Beware the murky place between the letter and intent of the law.

Most ethical quandaries can be boiled down to a basic conflict of interest: you—your interest, that is—and whatever gets in the way of that. Then, there is your practice, hospital, or company…and whatever gets in the way of that.

Recent headlines indicate an ethical flu has infected American business, and that bug has made its way into the hallowed halls of medicine.

Back in August, Saint Barnabas Health Care System agreed to pay the government $265 million in a wide-ranging fraud investigation into hospital practices of inflating bills for the sickest, elderly patients, for the purpose of receiving outlier payments. Moreover, the practice of inflating the costs of outliers is so prevalent that before the investigation concludes, 450 hospitals and $6 billion in Medicare billings are expected to be involved. “The way the system has operated, it’s almost irresponsible corporate governance for hospitals not to cheat Medicare,” Patrick Burns, an analyst at Taxpayers Against Fraud, a leading watchdog organization, told the New York Times.1

An October article in the New England Journal of Medicine investigated the role of drug manufacturer Eli Lilly in funding and, therefore, influencing a panel of physicians empowered to develop practice guidelines for treating sepsis, for which Lilly manufactures a drug.2 With the current push for pay-for-performance initiatives, such consensus documents are ready-made for use in these programs, raising the potential for widespread adoption and, in this case, vastly improved sales for Eli Lilly.

Now, in response to a request for guidance from an unnamed source, the Office of Inspector General has warned physicians that it intends to scrutinize physician investments in medical device and distribution entities for improper practices,3 citing its 1989 Special Fraud Alert on Joint Ventures as guidance. A 2003 notice in the Federal Register provided this description of such joint ventures: one line of business expands into a related health care business by contracting with an existing provider of a related item or service to provide the new item or service to the first-named health care provider’s existing patient population.4 One hallmark of the examples provided in this Special Advisory Bulletin was that the first-named entity provided little more than the referrals and the second entity provided the rest.

Over the past few years, we have witnessed the ethical collapse of many corporate executives, most recently in the executive offices of Hewlett-Packard. Why are so many business leaders going down in infamy today? To what do we attribute America’s apparent readiness to do the wrong thing? Waning attendance at weekly religious services? The maddening inability of most people to admit that they did something wrong? Too much self-esteem?

It is not clear whether the problem of ethics in America is more serious today than in the past or if our current methods of policing and publicizing ethical lapses are simply more vigorous. Nonetheless, the headlines make clear that many of us struggle with these issues.

Our cover story this month poses eight real-world ethical dilemmas and the thoughts of eight contributors who were invited to respond. Because this journal is the place where business and radiology intersect, we felt obliged to raise these issues, and we owe a great debt to Leonard Berlin, MD, for helping to formulate the questions, and to our participants for sharing their thoughts in this forum.

In his introduction, Berlin notes that ethics typically hold us to a higher standard than the law. Because the ethical choice is not marked in neon, we often see the erosion of ethics in that murky, gray space between the letter of the law and the intent of the law. In doubt? Ask a colleague, urges Berlin. As the above anecdotes attest, when ethics fail, the law is not far behind.


  1. Kocieniewski D. Hospitals grew with Medicare paying the way. New York Times. August 20, 2006. Available at: Accessed October 30, 2006.
  2. Eichacker PQ, Natanson C, Danner RL. Surviving sepsis—practice guidelines, marketing campaigns, and Eli Lilly. N Engl J Med. 2006;355:1640–1642. Available at: Accessed October 30, 2006.
  3. Robinson VL. Response to request for guidance regarding certain physician investments in the medical device industries [letter]. Washington, DC: Office of Inspector General, Department of Health and Human Services; October 6, 2006. Available at: Accessed October 30, 2006.
  4. Contractual Joint Ventures [Special Advisory Bulletin]. Washington, DC: Office of Inspector General, Department of Health and Human Services; April 2003.

Cheryl Proval
Editorial Director