Ms. Barnard is a business woman who has opened a medical clinic across the street from an existing facility. She suspects that the Other Clinic is “playing unfairly” by not having a physician on site. Since a physician costs a lot of money to employ, the Other Clinic could be undercutting the competition if this were true as well as violating their state license. Ms. Barnard asks her employee, Roger, to visit Other Clinic posing as a patient and seeing if indeed there was a physician present. Roger made an appointment for a check up for a fictional trip: He asked for anti-malaria medications for travel to sub-Saharan Africa. The nurse wrote the prescription and handed it to him.
Now Ms. Barnard wants Roger to file a complaint with the health department because of the lack of a present physician and a nurse giving the prescription. Roger fears this might come back to harm him. “Businesses have secret shoppers all the time, but might Other Clinic retaliate against me? After all, they have my SSN and insurance information.” A co-worker said that she felt Roger acted “dishonestly, unfairly, and like a spy.” Roger asks, “Should I feel badly that I acted unethically??”
Many websites and services exist to help physicians “spy” on their competition. The advise is usually to visit their website, sign up for their email, and track them on social media. In this case, however, an employer asked an employee to pose as a secret patient. Certainly other companies regularly visit competitors to find new ideas and see how the competition operates. But in this scenario, the goal was to find wrongdoing and then to report the competitor. And while visiting another retailer might entail some wear and tear on their store, using some megabytes, and perhaps taking some staff time while you ask questions or purchase an item, in this scenario a medical appointment that requires limited staff time and limited health care dollars was wasted. Someone in real need may have been denied an appointment, or has to suffer while sitting in the waiting room for longer during this secret patient visit.
Secret shopper visits are usually about quality control and improvement. This is actually a job that one can have. And yes, there are secret patients. Their task is to “evaluate cleanliness, patient confidentiality…and overall service” in public spaces rather than having medical exams and requesting treatment. This is also quality improvement. Roger was there more akin to a health inspector, trying to find out what was wrong. But a health inspector is sanctioned by a jurisdiction to investigate cases of wrongdoing and making sure that codes and standards are met. The inspector is supposed to be unbiased and objective. Asking an employee to spy on the competition and find a reason to harm them is a different thing.
That Roger’s ethical radar was only tripped when he thought he might get in trouble is disconcerting. He took an egoist approach, that it was only a problem when it was a problem for him, but did not question the tactic in which he engaged before then. It was only when his actions were questioned by a co-worker that Roger even wondered about his original behavior. This is one reason I tell people that we should not make ethical decisions alone—it’s usually helpful to bounce things off of another person whose ethical core you trust.
At the base of this whole scenario is the concept that medicine is a business and businesses need to know what their competitors are doing. Unethical businesses try to increase market share not by producing a better product or service, but by undermining their competition. Aside from the medical ethics issues in this case, there is a very basic business ethics concern: Do not harm another to further your own interest. One of the most important professional values in medicine is altruism—that your choices and behaviors are for the benefit of another, not yourself. Roger loses sight of that when he only sees a problem when he feels personally threatened. Altruism is a basic component of a profession. Medicine is a profession. Business is not. Thus, in this situation the values of medicine and the values of business collide.
The corporatization of medicine as a center of profit has lost sight of the goal, which is to help people in need. That a non-medical professional would open a clinic “as a side business” is disturbing. Medicine should not be a way for one to achieve wealth, but rather be a way to be a servant to the community. Business ethics should always come second to medical ethics in a healing environment.
Instead of competition, the healing professions should focus on collaboration. Collaboration is working together to create something or to achieve a shared goal. This is why teams deliver medical care—interdisciplinary cooperation and action benefits patients better than when the professions compete against each other. Instead of opening a competing clinic across the street, open one in an underserved part of town. Resources go further when we collaborate than when we compete.
Roger’s question has two parts: 1. “Did I act unethically?” and 2. “Should I feel bad about it.” The answer to the first is that by most rules of business and medical ethics, he did act unethically. Should he feel badly about it? That is a much tougher question to answer. I might hope that it bothers him, but obviously his feelings were not strong enough to have prevented his actions in the first place. The fact that he has to ask this second question is concerning in itself.
In my response to the real-life “Roger,” I did not answer his question. I asked him a series of questions to get him to think about what he did and what was asked of him. And then I let him know that in this state, advance practice nurses have the authority to write prescriptions and the doctor does not have to be in the same room (or even the same building). Roger did not know that piece of information. Clearly, neither did Ms. Barnard. By losing sight of the ethical issues (both medical and business) they let their lack of knowledge lead them down a dark path.