and wider issues. One of these relates to the political process of allocating resources between competing needs.
The additional resources that each year become available to a Government through buoyancy of revenue, or through savings in expenditure under certain heads, are never sufficient to satisfy more than a fraction of competing demands. In this situation, it is not easy to secure a rational distribution of whatever resources may be to hand; there is always a danger that in the hectic competition between rival departmental demands, vitally important needs may be overlooked.
Mr Justice Finlay's report says that between 1975 and 1994 successive ministers for health "failed adequately and appropriately to supervise the National Drugs Advisory Board" and to provide it with the resources that might have revealed the impact of contaminated anti-D upon the women to whom it was administered.
However, the responsibility of ministers for funding bodies like the NDAB is shared by their colleagues in Government, whose own departmental claims on resources inevitably reduce the amount available for health purposes. And, of course, issues like this also engage the responsibility of successive ministers for finance, and of successive Taoisigh like myself, all of whom have roles - to play in resource allocation.
ALL who have shared Cabinet responsibility have to recognise the danger that key needs which may have implications for people's lives can be all too easily overlooked in the course of the highly competitive process which each year sets spending Departments against each other - and all of them jointly and separately against the Department of Finance. More thought needs to be given to the question of how this danger can be avoided in future.
Another quite different issue has also been raised by this affair: that of the conflicting responsibilities of ministers - on the one hand to the community of taxpayers and on the other hand to the vindication of the rights of individuals and groups in society.
The general public interest in effective control of public spending requires a high measure of financial accountability in central and local government. Indeed, the whole public sector is dominated by this consideration: public servants and also ministers, are schooled to resist pressures for unauthorised disbursements of funds.
The standard response of the system to many demands made upon it, whether through political.. pressure or through legal action must be to resist them. In certain circumstances, failure to do so can constitute a dereliction of duty.
In most cases this system works well and is very much in the public interest. But on occasion it can lead Departments to react with striking insensitivity.
One such occasion was in 1989 when the Department of Health under Rory O'Hanlon resisted compensation claims by people who had been infected with AIDS through an imported blood product. As a backbench Opposition member of an all-party delegation to the minister, I was struck by the way the Department was clearly pressurising him to resist these claims, seeming to fear that: acceptance of responsibility for this earlier blood transfusion tragedy might be equated with acceptance of blame.
Indeed, I recall after this meeting privately advising Charles Haughey, then leading a minority Fianna Fail government, to persuade the minister and Department of Health to modify their position, if he wished to avoid a defeat for his government. I suspect that he may have taken my advice, but, if he did, it must have been vigorously resisted by the Department during his absence in Japan.
The truth is that there are times when, because the State or its agencies, whether by accident or through negligence, have been responsible for a human tragedy, the normal disciplines of public administration designed to protect the public purse simply have to be relaxed. And these two blood transfusion catastrophes were certainly cases in point.