The Continuum From Collaboration To Complicity To Resistance To Defiance: The Choices We Are Forced To Make
By
Leonard Zwelling
https://www.nejm.org/doi/full/10.1056/NEJMp2604906
I thought that this was a fascinating Perspective from The New England Journal of Medicine on August 13 by Matthew K. Wynia, MD, MPH from the University of Colorado School of Medicine. The content definitely speaks to my recent blog about rationalizing behaviors which are not good for you and sometimes not good for your patients.
This piece juxtaposes the twin forces that might impact any patient care physician who has found himself or herself in a bind when being asked to do something that is against his or her ethics. To wit, will I go along, and if so how willingly or, vice versa, will I not go along and how vigorous and public will be my lack of obedience?
Dr. Wynia points to the number of government physicians who have quit their jobs rather than go along with the policies of the current Trump-Kennedy Administration, at the CDC, the NIH, or the FDA, as an example of resistance. By contrast, hospitals that are dependent on federal dollars have decided to get out of the business of gender-affirming care are examples of going along to get along or even complicity or at least compromise that could negatively affect patient care. Grant applicants are compromising with nonsensical Trump Administration ukases by deleting words like “diversity” and “equity” from their documents for fear these words would eliminate any chance for funding, even if they are the best words to describe the proposed work. This is a small bit of complicity with a significantly amount of dishonesty.
On a personal note, as readers of my blog or books know, I have rarely gone along with any authority who I thought was compromising patient care, violating medical ethics, or flouting federal regulations. Has that gotten me in trouble? Often. Has it cost me jobs? It has. Do I regret my decisions? I do not.
Dr. Wynia lays out an algorithm to help with decision making when faced with such choices.
“First, whose interests are served?” Complicity is often accompanied by self-interest. Such actions cannot be ethical (e.g., acts of conflict of interest as I witnessed by the past President of MD Anderson supporting clinical trials at the institution he led with an experimental agent he developed and in which he had a huge financial stake without the human subjects receiving the drug being aware of their participation advancing his bank account).
“Second, what benefits and risks are at stake?” It is just wrong to participate in an unethical act to please a supervisor. This is something I saw and studied with surveys the results of which were published, (Mobley et al., PLOS ONE May 15, 2013). Some matters of research misconduct have their basis in students and post-docs fabricating results to underpin the theories of the lab chief in fraudulent publications so as to please the boss.
“Third, should an act of resistance be private or public?” In my experience, I tried to be private first when I thought a course of action within the institution in which I was working was taking a wrong turn. That often worked, but, unfortunately, not always. Being even a little bit public got me fired more than once.
In these matters of competing interests, one of which is often money, it is perhaps unwise to expect most people to make the decision that leaves the money on the table, but promotes the ethics. I have seen that behavior rarely.
The current President of the United States is clearly using his position to enrich himself, his family, and the family of some of his Cabinet members perhaps to the detriment of the American people.
The current President of MD Anderson is drawing a salary far in excess of anything being paid to anyone else at Anderson. He is among the highest paid individuals in the UT System. Why? How has he advanced the MD Anderson mission beyond driving the clinicians to see more patients so he can earn more money for himself, line his coffers, and gain accolades for his resume? Where exactly are the ethics of his $4 million salary when compared to that of the people who actually care for patients? What is his unique vision that warrants that level of reward?
Each of us in healthcare will have to make these sorts of decisions for ourselves and be somewhat understanding when our colleagues take a course of action that varies from the one that we might take. However, any physician who enriches himself or herself using compromised ethics or makes decisions that could compromise patient care, (and I consider the merger of MD Anderson Pediatrics and Texas Children’s oncology programs such a poor decision), ought to be called out for having done so.
It’s a lot easier for me to do that now that my job doesn’t depend on it, but even when my job did depend on it, I usually chose resistance over complicity. After 78 years, I have come to realize that resistance is my nature and I won’t lie to myself that I am anything else but a child of the 60’s. Right on!
