Ethical Erosion

Caroline McCarthy is a GP in Co Kildare, Ireland and a clinical lecturer at RCSI, University of Medicine and Health Sciences.

Most of us go into medicine to help and to heal. While we learn to accept that this isn’t always possible, sometimes we do worse than simply not helping—sometimes we cause harm. By harm in this context, I am not referring to medical errors or hazardous prescribing but rather the kind of harm that comes from not caring, from being unkind, from treating patients as problems rather than people. Mary Ann Kenny describes this harm in her raw and intimate memoir “The Episode: A true story of loss, madness and healing”.¹ The book recounts her descent into psychosis after the sudden death of her husband—and the prolonged hospitalisation that followed several months later.

It is a powerful and carefully documented account of Kenny’s inner turmoil and her outward experiences with the healthcare system. Kenny obtained and reviewed her full hospital records. Her ability to read, reflect upon and share these most intimate details which included nursing, medical and child protection conference notes, is testament to her intellectual curiosity and deep personal courage. The book interweaves her own recollections with direct quotes from her medical records. It is a fascinating and well-written account—so compelling, in fact, that I read it in a single sitting. In the closing chapters, Kenny describes her episode as comprising three distinct but interlinked traumas: the first, the sudden loss of her husband, leaving her to navigate grief while caring for two young children; the second, her descent into mental illness; and the third—and perhaps most devastating—her encounter with the healthcare system, particularly her hospitalisation. What resonated most with me reading the book were the interactions with the health professionals who looked after her, from the stern treating consultant “Dr Alpha” to the cold social worker “Cathy”, or the repeated encounters with nursing staff during her admission, so focused on assessing her level of risk that they seemed uninterested in the story of who she was, or how she had come to be in such distress. I was horrified by her story—but, truth be told, I recognised myself and echoes of some of my past encounters with patients in those characters. No one goes in to medicine to be unkind or uncaring. So how does this happen?

A few years ago, I came across the term ethical erosion, “an empirically observed phenomenon whereby medical students and doctors become less morally sensitive and ethically aware due to increasing cynicism, the negative effects of health-care training and practice, and the desire to ‘fit in’ with others in the profession”.² I feel this is an apt description of what may have happened to some of the health professionals involved in Kenny’s care. Certainly, it is a description that deeply resonated with me when I first came across it. As a fresh-faced intern, I remember being horrified by the casual way in which patients were being consented for life changing salvage surgery for recurrent head and neck cancer. However, over the course of that year I became desensitised to this, perhaps in part due to the system and my training but probably also from my desire to ‘fit in’. There are many aspects of clinical practice that we, as doctors, come to accept as normal—things that, at one point, might have made us deeply uncomfortable. Take the traditional ward round, for example. As others have observed,³ it often involves a large group of well dressed healthy professionals, standing over a patient clad in their pyjamas or hospital gown, who is at their most vulnerable and often in an open ward with a flimsy curtain for privacy. It’s oddly theatrical and if we are honest, perhaps oftentimes a little cruel. As a profession, our inability—or perhaps reluctance—to step back and reflect on practices that may need to change has no doubt contributed to our ethical erosion. But we are capable of change and reform both individually and collectively, one prominent example is Dr Kate Granger’s #hellomynameis campaign, that reminded us of the very basic and important task of properly introducing ourselves to patients.⁴

As GPs, we know our patients as people, and thus it is easier to remember to be kind. But there are other aspects of our practice that can contribute to cynicism and ethical erosion. For example, practicing within a system where the powers of medicine are seen as limitless and doctors are expected to fix the unfixable can be demoralising. This is perhaps alluded to in The Episode where in the early days of her grief, Kenny’s friends and family suggested seeing her doctor and considering medication. Although Kenny does go on to develop symptoms of severe mental illness and herself attributes her recovery in part to her medication, from her account of these encounters early in her grief, I wonder how useful they were. And in all honesty can the odd 10- or 15-minute consultation with a GP help a person navigate intense grief?

It can be hard to change the wider system-level factors that contribute to ethical erosion. But what can we do to limit our own erosion and the erosion of our students and trainees? On an individual level, reflective practice is important. That is being willing to pause and examine not just what we did, but how we did it and why. Reading human accounts like Kenny’s can be profoundly revealing, reminding us of our power as doctors and thus our potential to cause real harm. As trainers and teachers, we have a responsibility to model kind and compassionate care and to identify and share our own shortcomings and failings. Compassionate, open and vulnerable mentorship involves naming the discomforts of practice and reminding our trainees and students that kindness and curiosity are not optional extras but the core of good care. Reflecting back on one of my introductory lectures as a first-year medical student, the message that was delivered was around the need for excellence. What I heard was “I must be perfect; I must not fail”. In hindsight a more helpful message may have been to remind us that we are imperfect, that we will fail and that is part of being human, but in our position of power and privilege we have a responsibility to be humble, to admit our mistakes and learn from them. For me, this book was a powerful catalyst for reflection on the care I have delivered. Upon finishing it, I was struck by how, despite the pain of her experiences, Kenny’s tone carried remarkably little anger or bitterness. In the final chapters, there’s a striking generosity and willingness to reflect on and remain curious about the people who cared for her, even those who caused harm. I found this comforting and a reminder that that same gentleness and curiosity is something we, as clinicians, must extend not only towards our patients but also towards ourselves anchoring us when the forces of erosion wear us down.

References

1. Kenny M. The Episode: A true story of loss, madness and healing. Dublin: Sandycove, Penguin Random House; 2025.
2. Oxford Reference. Available from: https://www.oxfordreference.com/display/10.1093/oi/authority.20110803095759339#:~:text=An%20empirically%20observed%20phenomenon%20whereby,with%20others%20in%20the%20profession. [accessed 11/06/2025]
3. Launer J. What’s wrong with ward rounds? Postgrad Med J. 2013;89(1058):733-4.
4. Granger K. Hello My Name Is. Available from: https://www.hellomynameis.org.uk/. [Accessed 11/06/2025]

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