The Tylenol Recall transcript

Introduction

This is “What Just Happened?,” the podcast that looks at the biggest brand crises of our time, what they meant for organisational strategy and behaviour, and their lasting impact on our approach to crisis communication.

I’m Kate Hartley. And I’m Tamara Littleton. And together, we’ll delve into what happened, why it mattered, and whether it could happen again.

Episode 

Kate Hartley: So today, Tamara, we are going to look into a crisis that I think has shaped our thinking on crisis communications almost more than any other. This is the case of the Tylenol murders in Chicago in 1982. Seven people died, the murderer was never found, and the impact on Tylenol, a pain relief brand owned by Johnson & Johnson, was absolutely massive. 

Tamara Littleton: This is a well-known case, but I don’t imagine everyone knows the details. So what actually happened? 

KH: Seven people in the Chicago area died after taking Tylenol capsules, which were later found to have been laced with potassium cyanide. Someone had deliberately tampered with the containers that Tylenol comes in, putting the brand at the centre of a murder investigation, which is never what you want, is it?

I mean, just imagine the impact that would have on your brand. If you were an over-the-counter drug manufacturer, trust is probably the most important thing you can have. You’re asking people to put a drug into their bodies, trusting it’s going to do what it says on the bottle. And then suddenly, people were dying from taking Tylenol.

That trust was completely gone overnight. People were talking about the Tylenol murders. To have your brand associated with something like that is possibly the worst thing that could happen. And in fact, we still talk about the Tylenol murders all these years later. 

TL: How could anyone be prepared for that? How did they actually respond? 

KH: Well, this is the amazing part, I think. Johnson & Johnson’s CEO at the time was James Burke. Right away, he made the decision to recall more than 93,000 bottles of Tylenol from the batch linked to the first two murders. But then, when there was another death, they recalled another 171,000 bottles from the batch associated with that death.

A month later, once they realised the scale of the issue, he made the really tough decision to recall every single bottle of Tylenol from shelves across the US—31 million bottles. That was a huge decision, costing Tylenol more than $100 million. It was the first time anything like that had ever been done. People said you couldn’t do it—this was before digital stock records, before product tracking technology, all those things.

Just imagine the logistics of trying to reach every single person who had a bottle of Tylenol on their shelves at home, or every single hospital, convenience store, drugstore, petrol station, or corner shop all across the US. It was really, really difficult. 

TL: So how hard do you think it was to make that decision?

KH: I think it must have been really difficult. I mean, $100 million is a lot of money to lose in 1984. And actually, in the end, only about eight bottles were tainted. So it must have been really tempting to say, “Look, this is only happening in Chicago. Let’s limit the recall.” But what I find really interesting and kind of at the core of this case is that Burke had a guiding principle. And that’s what I want to look at today. 

Johnson & Johnson has a credo written by one of the founding family members, Robert Wood Johnson, that lays out the guiding principles of how the company operates. It states very clearly that their first responsibility is to their customers, followed by their employees, communities, and then stockholders.

This was really important in this case because the first line of that credo says, “Our first responsibility is to the doctors, nurses, and patients, to mothers and fathers, and all others who use our products and services. In meeting their needs, everything we do must be of high quality.” So if you know that’s your guiding credo, those kinds of decisions are easier to make. And I think that’s how Burke made that decision. He decided the company should put safety ahead of profit. Once you’ve decided that, it becomes easier to make the decision to recall the product across the whole of the US. It might have cost millions of dollars in the short term, but in the long term, that decision won back the trust of consumers and ultimately saved the brand’s reputation.

TL: And that’s such a powerful thing, to have that credo that, as you said, came from the founding family members and is at the heart of the company. I can see how that would have helped steer the decision-making. 

KH: Absolutely. But it’s a hell of a test of your principles, isn’t it? Everyone says we put safety first, but you’re not often tested on it. When you are, do you live by those principles? Johnson & Johnson did. They were really open and transparent about what was happening. They put out warnings to everyone across the US—to the general public, hospitals, pharmacies, and so on—about the risk. They were very open in the way they communicated, and that’s what helped the recall happen. 

TL: It was also a financial risk because there was no guarantee they would recover from that recall.

KH: Absolutely, it could have put them under. 

TL: So what do we know about James Burke? I’m curious to know more about him.

KH: He was a really interesting man. He was CEO of Johnson & Johnson between 1976 and 1989. He didn’t invent the company credo but was a real champion of it. He introduced credo challenge meetings, where people ensure the credo is still relevant and upheld. He also introduced an anonymous poll of employees to give feedback on whether the company is living up to that credo.

He had a real passion for creating an ethical business, which led to him being named one of Fortune Magazine’s 10 greatest CEOs of all time. In 2000, he was awarded a Presidential Medal of Freedom by Bill Clinton for his work after leaving Johnson & Johnson, including tackling illegal drug addiction across the US.

There’s a really interesting story on the company’s website about his early days at Johnson & Johnson. Apparently, he was in charge of developing a new product when he was relatively junior at the company. It was a complete disaster. He was called into Robert Wood Johnson’s office, who was the CEO at the time. He thought he was going to get fired, but instead, he was congratulated for trying. I wonder if that culture also helped him make the tough decision about the recall. If you’re congratulated for trying something and failing, you can take more risks. It’s about psychological safety. 

TL: Definitely. It’s something we talk about in crisis comms and crisis management: if people feel safe to challenge and suggest different directions, it indicates a psychologically safe culture. You need that because when people feel psychologically safe, they are more likely to take risks.
So, back to the case. What actually happened with it? 

KH: It’s fascinating because it was never definitively solved. But there was a suspect, James Lewis, who mailed an extortion letter to Johnson & Johnson. He promised to stop the killings if the company wired $1 million to a Chicago-based bank account. Just a little suspicious, isn’t it? 

He was already on the police radar when he was arrested on suspicion of a different murder and also during a credit card fraud investigation. He also wrote to President Reagan, saying he would fly all over the country with cyanide and jam Secret Service radios using model aeroplanes.

Another man, Roger Arnold, was picked up by the authorities after he was accused of telling people in a bar that he was using cyanide for a project. The police raided his house and found illegal handguns and instructions for making potassium cyanide. He later shot and killed a man he mistook for the barman who he thought had given the police his name. He was sentenced to 30 years for second-degree murder and served about 15 years before dying in 2008. 

TL: It’s awful, isn’t it?

KH: James Lewis was never actually accused of the killings but was sentenced to 10 years for mail fraud related to a credit card scam before the Tylenol murders. Later, he was convicted of attempted extortion. Fascinatingly, he offered to help the police solve the Tylenol murders by showing them how the killer might have tampered with the bottles. He remained under suspicion for most of his life and was continually interviewed between 2010 and 2022. He died in 2023, and as of today, the Tylenol murders are still officially unsolved.

TL: How did Tylenol respond after all of this was over? 

KH: I think the temptation must have been to say, “Thank God that’s over.” But instead, they took their credo one step further and took action to ensure this could never happen again. They created the tamper-proof containers we know today, including foil seals. This set the standard for the industry, and other manufacturers followed suit. They changed the industry standard for packaging to ensure something like this couldn’t happen again, which is incredible. Rather than just moving on, they learned from it and made sure it never happened again, ensuring not only their safety but the safety of the whole community.

TL: So what what’s the lesson here that’s relevant to business today? Because this was, as you say, a long time ago, and everything has changed. There’s so much digital now. 

KH: The lesson here is about creating company values that you can actually live by. When you’re tested, a crisis tests your values more than any other time. Johnson & Johnson lived by their values brilliantly. When we’re doing simulations with clients, the people in the room who are connected to the company values know exactly what they’re doing. They don’t have to question the direction—they’re all moving in the same direction. It’s incredible to see.

There is a bit of a backlash against companies having values or a purpose. But in a crisis, those values guide you on how you should behave. I don’t know if you remember this, Tamara, but we did a simulation some years ago with two groups from the same organisation. That organisation didn’t have any written values. It was about a product recall involving a device catching fire. One group said, “We must recall it immediately and keep people safe,” because of their personal values. The other group, not guided by company values but by personal values, said, “We’re not going to recall those products until I see evidence of burns.”

TL: In the absence of company values, the groups formed their own norms. 

KH: The first group felt their responsibility was to customer safety, while the other group felt their responsibility was to company finances. If company values had been set out, they would have known how to behave. That’s the lesson from Johnson & Johnson.

TL: The strategic intent in the Tylenol case is why this case study is often discussed. 

KH: It required long-term thinking. Short-term, it cost $100 million, but long-term, it regained trust in the brand. In a crisis, it’s tempting to make short-term decisions out of panic. But Burke thought about how the brand would be perceived in the long term. Tylenol is still one of the most popular pain relief brands in the US as a result of that action.

Break

KH: We are absolutely delighted today to be joined by the brilliant Jonathan Hemus, founder and CEO of crisis specialist consultancy Insignia, and author of “Crisis Proof,” which looks at the challenges leaders face in a crisis. We wanted to talk to you today, Jonathan, about strategic intent. Tylenol is an excellent example of how strategic intent was brought to life by a leader and shaped the company’s response to a potential disaster. Tell us about strategic intent and how it might shape a crisis response.

Jonathan Hemus: I’ve been working in crisis management for about 25 years now, and I’ve seen many examples where experienced leaders get very tactical in a crisis. They’re problem solvers and fixers, and they want to get down to the nitty-gritty and sort the problem out. But if they do this without setting strategic intent, it becomes an uncoordinated crisis response.

Strategic intent is a vision of success—a description of where the organisation wants to get to through its crisis management response. It has significant benefits. It aligns the crisis management team around a shared objective, makes decision-making easier by providing a destination to aim for, and allows for prioritisation by focusing on actions that will have the biggest impact. It’s a transformational change when leaders and teams embrace it.

Creating an environment for strategic intent involves making it a part of the crisis response process, rehearsing it through simulations and exercises until it becomes second nature. It’s about having it written into your plan and rehearsing it so that it becomes a mental muscle memory.

A good crisis management plan is not an A-to-Z guide but a framework for a way of working that enables you to be purposeful, focused, structured, and ultimately successful. It’s a way of working, not an answer sheet for every crisis.

TL: I’d love to go into more about this way of working and culture. Kate and I talked about James Burke, the CEO, making a very brave decision to do the recall. What would you say Tylenol’s response says about its leadership and culture?

JH: It says they have a culture of psychological safety. It’s a culture that enables leaders to respond effectively to a crisis by being courageous in decision-making and helps prevent crises by allowing people to challenge groupthink and alert leaders to early signs of a crisis. Burke felt empowered and backed by the organisation to do what he believed was right, indicating a very healthy corporate culture designed to succeed in crises.

KH: Thinking about how leaders make tough decisions, you talk a lot in your book about the pressures a leader faces, describing it as potentially the worst day of their business life. Leaders often lose their jobs after major crises, sometimes within six months or a year. How do you make those tough decisions? What qualities does a good leader need to deal with the pressures during a crisis?

JH: A crisis presents an extraordinary challenge, even for the most experienced leaders. There’s pressure from the stock price going down, media scrutiny, social media criticism, and personal pressure regarding their job security. Making good decisions in a crisis involves practising and rehearsing decision-making under pressure. It also requires the courage to do what is right, not necessarily what is easy, and to follow the organisation’s values. Leaders need to take a deep breath, look themselves in the mirror, and do the right thing.

In a crisis, the outside world finds out whether an organisation’s values are real or just words on a website. If values are deeply embedded, they will naturally guide decision-making. Problems arise when values are not genuinely part of the organisation’s culture. The leader of the organisation is the guardian of those values, ensuring they are deeply embedded so everyone follows them in a crisis.

TL: In simulations, people who can fall back on their values find it easier to navigate crises. There is a backlash against values, but they are crucial in a crisis. They guide behaviour and decision-making. At Johnson & Johnson, the courage displayed during the Tylenol crisis likely impacts how employees approach crises today.

JH: During a crisis, employees should be a top priority. They are worried about their jobs and the organisation’s reputation. Demonstrating values during a crisis binds employees to the organisation, making them part of the solution. If employees see their employer behaving in a way that aligns with their values, they are more likely to support the organisation.

KH: Jonathan, thank you for joining us. It’s been amazing to talk to you. I thoroughly recommend Jonathan’s book, “Crisis Proof.” It’s full of great case studies, interviews, quotes, and practical examples of how to behave in a crisis. Thank you very much for joining us.

Outro

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