Tainted Blood

The Tainted-Blood Tragedy in Canada

Tainted Blood Book

A Cascade of Governance Failures

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Canada experienced a tainted-blood crisis in the latter part of the 20th century. It left a number of Canadians dead, and a large number incapacitated or seriously handicapped. It has been established by the court that there was no criminal negligence at the source of this event, but there were most certainly governance failures. This latter aspect of the tragedy has not received the attention it deserves. These governance failures have transformed the crisis into a tragedy, and the tragedy generated a miscarriage of justice – if justice delayed for decades may be regarded as justice denied.
This book has been written by a specialist on governance, and a medical doctor and scientist, who managed the Canadian blood transfusion system for 17 years. It challenges the conventional wisdom that underpinned the four ill-founded accusations against a few persons levied by interest groups, the media, and the Office of the Solicitor General of Ontario, and it argues that the tragedy was the result of a cascade of pathologies of governance.
A systemic reconstruction of the tragedy is proposed, the administrative processes that we argue were responsible for the pathologies of governance are exposed, and suggestions are made to neutralize such malefits in the future. The full-text of the judgment and reasons provided by Justice Benotto, when one of the ill-founded accusations was brought to court, is enclosed. This led the Crown to drop the other three ill-founded accusations. A postface underlines the lack of critical thinking that has allowed such a tragedy to follow its course.

Gilles Paquet is Professor Emeritus at the Telfer School of Management, a Senior Research Fellow at the Centre on Governance of the University of Ottawa, and Editor in Chief of www.optimumonline.ca, an electronic journal on public governance and management that reaches some 10,000 subscribers. For more information, visit his website www.gouvernance.ca.
Roger A. Perrault is a medical doctor and an internationally known immunologist, who managed the Canadian Blood Transfusion Service between 1974 and 1991.




    Introduction Factum, Explanandum and Explanans

  • Chapter 1 A Cascade of Pathologies of Governance
  • Chapter 2 Four Ill-founded Accusations
  • Chapter 3 A Systemic Deconstruction
  • Chapter 4 Modest General Propositions
  • Conclusion The Organizational Design Imperative


The Benotto Judgment, October 1, 2007

Postface Requiem For Critical Thinking?

Addendum About the Centre on Governance of the University of Ottawa

Quality Paperback with images of judgment document, 5½×8½” 162 pg, Publication date: March 2016, ISBN 978-1-927465-30-1: $15.95

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