HEC Forum (2012) 24:293–305

DOI 10.1007/s10730-012-9199-4

The Eroding Principle of Justice in Teaching Medical

Professionalism

Jason E. Glenn

Published online: 1 November 2012

 Springer Science+Business Media Dordrecht 2012

Abstract This article examines the difficulties encountered in teaching profes-

sionalism to medical students in the current social and political climate where
economic considerations take top priority in health care decision making. The
conflict between the commitment to advocate at all times the interests of one’s
patients over one’s own interests is discussed. With personal, institutional, tech
industry, pharmaceutical industry, and third-party payer financial imperatives that
stand between patients and the delivery of health care, this article investigates how
medical ethics instructors are to teach professionalism in a responsible way that
does not avoid dealing with the principle of justice.

Keywords Medical professionalism
Social justice
Medical students
Teaching

professionalism

Every year in teaching clinical ethics to first year medical students we have a
session on ‘‘truth telling.’’ To illustrate the case, our students face a scenario where a
standardized patient asks the student at the end of the examination if his prescription
can be written in his spouse’s name as the spouse has health insurance which
includes prescription drug coverage while the patient does not. Many of my
colleagues find the exercise troubling for a number of reasons. Essentially, the case
poses the question as to whether it is ethical for physicians to deceive third party
payers to secure coverage for their patients.
Though we are never expressly instructed to tow a party line, there is a ‘‘correct’’
answer to this ethical quandary as far as the institution we work for is concerned.

J. E. Glenn (&)
Institute for the Medical Humanities, University of Texas Medical Branch, 301 University Blvd.,
Galveston, TX 77555-1311, USA
e-mail: jeglenn@utmb.edu

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Students who express a willingness to practice deception of third party payers for
the good of their patients are to be commended for having their heart in the right
place. However, we discuss many reasons why this action would not be a good
solution to the problem. One of the issues is that to do so would be committing
fraud. The commission of fraud puts the health care institution, the patient, and the
doctor at risk of criminal liability. Writing a prescription for a patient under
someone else’s name fits under the umbrella of billing fraud, which also includes
up-coding charges and overbilling insurance companies. Insurers fight vigorously
against such practices and failure to comply with the law could result in federal
prosecution. To risk the licensure or accreditation of the entire institution would
jeopardize the care provided to other patients.
The patient and the patient’s spouse would also be at slight legal risk but perhaps
more importantly, the spouse’s medical chart would then indicate the use of a
medication that he or she is not actually taking. This could potentially harm the
spouse in a number of ways. If the newly prescribed medication is known to have
negative side effects when used in conjunction with another medication that the
spouse is currently taking or one day may need, a doctor or pharmacist may not fill
the other prescription for fear of causing harm. The spouse would then be placed in
a position where he or she may feel the need to lie to their health care provider in
order to protect their partner or admit to wrongdoing, thus involving other health
care providers in their fraud scheme.
The prescribing physician would also be putting her or his career at risk by
committing fraud in this manner. Depending on the state and the nature of the
offense, doctors convicted of committing insurance fraud could face fines of up to a
few thousand dollars and/or jail time up to 5 years (Fritsch 2001; Associated Press
2001). In addition, such an offense would be reported to the state licensing board
where that physician’s license to practice medicine could be suspended or revoked.
After explaining all this to the students the lesson is clear: it may seem like a noble
thing to help a patient in this way but doing so would also put one’s future ability to
care for many other patients at risk.
Someone—student or other faculty—inevitably argues that the commission of
insurance fraud does harm to honest businesses (one supposes that insurance and
pharmaceutical companies are being referenced as ‘‘honest businesses’’ here) who
lose revenue and pass on their losses to other patients in the form of higher
premiums. Employers, faced with increasing high insurance costs for their
employees, must also pass on these higher costs by charging more for their goods
and services, which hurts everyone. One small lie to help one patient begins to seem
not so small when weighed against such evidence.
There is also the question of the cultural authority of the field of medicine as a
whole. We ask the students to think about the effect on our cultural perceptions of
medical professionalism if a doctor lies and participates in committing fraud, even if
it is for the good of the patient. Would patients feel confident that they could always
trust their doctors if they knew that some doctors are willing to lie? In addition to
causing harm to the profession as a whole, the individual doctor-patient relationship
could be placed in jeopardy. Some argue that any form of lying undermines the

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entire medical profession by undermining the cultural authority hard fought for and
won by doctors over the past century or so (Pimple 2001; Jackson 1991).
Despite these risks, there is evidence that many doctors are willing to engage in
deception of third party payers in order to secure treatment for their patients,
particularly doctors who see larger numbers of Medicaid or managed care patients
(Bogardus et al. 2004). According to Bogardus et al. (2004, p. 1843), the prevalence
of this type of deception ‘‘may be a barometer of those areas in which the
dissonance between care and financing rules has become so severe that physicians
see lying as the only way to do their jobs’’.
Perhaps mimicking the impossibility of taking a good patient history in a
7 minute interview, we medical humanists/bioethicists are tasked with holding this
discussion over a 1 hour ethics ‘‘consultation’’ in the first year school of medicine
curriculum. Over the first few years of having this conversation with young medical
students, I have always come away feeling empty and flat. Framed as a session on
the ethics of ‘‘truth telling,’’ the conversation and the readings we provide to prepare
for it works to obfuscate the much larger ethical issue impossible to tackle in an
hour’s time. In essence, ‘‘truth telling’’ is only a secondary ethical issue at play. The
more important ethical issue is a question of social justice: what commitment do
doctors have to poor patients and making sure that they get the health care services
that they need?
Social justice is one of the central themes of most contemporary definitions of
medical professionalism yet it is the one that seems to get the least attention in
medical ethics instruction (Kirch and Vernon 2009). This has not been for lack of
scholars sounding the alarm bell. As the corporatization of medicine has
increasingly prescribed and proscribed the parameters of medical practice, many
scholars have tried to combat this trend with a refocus on professionalism in medical
education. The alarm bells rang most loudly perhaps in the 1990s, nicely
summarized during the Presidential Address of Diane Schuller, MD, at the annual
meeting of the American College of Allergy, Asthma, and Immunology in Dallas,
Texas, 1995:
Our healing has evolved into a business…[T]he environment and this unique
profession of medicine have changed and we are being forced by a variety of
outside factors to make decisions regarding patient care that might not always
be in the patient’s best interest. And these factors are not benign; rather, a
series of financial and business factors having little to do with patient care
have become paramount (Schuller 1996, p. 28).
Subsequent articles continued this critique, railing against the new corporate age
of medicine (Relman 1998) and the growing clash between the values of business
enterprises and the traditional profession of medicine (Swick 1998). In all of these
cases, the authors call on medical schools to rededicate themselves to emphasizing
professionalism in their curricula. Others extol the need for a return to the virtues of
the Hippocratic Oath, now significantly transformed from the original (Graham
2000; Smith 2008) or even omitted altogether at some institutions (Irish and
McMurray 1995).

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It is worth pausing here to remind ourselves that in each generation, it is always

tempting to reflect longingly upon the past as a mythic time when we did things
right, contrasted with the present day when we always seem to be heading straight to
hell in a hand basket. Stephanie Coontz has demonstrated the extent of this
phenomenon in the perceptions of American family life (Coontz 2000) but it is no
less true in how we idolize the history of medicine, imagining a mythical past when
doctors were all like Sir William Osler and took the Hippocratic Oath seriously
(Bryan 1994). The professional decorum of the physicians of yesteryear was in no
way perfect. Doctors routinely practiced benevolent deception of patients, hiding
bad diagnoses from the sick and the dying and knowingly prescribing placebos to
pacify annoying or bothersome patients. Doctors over-prescribed opiates—partic-
ularly to women (Kandall 1996)—to perhaps mask their own discomfort in dealing
with what they perceived as mental health issues (Courtwright 1982). Less
benevolently, doctors subjected patients to all manner of dangerous and deadly
experiments without consent, often knowing that the patient would receive no
benefit and that there was a significant likelihood of harm (Goodman et al. 2003;
Lederer 1995). Today’s doctors look pretty good in light of this history. Was there
ever a time when doctors treated patients with no regard to their ability to pay? Can
we say that there was ever really a period in our history when economics did not
play an important role in medical decision making?
Doctors did not become capitalists overnight beginning in the 1980s. But
historians point to a shift that did occur in that period that has definitely transformed
the practice of medicine (Starr 1984), particularly in the treatment of patients who
do not have the ability to pay. Cost-effectiveness and conservation of health
resources became the paramount priorities, but only in a very limited way. Cost-
effectiveness was not demanded of pharmaceutical companies, nor was it demanded
that medical technology companies price their devices in order to conserve health
resources. However, managed care organizations began dictating how doctors could
treat patients, sometimes against the evidence base of good medical practice (Lee
1995; Kreier 1995). There is also now a barrage of administrators who keep patients
from ever seeing a doctor if they do not have the ability to pay. Once-upon-a-time
under-insured persons could get in to see a doctor even if only to be saddled with a
large bill afterward, which may be sold to a debt collection agency if it was not paid.
Currently, most health care organizations demand all fees and co-payments up front
as a condition to getting in to see the doctor. This practice increasingly segregates
doctors from the decision making process of even being able to treat patients who
cannot fully afford their services.
A perfect example of this conflict between doctor as healing professional and
doctor as business person was described in an issue of American Medical News not
long ago. The article described the practice quite common in family medicine where
a parent with one sick child asks the doctor to take a look at another sick child
during the same appointment made only for the first child. The author made light of
such patients, referring to them as ‘‘‘two-fers,’ ‘freeloaders,’ or some other term
that’s probably best kept to the back offices at your practice’’ (Norbut 2004, p. 23).
The general tone of the article paints such requests as patients trying to game the
system and take advantage of doctors. ‘‘It’s time wasted and revenue lost if you

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don’t pull a chart and charge them for an office visit’’ (Norbut 2004, p. 23).
Completely oblivious to the fact that he is delving into an area of intense ethical
conflict and debate, the author quotes one family physician as saying ‘‘We’re torn
between wanting to be nice guys and wanting to run a business’’ (Norbut 2004,
p. 23). Really?
Buried in the article is the astute observation by one pediatrician that the issue is
socio-economic, not one of rude patients disrespectful of a physician’s time. ‘‘If
they have a[n insurance] plan with no co-pay, they’re making appointments for all
their kids,’’ (Norbut 2004, p. 23) whereas insurance plans with co-pays push many
parents into trying to get multiple children examined in one appointment. The
author makes a straight forward argument that doctors should set boundaries against
patients asking for such ‘‘favors’’ by telling parents who make such requests that the
second child’s chart will have to be pulled and that they will be charged for a second
visit. This suggestion is given without any acknowledgement that there is an ethical
conflict here between the business needs of family practices and the medical needs
of poorer patients.
It is important to acknowledge that family doctors and pediatricians are the
lowest paid out of all medical specialties (Dorsey et al. 2003). The challenges,
therefore, to keeping a family medicine practice in good financial standing are not to
be summarily dismissed. The fact that the article takes for granted that financial
stability is the only concern of which to be mindful speaks volumes as to how little
regard the profession has for tackling issues that deal with the social justice aspect
of professionalism.

Defining Professionalism

By the late 1990s, professionalism had come to mean many things and was only
loosely defined so the field set itself to the task of trying to piece together a unified
definition. That unified definition came in an article by Herbert Swick at the turn of
the century, ‘‘Toward a Normative Definition of Medical Professionalism’’ (Swick
2000). Today, the AAMC and ACGME both rely on Swick’s article to form their
working definitions of medical professionalism. Swick identified nine competencies
that constitute medical professionalism and that physicians must exhibit in order to
live up to their obligations to patients, communities, and the profession as a whole:
(1) subordinate their own interests to the interests of others; (2) adhere to high
ethical and moral standards; (3) respond to societal needs and work toward the
benefit of the communities in which they live and serve; (4) adhere to the core
humanistic values of honesty and integrity, compassion, altruism, empathy, respect
for others, and trustworthiness; (5) exercise accountability for themselves and for
their colleagues; (6) demonstrate a continuing commitment to excellence; (7)
maintain a commitment to scholarship and to advancing the field of medicine; (8)
deal competently with high levels of complexity and uncertainty; and (9) reflect
upon their actions and decisions. Competencies 1, 3, and 4 in this list expressly have
to do with social justice, but they are non-specific in how far they extend. They are
generally taken to mean that doctors should treat patients with an equally high

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quality irrespective of their race, ethnicity, gender, religion or cultural background

according to what is best for them. In most codes of professionalism, however, class
is not expressly implicated.
The professionalism code adopted by the American Board of Internal Medicine
in 1999 was bolder and specifically states that doctors are to advocate for ‘‘the best
possible care [for their patients] regardless of the ability to pay’’ (American Board
of Internal Medicine 2008, p. 282). But where in the medical school curriculum do
we teach medical students to be strong patient advocates and take on third party
payers and hospital administrators? We now discuss the importance of prescribing
generic drugs and we warn against the influence of big pharma, but when do we
teach students to rebel against the high cost of medical education that drives
students toward boutique medicine and fields of specialty care that offer the most
money and most comfortable lifestyles?
In the field of bioethics, the larger definition of professionalism has been
condensed into four tenets: beneficence, nonmaleficence, respect for persons, and
justice (Beauchamp and Childress 2008). Kirch and Vernon argue that the
‘‘commercialization of medicine has fostered a distortion of emphasis among the
basic tenets of medical ethics, and this unbalanced emphasis has created serious
barriers to improving the health care system’’ (Kirch and Vernon 2009, p. 1482).
When it comes to justice in medical ethics instruction, the parameters of the
discussion are usually constricted to focus on the conservation of health care
resources and rationing care rather than providing more care to more patients.
This is not to say that the concerns over the costs of providing health care in
America are unfounded. It is old news that Americans spend far more on health care
than any other nation and we receive far worse results in terms of overall health and
life expectancy. The U.S. ranks 34th in the world in infant mortality (United Nations
2011), 42nd in the world in mortality of children under the age of five (United
Nations 2011), and 50th in the world in life expectancy (Central Intelligence
Agency 2012). Even in the areas where its technological advances allow the U.S. to
provide superior care, that care is distributed so inequitably as to not be well
reflected in its overall health status as a nation. Hospitals, insurance, medical
technology and pharmaceutical companies have all played their role in inflating the
costs of health care in America, and so have doctors. Physicians are educated
longer, trained longer, and worked longer and harder. Coupled with the fact that
doctors are made to assume such an enormous amount of debt to get out of medical
school, of course they would act to maximize their salaries. We have created an
entire system where all the middlemen that stand between a patient and her health
care are expecting to get rich. No oath or professionalism curriculum is structured to
teach medical students how to ethically and morally navigate through that.
How did the terms of the debate get so co-opted by the health care economists?
For starters, the high price of providing care in America is taken as a static non-
variable. Tech companies have to make good on their investments, pharmaceutical
companies have to act according to their fiduciary responsibility to their share
holders as do insurance companies, hospitals have to turn a profit to keep their
employees employed, and doctors have to pay their student loans and support their

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families. When the argument gets framed with these non-adjustable factors, the only
logical conclusion is to cut patient services and treatment.
Teaching students to deconstruct these claims would go a long way toward their
ethical development. The US is the world leader for creating state-of-the-art new
technology and medical devices, always touted for how they allow new therapeutic
treatments with the potential to save millions of lives. But use of new technology
often comes at such a stiff price that only a tiny fraction of the patients who need the
treatments they offer actually receive any benefit. We live under this narrative of
technological advancement where we are taught that the introduction of new
technologies helps lower costs by eliminating waste and increasing productivity. In
many industries, that rings true. In the field of medicine, however, technology has
become a major factor in increasing the costs of health care. Concrete examples that
demonstrate how new technologies have produced long-term savings are few. The
Congressional Budget Office concludes that ‘‘roughly half of the increase in health
care spending during the past several decades was associated with the expanded
capabilities of medicine brought about by technological advances’’ (Congressional
Budget Office 2008, p. 12). In the CBO’s analysis, they point to many factors, one
reason being overuse and misuse of technology as preventive medicine. They
further explain how many medical advances in technology increase spending
because they make treatments available for conditions that were previously
impossible to treat or were not aggressively treated. The report also cites how new
advances in medical technology that decrease mortality or help patients survive
chronic health conditions paradoxically increase our overall spending on health care
because the surviving patients live longer and use more health services for many
more years.
Blatantly absent from this discussion, however, is any mention of how new
medical technologies get priced. A basic assumption often made is that the price of
putting new medical technologies to use reflects the costs of production. This claim
warrants further investigation. For-profit companies set the ‘‘price’’ of a product or
service as what someone is willing to pay for that product or service. ‘‘Price’’ is
really more of a measure of demand. Most people would pay almost anything for
something that could save or prolong their lives. Companies marketing new medical
technologies price their products with this in mind (Cutler 2005). The question left
on the table that we need to be asking our students is should a person in such a
vulnerable situation have to pay almost anything?
We should be asking similar questions in teaching students to deconstruct the
claim perpetuated by pharmaceutical companies that it costs them $1 billion to bring
a new drug therapy to market. Mainstream medical publications routinely recite this
claim and make little-to-no attempt to confirm its validity. As reported in the
Harvard Business Review, ‘‘the cost per new approved drug has increased more than
800 per cent since 1987, or 11 per cent per year for almost two decades’’ (Raynor
and Panetta 2005, p. 15). This figure of the $1 billion ‘‘cost’’ incurred by
pharmaceutical companies for developing a new drug therapy can be traced back to
a study published in the Journal of Health Economics from the Tufts Center for the
Study of Drug Development (DiMasi et al. 2003).

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In training students to critically evaluate this claim, it would be helpful to know

that The Center for the Study of Drug Development gets 65 % of its funding from
pharmaceutical companies (Sharife 2011). The study examined the R&D costs of 68
randomly selected drugs, and concluded that the cost of the development of each
new drug was $802 million (adjusted to $1 billion for inflation). American law has
been written which allows pharmaceutical companies not to disclose exactly what
all is included in R&D costs, claiming that such information is proprietary.
Interrogating this assertion, Marcia Angell notes that nearly half of that figure
comes from what the industry calls ‘‘capitalized costs,’’ additional dividends paid to
investors to offset the expected returns that they forego during development when
they invest in pharmaceutical R&D instead of a risky but more profitable portfolio
of financial securities. As Angell points out, ‘‘the Tufts consultants simply tacked it
on to the industry’s out-of-pocket costs. That accounting maneuver nearly doubled
the $403 million to $802 million’’ (Angell 2004, p. 45).
American law is also written to provide a 39 % tax reduction subsidy to
pharmaceutical companies for the dollars they ‘‘invest’’ in R&D (Light and
Warburton 2011), also not taken into account in the Tufts report. Two additional
factors shed further light on this ‘‘cost’’ of R&D. The first is that the pharmaceutical
industry may include what it spends on advertising and lobbying as part of its R&D,
arguing that it technically counts as part of the costs of bringing a new drug to
market. The second issue is that over 80 % of the original research that leads to
the development of any New Molecular Entity (NMEs, which are eventually
developed into new drug therapies) is usually done in universities funded mostly by
the NIH. Thanks to the Bayh–Dole Act of 1980—which gave universities and other
non-profit organizations the intellectual property rights to NMEs and other new
technologies developed through federally funded research—universities are able to
turn around and license these products to private for-profit companies (Editorial
2005). The licensure agreements allow pharmaceutical companies to acquire the
rights to manufacture and market new drugs at a fraction of the price of what they
would have paid if the drug were developed in-house, a further way that their R&D
costs are subsidized by tax payers (Loise and Stevens 2010). Taking all these factors
together, a more accurate assessment of the costs spent by pharmaceutical
companies on drug development is likely somewhere in the range of $50–$200
million (Angell 2004; Sharife 2011).
Similar deconstructions have been done breaking down hospital costs (Aaron
2003), as well as a historical analysis of how health care organizations bill insurance
companies (Peden and Freeland 1998). A look at the pricing of medical school
education deserves a similar critique. For nearly three generations, debt has become
an inescapable part of training to become a doctor. For the past quarter century, over
80 % of each US medical student class has graduated in debt. During this time
period, the increase in the total overall debt carried by students has risen at a rate far
outpacing inflation and the consumer price index (Chen 2011). According to
statistics published by the Association of American Medical Colleges, doctors who
graduated from medical school in 2010 had an average debt of $158,000, or $2.3
billion for the group as a whole (Greysen et al. 2011). Nearly one-third owe more

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than $200,000, an amount that will nearly double once the final payment is made
over a 25–30 year payback period.
This escalation of medical student debt has not been a product of the rising costs
of education. It is true that many American states are moving toward abandoning
their support of public education in the name of austerity. While this is indeed
alarming and also related to the culture of neoliberalism that is posing the biggest
threat to health care workers being able to adhere to the professionalism core value
of social justice, it would be misleading to point to this trend as the biggest factor in
determining the enormous amount of debt medical students are made to assume. A
number of other major factors are also at play. Much of the initial rise in the amount
universities charge for tuition coincided with the lifting of the federal loan
borrowing limits under the Higher Education Act of 1965 (Kassebaum et al. 1996).
Part of Lyndon Johnson’s Great Society program, the act was intended to strengthen
the educational resources of colleges and universities and provide financial aid for
students in higher education. The law increased the amount of money given to
universities by the federal government, created scholarships, and provided low-
interest loan guarantees for students (Pub. L. No. 89–329 1965). With the
government subsidizing higher education for lower-income students, colleges and
universities started admitting more students and charging more for tuition—because
they could.
Another important factor is that universities now increasingly use tuition to
support institutional projects that may be only indirectly related to student
education. For instance, many university systems now use student tuition dollars as
collateral for construction bond debts. This practice is perhaps best exemplified in
the University of California system. Since 2004, the primary use of student tuition
and fee revenue by the UC system has been as collateral for bonds to fund campus
construction projects, all while they have cut funding for instruction and research
(Meister 2011; Rosenberg 2011). This practice amounts to a form of a credit swap
where students are pushed to assume higher and higher amounts of debt at interest
rates as high as 6 %, in order that the school can borrow money at a reduced rate to
construct new buildings, build a bigger campus, take in more students, and increase
executive pay (University of California 2010).
As Pauline Chen points out in her article in the New York Times, students accept
going into enormous debt because of the way our culture has shifted over time
whereby Americans have largely naturalized going into debt to train for decent
employment, to purchase a car, and to secure housing (Chen 2011). Because our
society has come to understand graduating medical school with a mortgage-sized
debt as normal, we have not stopped to think about how the assumption of such debt
influences how medical students choose the type of medicine they wish to practice.
As Greysen et al. (2011) point out, assuming so much debt has transformed medical
education which was once a path to public service into a financial investment that
students and parents expect to yield returns. In medical education, we constantly
talk about the looming shortage of primary care and family medicine practitioners.
Yet, when we talk to students about their intended fields of practice, rare is the
student who mentions either of these as their goal. We commonly observe students
who enter medical school with the desire to build a career providing primary health

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care to poor and underserved populations who by their third and fourth years have
long abandoned these ideals. For many students, graduating with a large amount of
debt means eschewing a calling to serve high-need, less lucrative patient
populations and instead pursuing a well-compensated subspecialty that caters to
the middle class and well insured.
All these questions should be at the center of any professionalism discussion in
medical education, particularly as they pertain to the principle of social justice. We
emphasize beneficence and nonmaleficence as classic principles of the profession
that can be traced back to Hippocrates. When we discuss respect for persons, patient
autonomy and cultural/gender sensitivity are the themes given the most attention.
But the structure of our current medical system has created a network of health care
providers, researchers, purveyors and administrators who have strong financial
incentives to work against the best interests of patients. This situation makes it
difficult to talk with students about the ethical principle of justice in any meaningful
way that is not hypocritical, leaving it seldom emphasized relative to the other three
core principles of medical ethics.
With all decision making subjugated to financial imperatives, where does an
assessment of the overall health impact fit into economic logic models? How do we
teach students to consider things like the overall community or environmental
impact of our health policies? How do we instill in students a commitment to
prioritize the overall human impact of medical decision making over the economic
bottom line in this health care climate?
Discussions of justice are further hampered by the fact that there is no strong
cultural consensus for what justice entails. In the world of bioethics, theories of
justice have coalesced around Rawls’ concept of social justice. Rawls’ theory of
social justice has gained prominence since the 1970s with the publication of his
major treatise in 1971. Rawls based his theory on two basic principles: (1) that
‘‘each person is to have an equal right to the most extensive basic liberty compatible
with a similar liberty for others’’ (Rawls 1971, p. 60); and (2) that ‘‘social and
economic inequalities are to be arranged so that they are… reasonably expected to
be to everyone’s advantage’’ (Rawls 1971, p. 60). With this second principle, Rawls
is suggesting that our actions should be geared toward achieving social equality. In
the broader US culture, our notion of justice only emphasizes equality of
opportunity while those who argue for equality of outcome are attacked as
socialists.
What lies underneath this debate is the fact that as a society most Americans do
not think people are equal. We think some people are smarter than others; we think
some people are stronger than others; we think some people are more talented than
others; and we think some people work harder than others. We think the difference
in these individual aptitudes occurs naturally and we believe that individual socio-
economic status reflects this natural distribution. Many Americans therefore think
that any notion of justice that goes beyond advocating for equality of opportunity
rewards the less intelligent, the lazy, and the dishonest.
These tightly held and hotly contested beliefs are the pink elephants in the
classroom when we engage students in discussions about their professional
development and the principle of justice. This is the reason why we, as medical

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humanists, are asked to awkwardly lead a discussion about a pressing social justice
issue that has instead been framed as an issue of truth telling. The logic of the
market has become one of those cultural values that is so familiar that we take it for
granted and assume that this particular organization of our society is natural. We
forget that it is a choice that we have made, though if we paused for a moment to
reflect we may find it disturbing. ‘‘The more pervasive a set of values, the more
ubiquitous a set of practices, the harder it is to judge their implications…’’
(Schlesinger 2004, p. 92).
How can we cultivate within our students an understanding of the threats to
medical professionalism posed by the conflicts of interest inherent in the various
financial and organizational arrangements in the practice of medicine? (AAMC
1998) We start by not shying away from the conversation.

References

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Aaron, H. J. (2003). The Costs of Health Care Administration in the United States and Canada—
Questionable Answers to a Questionable Question. New England Journal of Medicine, 349(8),
801–803.
American Board of Internal Medicine. (2008). Project Professionalism, 1999 (revised). In R. L. Cruess, S.
R. Cruess, & Y. Steinert (Eds.), Teaching medical professionalism (p. 282). Cambridge: Cambridge
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