Some bad news took me by surprise this week, taking the form of an article in the Annals of Family Medicine entitled, “Why Medical Schools Are Tolerant of Unethical Behavior.” The authors described a medical school graduation ceremony in which the speaker thanked professors and healthcare professionals not just for competent and humane care, but for providing examples of “pure unethical behavior.”
I wondered if my surprise at these circumstances was a bit of bad news in itself. Either I was blessed to be away from such an environment, or ignorant of similar problems around me. To some relief I found (after looking quickly) that the authors were from Brazil, but a book by an American author is but the most recent reminder that the problem resides between our shores as well.
The authors themselves seemed surprised by the audience’s lack of unease or objection to the allegation, and concluded that the professional environment must be tolerant of the behaviors. They asked why, and described these possible reasons:
- Barriers to reporting, due to fear of retaliation, lack of anonymity, and complaining seen as a sign of weakness;
- Leaders turning a blind eye to problems;
- “Systemic disrespect,” that is, widespread problems of the healthcare system that produce long waiting times for patients, excessive staff workloads, and a culture where mistakes are not acknowledged and apologies not made;
- Lack of accountability by accrediting organizations for ethical behavior.
They go on to discuss conflicts between explicit and implicit values, with the implicit ones being “culturally appropriate” yet far from admitted publicly. Such conflicts produce a systemic delusion, as well as cynicism in the young and developing healthcare professional.
That such a situation exists merely highlights how critical the truth is to ethical behavior. Organizational dishonesty, in whatever form, corrodes the integrity of individuals and provides fertile ground for unethical behavior. Integrity requires a willingness both to hear bad news and to give it. Values greater than one’s personal image, comfort, or success must be paramount, or else bad news becomes a problem unto itself, as opposed to a useful and necessary tool for ferreting out problems and making organizations better.
We can’t find such integrity from purely utilitarian arguments. The authors cite, unfortunately, only utilitarian arguments for building a professional ethic (increased costs, medical errors, etc.), reminding me how the language of virtues has long ago faded from modern societies. They do note utilitarianism’s inadequacies in the problem of “administrative evil,” in which “standard operational procedures within an organization inflict harm or suffering on individuals by blindly following a cold bureaucratic rationality committed for the ends but not the means to those ends.”
It is virtue ethics that is required to fight the corrosive effect of pure utilitarian thinking, for it reminds us that one of the ends produced when disregarding means is that one becomes the sort of person who uses those means. This requires an understanding of virtues and the central nature of the character of man to any ethical system.
I am not confident that modern society is ready to recover the lost language of virtue. Virtue, it seems, must not be spoken of, lest the speaker be subject to the vitriol as experienced in the strident denunciations of Christianity we hear more and more about. To escape our mean state, however, we must venture to do so.
To discuss virtues, in turn, requires that we articulate a robust vision of the telos—the purpose and ends—of the practice of medicine. A description of a state of being greater than our common existence, greater than mathematical calculations of gains and losses, would give direction and meaning to our efforts. It would enable us to see beyond self-interest, to make the necessary sacrifices for the truth, to move ourselves and our organizations along the road to that greater goal. For such a journey, bad news becomes not an impenetrable wall or obstacle to avoid, but merely a stepping-stone.