Ethical Erosion: How Good People Lose Their Way In Healthcare

As we embark on our journeys in the healthcare arena, we often do so driven by altruistic motivations. We resonate with the ethic of “helping people” and hold close the belief that we will “do well by doing good.” Yet, as the years roll by, those lofty aspirations can seem increasingly remote. What was once a commitment to service may shift, leading us to prioritize job security, management approval, or KPIs. In this shift, we sometimes find ourselves unwittingly complicit in practices that may undermine the very mission we championed.

But how does this transformation occur?

Understanding Ethical Erosion

The phenomenon of ethical erosion refers to the slow degradation of moral principles, an issue extensively studied in various contexts—including notable examples like Zimbardo’s “The Lucifer Effect,” which examined the Stanford Prison Experiment, and the compelling study by Feutdner, Christakis, and Christakis regarding medical students.

This erosion does not occur abruptly but rather unfolds gradually—a series of small justifications, subdued discomfort, and the growing acceptance of the mantra “this is just how things operate.”

Consider the pharmaceutical executive who shepherds high-impact treatments into existence but simultaneously prices them out of reach for those in dire need.

Or take the nonprofit hospital executive who champions community health while still endorsing financial practices that drive families to bankruptcy.

Or even the managed care leader who flaunts generous benefits while endorsing policies that deny care at critical moments.

Or the healthcare investor seeking to improve people’s lives through investments but endorsing companies that prioritize revenue capture over genuine care enhancement.

When visiting these organizations, one often encounters values boldly displayed on walls: “Patients First.” “Compassion Always.” “Integrity Above All.” “Whole Person Care.” Yet, the reality of their actions frequently stands in stark contrast to these noble declarations.

This disparity raises an essential question: how does such a decline manifest across numerous sectors of healthcare?

The Mechanism of Cognitive Dissonance

Psychologist Leon Festinger provided valuable insight into this phenomenon. Cognitive dissonance characterizes the discomfort we feel when our actions contradict our core values.

Because humans yearn for a sense of coherence, we often seek resolution to these conflicts through one of three strategies:

1. Altering our beliefs or actions.
2. Justifying our decisions with new narratives.
3. Downplaying the conflict’s importance.

It is the latter two strategies that can lead to ethical erosion. Rather than confronting the unsettling reality, we develop narratives that protect our self-image: “Yes, our billing practices can seem aggressive, but we are providing lifesaving care.” Or, “The high cost of medication fosters funding for future research.” Or, “Denying certain treatments keeps overall costs lower, enhancing affordability for more.”

Over time, we may become desensitized to these contradictions.

We amplify aspects of our narrative that reflect well on us, while suppressing less flattering truths.

What begins as a coping mechanism can evolve into an entrenched way of functioning.

Compounding the Slippery Slopes of Justification

With these incremental compromises, a slippery slope emerges, often making it impossible to remain neutral.

This is how a genuine attempt to address untreated pain spiraled into a nationwide opioid crisis.

It’s also how medical expenses became the leading cause of bankruptcy across the United States.

And how healthcare expenditures have ballooned to nearly 20% of GDP while access to essential care increasingly eludes ordinary Americans.

These crises did not emerge from overtly malevolent actors. They resulted from well-intentioned individuals making rationalizations, downplaying discomfort, or deflecting blame.

This brings me to a prevalent observation in healthcare discussions: “The system is broken.”

The “Broken System” Frame

This line is often delivered with a sense of resignation, as though it absolves us of accountability. Insurers blame healthcare providers. Providers blame pharmaceuticals. Pharmaceutical companies blame regulatory bodies. Policymakers blame systemic issues. The cycle of blame appears endless. Brian W. Powers, Christine K. Cassel, and I discussed this dynamic in JAMA.

However, the uncomfortable reality is that systems don’t collapse independently. They falter because of the behaviors of individuals operating within them.

This means that all of us—regardless of our position—bear some responsibility for perpetuating dysfunction.

Shifting blame to “the system” while neglecting our involvement in its failings constitutes a form of ethical erosion itself. It allows us to evade accountability, rationalizing our compromises as unavoidable. This is a convenient narrative, but it lacks integrity.

Experiencing Moments of Clarity

Occasionally, something breaks through this haze. At times, psychologists refer to these instances as “moments of clarity”—brief periods where we perceive reality devoid of justifications.

In my experience, these moments often emerge in unexpected contexts: listening to a patient recount the financial fallout from a hospital bill, engaging with seniors whose benefits fail to meet their needs, hearing a frontline nurse express exhaustion from staffing shortages, or listening to a newly minted doctor doubt high-risk patient protocols that place inexperienced clinicians with severely ill patients.

These revelations can be jarring, stripping away the narratives we craft to protect ourselves. They remind us that our compromises affect real lives.

Yet often, these moments dissipate. We revert to the comforting stories that shield us from the hard truth. We convince ourselves there is no alternative. We tolerate the dissonance as part of survival.

A Call for Lasting Clarity

What if we did not allow these moments to fade? What if we extended them, allowing them to alter our actions rather than merely our emotions? Moreover, what if we inspired others to embrace this practice as well?

The antidote to ethical erosion isn’t another lofty mission statement or values inscribed in glass. It’s a commitment to maintain clarity, even when uncomfortable.

This entails remaining connected to the authentic experiences of individuals using our services and products daily.

This also means posing challenging questions regarding our ethos:

Are our choices consistent with the values we profess?

What rationalizations are we holding onto that we inherently know are flawed?

Which small infringements today might snowball into tomorrow’s crises?

The complexities and competing incentives of healthcare are plentiful. Yet so too are the individuals still eager to do the right thing. The challenge lies in thwarting the slow erosion of those instincts.

If ethical erosion can accumulate gradually, so too can a restoration of ethics.

This journey starts with clarity, strengthens through accountability, and persists as we commit to embodying the values we once merely inscribed on walls.