EXECUTIVE SUMMARY

Of 280 serious ethical violations, almost all cases involved repeated intentional wrongdoing that went undetected, researchers found. Other key findings:

• systems were ineffective at identifying, tracking, and preventing repeat occurrences;

• nearly all cases involved males in nonacademic medical settings and a selfish motive;

• more than half of cases involved a person with a suspected personality disorder or substance use disorder.


Often, training is viewed as a way to stop ethical violations. But a recent analysis of 280 cases suggests this is not the answer. Nearly all cases of serious ethical violations involved repeated instances of intentional wrongdoing that went undetected.1

“We were surprised at how ineffective systems are at identifying wrongdoing, tracking it, and preventing repeat occurrences,” says James M. DuBois, PhD, DSc, the study’s lead author. Key findings include:

• Ninety-seven percent of cases involved repeat offenses;

• Ninety-nine percent were intentional violations;

• Selfish motives, such as financial gain, drove 90% of cases;

• Ninety-five percent occurred in nonacademic medical settings, with 89% experiencing oversight issues;

• Personality disorder or substance use disorder are suspected in 51% of violators.

It is unrealistic to think that ethicists can prevent all first occurrences of wrongdoing. “But something has gone terribly wrong when someone like Larry Nassar [former medical staff for USA Gymnastics and Michigan State University athletic teams] can abuse more than 250 young women and girls before he is stopped,” says DuBois.

The researchers found that despite clear patterns, no factors provide readily observable red flags. This makes prevention difficult. In any field, there will be bad actors, says DuBois: “But in medicine, bad actors are able to do surgery, perform intimate exams, and prescribe opioids. The stakes are higher, and oversight is needed.”

The Federation of State Medical Boards has observed that hospitals and health organizations regularly ignore reporting requirements.2 “Hospitals need to investigate whether reports of professional misconduct are credible and to fulfill their reporting requirements,” says DuBois, the Steven J. Bander professor of medical ethics and professionalism in the School of Medicine at Washington University School of Medicine in St. Louis.

Hospital-based ethicists often receive informal complaints against healthcare providers. “It’s important that they not keep this information to themselves,” says DuBois. “Bring it to the attention of the appropriate leaders.” Follow-up is important to ensure that allegations are investigated.

“For more mild behaviors, it may be appropriate to speak with clinicians directly, particularly if you have an existing relationship,” says DuBois. For more egregious behaviors such as sexual assault, it is best to work through formal channels. In some cases, it might make sense for the ethicist to contact the state medical board, or to encourage complainants to do so. “Hospitals frequently have anonymous compliance hotlines that might also be used in difficult cases,” suggests DuBois.

Burden of Responsibility

As an ethics educator, Rebecca Volpe, PhD, would love to believe that the courses she teaches actually change students’ behavior. “But there is very little evidence for that, unfortunately,” says Volpe, vice chair for education in the department of humanities at Penn State College of Medicine and director of the clinical ethics consultation at Milton S. Hershey Medical Center.

This is particularly true for shorter course curricula. The ethics course at Penn State College of Medicine is 24 contact hours. “If we are not going to stop wrongdoing or change trainees’ behavior, the question then becomes, ‘Why are we doing it?’” asks Volpe. Ethical sensitivity is one obvious answer. “An individual then knows he or she is standing toe-to-toe with an ethical dilemma,” says Volpe. But that does not mean the individual knows what to do about it.

The timing of ethics education is another potential barrier to action. “As far as the type of physicians they become, their professional identity, that doesn’t really happen when they’re in the classroom. That happens during clerkships and residency,” says Volpe.

Penn State’s ethics course occurs in the second year of medical school. “We have been working so hard to get ethics education into residencies. But there are a lot of logistical barriers,” says Volpe. One possible solution may be embedded ethics rounds for residents. “But that requires a significant time investment for the ethicist — and assumes the institution even has an ethicist,” says Volpe.

It is easy to imagine trainees struggling with how to raise ethical concerns. One reason is fear of retribution. “Students’ perception is that they are graded in large part on how well they get along with the team,” says Volpe. Speaking up is difficult if students fear their future hangs on good evaluations. “It’s important to teach physicians in training to report wrongdoing when they witness it,” says Volpe. “But there are a lot of reasons for them to stay silent.”

Even clinicians struggle with reporting their peers, regardless of whether the concern is cognitive impairment or unethical conduct. “But clinicians have significant power and authority in society,” says Volpe. “And because of that, we have a big burden of responsibility for policing our peers.”

REFERENCES

1. DuBois JM, Anderson EE, Chibnall JT, et al. Serious ethical violations in medicine: A statistical and ethical analysis of 280 cases in the United States from 2008-2016. Am J Bioeth 2019; 19:16-34.

2. Federation of State Medical Boards. Position Statement on Duty to Report, April 2016. Available at: https://bit.ly/2Hfsx2B.

SOURCES

• James M. DuBois, PhD, DSc, Director, Bioethics Research Center, Washington University School of Medicine, St. Louis. Email: duboisjm@wustl.edu.

• Rebecca Volpe, PhD, Vice Chair for Education, Department of Humanities, Penn State College of Medicine/Director, Clinical Ethics Consultation Service, Milton S. Hershey (PA) Medical Center. Phone: (717) 531-8778. Email: rvolpe@pennstatehealth.psu.edu.