Welcome to "The Hypocritical Oath," my 鶹ý series where I explore professional, educational, and ethical failures in medicine, from shortcomings in medical culture to abuses of power and patient harm. I try to give a voice to those that have been dismissed in an effort to inspire better doctors, committed to upholding our stated values.
The Case
The following is a fictionalized account of a situation that may arise in a healthcare setting.
Two classmates, a man and a woman, begin their medical school journey together, but their relationship takes a dark turn. The woman, Kate, reports a sexual assault by her former friend to the medical school. Nothing is done. Shortly thereafter, she receives an onslaught of frightening text messages threatening rape and physical violence. The messages sound strikingly like him.
Kate reports it. Again, nothing is done -- not even the beginnings of an investigation. She posts the threatening messages to the class group chat to show the urgency of her situation; the school demands that she remove them. The man roams the campus freely. He even wins praise from the medical school and an Alpha Omega Alpha fellowship as Kate lives in fear.
Hushed, terrified warnings spread along a whisper network of female medical students, whose institution has shown that it will not protect them from the specter of violence. One such student, Valeria, is placed on a surgery rotation and in shared housing with the alleged attacker. She wonders if she might be in danger. She frantically begs Kate, "Please tell me what he did to you."
Kate's response crushes her: "I'm sorry. Legally, I can't talk about it. Please don't ask me anything else. I want to apply into surgery, and I can't afford to get a reputation in the department. I regret saying anything about him."
Valeria sits in stunned silence. Does Kate mean a non-disclosure agreement (NDA)? Why would a medical school have a sexual assault victim sign an NDA? The female students never learn the truth of what happened to Kate and a palpable uncertainty begets fear and unrest amongst them.
Meanwhile, the alleged attacker contentedly walks the campus, contemplating his promising future in medicine.
Concealing Misconduct
Non-disclosure agreements (NDAs) are confidentiality agreements meant to such as trade secrets or business negotiations. Unfortunately, they are also often used to of all varieties. Some employees are required to sign them as a condition of taking a job, forbidding them from discussing "sensitive information" related to a workplace, including allegations of sexual misconduct, and many settled cases of workplace misconduct include NDAs as part of the settlement.
You would think restrictive NDAs have no place in a field held to a higher ethical standard than most. However, a deeply perturbing NBC News investigation by public hospital systems, including the University of Washington (UW) Medical Center, the University of Kansas Hospital Authority, and the University of Texas-MD Anderson Cancer Center, to conceal alleged patient harm.
The UW Medicine case was especially devastating. NBC News reported that Hana Hooper, a then 19-year-old college student who urgently required a heart transplant, endured a stroke and lost her vision after cardiac surgeon Nahush Mokadam, MD allegedly used a technique during a "bridge to transplant" surgery that increased her stroke risk without informing the family. They alleged that Mokadam attempted to conceal his actions by lying about his operative findings and threatening to tell other transplant centers that Hana was not a candidate for a heart transplant when the family wanted a second opinion.
In 2023, UW Medicine settled the case with the Hoopers for $12 million without admitting any wrongdoing; the settlement included a confidentiality clause that prevents the Hoopers from discussing the case publicly. NBC's investigation revealed that 70 of 89 cases settled by UW Medicine and other UW-affiliated hospitals included confidentiality clauses barring patients and their families from speaking out about their claims and/or settlement payment amounts.
UW Medicine justified its use of NDAs, stating that they "[ask] for confidentiality in order to achieve finality and certainty when a claim concludes." While UW Medicine can achieve finality, Hana Hooper and her family still live with the consequences of the ordeal and the inability to share their story freely.
While public taxpayer-funded hospitals are subject to public records laws -- which is how NBC obtained these documents through public records requests -- this isn't the case for every healthcare facility. I have questions about medical systems that are not subject to transparency laws: what information don't we know, and how common is this practice of weaponizing NDAs among hospitals?
Silencing Victims: A Tactic of Abuse
The dynamics at play here mirror those between an abuser and their victim. An abuser steals so much from you. They steal your time, your happiness, your sense of self-worth, your safety. And through NDAs -- and, a close relation, the threat of defamation suits -- they commit the greatest theft of all: your voice. They steal your ability to tell your story, making it appear as if it never happened. They steal your reality from you, denying you even the acknowledgment that your pain exists. It's a second assault that screams audaciously of entitlement, as though they have the right to harm you, and the right to demand and receive your silence about the harm they caused.
That is the helplessness I imagine patients must feel when a medical center robs them of their voice with an NDA that many feel they have no choice but to sign. The practice of using NDAs in medicine is intimidating and abusive.
NDAs as a means of obtaining silence -- whether from victims of malpractice or assault -- is a sinister tactic that came to light during the #MeToo movement. Harvey Weinstein's use of restrictive NDAs is a classic example; Fox News, U.S. Gymnastics, and other prominent institutions also for allegedly weaponizing NDAs against victims of sexual harassment and abuse.
that they could not even share their traumatizing experiences with doctors, therapists, or loved ones. Meanwhile, Weinstein went on to win Oscars and, unsurprisingly, to allegedly victimize even more women. NDAs that are used in this way shield predators who pose a continued risk of harm, as the perpetrator faces no consequences and may be further emboldened to carry on with their behavior, while the victim has no way of disseminating crucial information to protect future potential victims.
We may similarly consider the use of NDAs in medicine a patient safety issue. By prohibiting free discussion of "sensitive information," medical institutions that use NDAs are intentionally stifling reports that could trigger investigations, accountability, and quality improvement. When critical information is actively suppressed, there is no opportunity to act on that information and improve patient care.
Imagine the medical student in the case at the beginning of this article -- what if failure to investigate his potential to cause harm led to physical violence against another female classmate? What if he began residency and harmed patients? The NDA would have been responsible for silencing the initial victim who could have raised the alarm and stopped a predator. This is definitely not a strategy that we in medicine should condone or support, especially when we claim widely that our patients are our first priority, our "true north," our "guiding principle," or our "beacon."
I have only one word for any physician who claims to dedicate their professional life to their patients' care while knowingly concealing information about or enabling misconduct that harms patients: hypocrite. Just because something is legal does not mean it is ethical. If a legal tactic for self-preservation is a commonly-known weapon in the arsenal of individuals known to be predatory, we probably shouldn't be using it routinely in medicine.
is a resident physician in the Department of Psychiatry at the University of Rochester Medical Center in New York.