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Posted on January 29, 2019 at 9:00 AM

Through special arrangement with Taylor & Francis, AJOB posts its editorials on bioethics.net. This essay and the articles it references are also available on the publisher website.

by Alyssa M. Burgart

Prepare to cringe as you read this issue’s article entitled “Serious Ethical Violations in Medicine” by DuBois, Anderson, and colleagues. In their analysis of 280 physician misconduct cases between 2008 and 2016, they focused only on cases where behavior promoted patient harm: when physicians overprescribed opioids, performed unnecessary procedures, or engaged in inappropriate sexual acts. In this set, they found 95 physicians who sexually assaulted at least one patient: undeniably criminal behavior. The #MeToo movement has increasingly shed light on women’s lived experiences of assault, and it should come as no surprise that 100% of the cases DuBois and colleagues found were perpetrated by men, and greater than 85% of victims were women. Women already live in fear of men, which not inappropriately includes their male physicians. The Agency for Healthcare Research and Quality defines sexual assault in the health care space as a “never event,” an event that should never occur and is always preventable. Yet while sexual assault by physicians should never happen, it is nowhere near rare enough. The lack of clearly defined consequences for physicians who violate such obvious norms demonstrates a lack of sufficient safeguards to protect patients and maintain public trust.

Sexual assault by any physician is horrifying. It is a serious form of moral disengagement and evidence of a physician who lacks the moral fortitude to accomplish a core mission — to protect patients from harm. However, the trend to consider such violations as primarily a problem of individual behavior is a key component to why these cases have not decreased in frequency.

Original art by Isabel Romero Calvo

In a sample where 100% of perpetrators are men, I know one thing for certain: More men in leadership positions in medicine is not the solution. Egregious ethical violations by individuals are the downstream symptoms of the systemically gendered culture of medicine, from training to the bedside to the boardroom. For women, who are affected both as physicians and as patients, we are in a unique position to see how the bigger picture of gender inequity is harming us — physically, emotionally, and professionally. A growing body of evidence indicates that patients in the hands of women are safer: Women’s patients have lower readmission rates, and more women in operating rooms promotes cooperative behavior (a quality essential for preventing medical errors). The medical profession has a moral imperative to achieve gender equity in our highest echelons. The sooner, the better, for every patient’s safety and well-being.

Fear of sexual harassment, sexual assault, and being dismissed for being a woman are the hidden curriculum of girlhood. The National Academies of Sciences, Engineering, and Medicine’s recent report (Committee on the Impacts of Sexual Harassment in Academia, Committee on Women in Science, Engineering, and Medicine, Policy and Global Affairs, and National Academies of Sciences, Engineering, and Medicine 2018) shows that this curriculum extends long into women’s medical careers, stalling the professional advancement of women. Women in medicine are harassed to an even greater degree than women in sciences and engineering, with up to 50% of medical students reporting harassment in one study. Gender inequity in medicine perpetuates unethical behavior by normalizing everyday gendered micro-inequities (unintended snubs, slights, and insults), creating an environment where professional macro-inequities (like the gender wage gap), and serious ethical violations (such as sexual harassment and sexual assault) may ultimately flourish.

Men have historically dominated medical leadership, and continue to do so, with 85% of department chairs still occupied by men. The #MeToo and #TimesUp movements have society finally acknowledging that men do not understand and cannot represent the lived experiences of women and that it is costing us human capital. Leaders establish and maintain an organization’s moral culture, leading to implicit and explicit behavioral norms. When leaders are predominantly men, the idea of what is “normal” is highly influenced by the inherent biases of male-centric thinking. These cognitive errors cannot be corrected when the alternate perspectives remain unrepresented. This is a setup for unethical attitudes and behaviors.

The ethical response is to systematically promote women and diverse people into leadership positions. Women are the majority group in the health care workforce. If the most exceptionally educated, remarkably qualified, and highly trained women cannot achieve the value, compensation, and respect we deserve, then equally qualified ethnic, gender, and disability minorities and our patients will continue to suffer. When we do not actively address inequality, we are complicit in its downstream effects. Want medical boards to take sexual assault and harassment more seriously? Make sure there is gender parity and diversity in every state medical board.

Gender equity is the moral imperative. Women deserve equality and patients deserve a safe haven. Women physicians protect patients in their practices, and any organization that fails to root out inequity is effectively shortchanging its patients and their safety. Women physician leaders protect patients and health care workers by promoting a perspective that is sorely lacking today. Dr. Julie Silver’s Be Ethical Campaign lays out a scientific methodological framework on which to build gender equity in every organization. Cringing about physicians’ ethical violations is not enough. Hire, mentor, and promote women. Do not host men only panels at conferences. Every editorial board needs gender parity and to publish work authored by women.

There is no excuse for excuses: Now we must act.

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