Establishing a code of conduct in the life sciences

A Hippocratic oath is merely lip service, rigorous ethical standards need to be developed to properly vet those pursuing a career in the life sciences.

Should life scientists make an oath analogous to the Hippocratic oath that newly minted physicians make in the belief that they will “do no harm” once they utter the hallowed words? The goal of a Hippocratic oath for life scientists would be to instill a sense of professionalism and responsibility so that they will not engage in potentially harmful activities. A number of advocates have supported the establishment of an oath for life scientists as a way to address concerns about potential future bioterrorists.

But has the Hippocratic oath instilled a sense of responsibility in all physicians? Are they all exemplary in their conduct, ethics, and professionalism? Of course not. There have been many highly publicized, and not so publicized cases, of “bad apple” physicians. While the vast majority of physicians are highly ethical and responsible, some are not. Unfortunately, the medical profession does not have a good track record in policing itself.

Part of the problem is the entire medical education process. The main obstacle to becoming a physician is acceptance into medical school. Once accepted, students can perform poorly and still make it through the system, emerging on the other side to practice medicine on unsuspecting patients. For example, Maxine A. Papadakis and colleagues found a strong association between unprofessional behavior in medical school and subsequent disciplinary action by state medical licensing boards. They studied 235 graduates of three medical schools who were disciplined by one of 40 state medical licensing boards (between 1990-2003) and 469 control physicians who were matched by medical school and graduation year.

They found that irresponsible behavior and diminished capacity for self-improvement independently predicted future disciplinary actions threefold compared to the control group of physicians who were not disciplined. Examples of irresponsible behavior in medical school included unreliable attendance at clinic and not following up on activities related to patient care. Failure to accept constructive criticism, argumentativeness, and a poor attitude were examples of diminished capacity for self-improvement. Lack of motivation, lack of enthusiasm, and passivity showed poor initiative.

Despite these known serious behaviors and personality traits, these individuals were allowed to continue their medical education and graduate. Paraphrasing a one-time oath is not going to reverse years of poor behavior.

What were the unprofessional behaviors once these physicians began to practice? The most frequent type of violation–at 15 percent–was use of drugs and alcohol. Eleven percent were disciplined for unprofessional conduct. Two categories–negligence and conviction of a crime–were tied at 6 percent. Other types of unprofessional behavior included sexual misconduct, fraud or inappropriate billing practices, and conduct that might harm the public. Another type of violation, separate from unprofessional behavior, was incompetence which constituted 6 percent of violations.

Unfortunately, seriously dealing with these bad apple physicians is frequently delayed until after a patient is harmed and/or dies. In other words, oversight primarily relies on litigation after the fact. This is much too late. These individuals should never have been allowed to graduate from medical school in the first place.

Once a student finishes medical education and training, the system of oversight by medical licensure is fragmented. Each state has its own licensing board, so if a physician gets disciplined in one state, all he or she has to do is move to another state. (This is also the case for nurses, and there have been several high-profile cases in which criminally negligent physicians and nurses continue to practice by skipping from state to state.)

Instead of mandating meaningful changes, Congress enacted the Healthcare Quality Improvement Act in 1986, which established a National Practitioner Data Bank (NPDB) that the Department of Health and Human Services maintains. The law requires that hospitals, professional licensing boards, and other health care entities report to and retrieve data from the NPDB in order to have up-to-date information about physician competencies. The data is not available to the general public, and the overall usefulness of the NPDB has come into question.

A news report in the June 9, 2001 issue of The Lancet reported that managed care companies and hospitals are routinely failing to report poorly performing physicians to the NPDB, as required by law, according to a study conducted by the Office of the Inspector General of Health and Human Services. The study found that the NPDB was incomplete and inaccurate. The American Medical Association has opposed efforts to gather information on physicians and prefers that these efforts remain with state licensing boards. For a fee, the public can inquire about their physician’s professional history from the Federation of State Medical Boards.

However, state licensing boards rarely revoke or suspend licenses. A better system would be national licensure such as pilot licensure with the Federal Aviation Administration. The safety needs in medicine have been compared to those in the aviation industry; medical licensure done at the federal level would be far more efficient and effective than the current piecemeal, state-by-state approach.

So how do these challenges of oversight apply to life scientists? For life scientists, the educational process is quite different than for medical students. Unlike medical students who can repeat failed exams and courses many times, life sciences graduate students in the United States can fail and be removed from their programs at several points. They can fail if they don’t pass their master’s degree generals exams or if they don’t pass their doctoral level thesis defense. Many students take years to finish their thesis, and one would expect that their thesis advisers would provide close, one-on-one supervision of their work over several years.

Also, graduate students do not typically enter the process expecting a guaranteed well-paying career. (Of course, they usually don’t take on the large debt that medical students typically incur for their studies either.) Academic positions are not easy to come by and competition is fierce. In contrast, depending on the specialty and location, physicians are usually in high demand.

A Hippocratic oath for life scientists would be nice window dressing, but it would simply be that. The more important method to ensure that graduating life scientists are ethical and responsible citizens is the oversight provided by their laboratory supervisors, mentors, and/or thesis advisers. These individuals have an important role in watching their students’ behavior over the years. Those who show irresponsible behavior and a diminished capacity for self-improvement should not be allowed to graduate (as should be the case in medical school). Graduate schools (and medical schools) should develop policies and procedures for problem students. Behavioral infractions should be carefully documented and should be just as important in the evaluation of a student’s academic future as the traditional graduation requirements.

This effort should extend globally. In other countries, different issues might arise that could impact on behavior beyond having formal codes of conduct.

For example, while Australian universities have a code of good practice for postgraduate research studies and supervision, there are economic incentives that undermine this policy. According to an Australian microbiology professor, who prefers to remain anonymous, the Australian federal government provides core funding for essentially all universities and encourages intense competition for graduate student scholarships. These scholarships are quite generous: Students do not pay tuition fees or income tax, yet amazingly, they are still eligible for all full-time student discounts both in Australia and overseas. The scholarships range from $19,000 to $40,000 per annum.

The big flaw in the Australian system is the heavy financial leverage of completing PhD degrees. There is a push to “corporatize” the universities so the output of an academic institution is partly assessed by the number of PhDs that it graduates. Therefore, there is a great incentive to push people through, regardless of their academic ability or behavior, in order to improve the institutions’ graduation statistics. This policy modifies behavior at all levels of academia and does not create a healthy environment for instilling high standards of professional conduct and ethical behavior in graduating researchers.

The bottom line is that on a global scale, this issue is far more complex than simply having a code of conduct or having students recite a Hippocratic oath upon graduation. In order to ensure a professional, ethical, and competent workforce, many factors must be taken into account, including students’ academic performance, responsible behavior, attitude, and perhaps most importantly, a willingness to accept criticism. Other issues that might influence students’ behaviors must also be considered, including economic incentives, as well as the political and social academic environments in which they work.