Why the Title Detroit Heroic?

Dr. Matthew Wynia writes in The New England Journal of Medicine, “Resistance, Strategic Compromise or Complicity? Physicians Choices under Ethical Pressure” (August 13, 2026).

Detroit Heroic celebrates heroes, particularly physician heroes.

Early in my career I had to make a difficult life-and-death ethical decision. It proved costly to me professionally. Therefore, I have little sympathy advocating for complicity or compromise when one believes innocent patients are being subjected to serious harm.

If the events are truly thought to be worth advocating for, then complicity is cowardice. If in retrospect what you are advocating for is not of a sufficient magnitude to evoke personal risk, then the cause does not hold weight and is of little value.

Dr. Edith Eger points out in her memoir The Choice, “doing what is right is rarely the same thing as doing what is safe.”

An example that Dr. Wynia cites as compromise refers to those physicians that continue to be employed in a hospital that has dropped gender-affirming treatment rather than lose federal funding. The proponent physicians remain employed despite the harm they believe is inflicted on their patients. The author asks: are these acts of complicity or strategic compromise?

I say cowardice. If they are not willing to sacrifice, then perhaps their cause is anemic.

Dr. Wynia evokes Plato, who states that any participation in injustice, no matter how small, disorders the soul. He cites Plato’s student Aristotle as endorsing compromise. I would have included Socrates, who refused to give up his beliefs and was sentenced to death.

The doctor cites a spectrum of complicity. At one end are enthusiastic collaborators in clearly unethical behaviors. The Tuskegee Syphilis Study comes to mind.

Professional disobedience in defense of medical ethics and vulnerable patients despite personal risk is at the opposite end of the spectrum. It is the higher ethical calling.

He proposes three tests of compliance and compromise.

The first test is whether going along with unethical practices benefits the doctor but harms patients; this is clearly to be condemned. This is the situation I found myself in years ago. I resisted and paid the price. Ethics can be very burdensome but keeps us on the side of the angels and in league with a higher order of societal obligation that transcends the needs of an individual or organization.

Sad to say that other doctors went along with the harmful practice. They were never outed or condemned. They benefitted and prospered.

The second test is self-defensive complicity. He cites going along to prevent severe personal penalties such as incarceration or losing a medical license. He states that going along to obtain a promotion is clearly unethical, and once again I found myself in this situation. I declined a chairmanship rather than participate in a practice that was clearly hurting patients. (Other doctors jumped at the chance and so received promotions and a nice pension.)

The third test is should such an act of compliance be public or private? I kept the unethical behavior private and naively thought that once the situation was identified the institution would correct itself from within. I did not realize the strength of the cover-up. The cover-up violates the second test mentioned above, as the patients were harmed but the institution and the senior physicians in charge benefitted by the cover-up.

I realize now that institutions need outside pressure such as a visit from the attorney general or the loss of federal funding to correct their behavior.

The author opines that healthcare institutions and lawmakers should support moral courage from physicians who are pressured to subvert professional ethics. It would be nice, but I see this as being incompatible with private equity interests and the corporatization of healthcare.

Bad behavior can be hidden by the corporate.

The title of my book, Detroit Heroic, celebrates physicians who took great personal risks in advocacy for their patients.

The title came to me after reading Dr. Philip Zimbardo’s The Lucifer Effect.

Dr. Zimbardo writes of the transformation of ordinary people into perpetrators of evil in response to the corrosive influence of powerful situational forces. He writes of the Stanford Prison Experiment and the behavior of individuals at the Abu Ghraib prison. He notes, “when most give in and few rebel the rebels can be considered heroes for resisting the powerful forces toward compliance, conformity and obedience.”

In medicine physicians face ethical challenges with few options.

I came across this written by Carl Elliott in The New York Times, May 7, 2024: “In Medicine, the Morally Unthinkable Too Easily Comes to Seem Normal.”

He states, “To embark on a career in medicine is like moving to a foreign country where you do not understand the customs, rituals, manners, or language. Your main concern on arrival is how to fit in and avoid causing offence. This is true even if the local customs seem backward or cruel. What’s more, this particular country has an authoritarian government and a rigid status hierarchy where dissent is not just discouraged but also punished.”

Punished is not a strong enough word. I would say persecuted.

Finally, the inability to change the ethical failures appears to be the source of what has become known to physicians as “moral injury.” It is thought to be a more appropriate term than “physician burnout.”

Moral injury is a term first described in the military, associated with soldiers returning from the Vietnam War. It is different from PTSD. It appears that PTSD is the result of direct bodily harm, injury, or the constant threat of being killed or wounded. The brush with death lingers, haunts, and leads to the persisting nightmares and PTSD.

Moral injury, on the other hand, is the result of being witness to events that question one’s long-held belief of their own morality. The most infamous is the effect on soldiers who witnessed the murder of innocent civilians at My Lai. (The My Lai massacre occurred in 1968, the year Detroit Heroic takes place, and it too was covered up.)

Moral injury occurs when one is witness to, is an accomplice in, or fails to prevent immoral events sanctioned by superiors and other authoritarian figures. The betrayal of trusted authoritarian figures, and senior leaders, that should have prevented such events plays a dominant role.

I discovered moral injury after reading a book review by Dr. Aaron Rothstein. He reviewed If I Betray These Words, co-authored by Drs. Wendy Dean and Simon Talbot. Dr. Rothstein states, “Burnout now consumes American physicians, who are overworked, nonautonomous and adrift without help.”

Drs. Dean and Talbot take exception to the term “burnout” in favor of “moral injury.” Burnout places the fault with the weakness of physicians. On the contrary, the authors state it is not the physician but the dysfunctional healthcare system that is to blame, and that physicians are “victims of a profit-generating machine that has taken over healthcare.”

The physician is marginalized and subject to bureaucratic, political, and arbitrary sanction without recourse. Shut up and put up, obey or else receive toxic and threatening communications.

Perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations are the root cause of a moral injury.

Moral injury can produce shame, guilt, and anger, but it can also have a positive effect. After being witness to unethical behavior I doubled down as a patient advocate. I also began writing fiction and essays about medicine and the plight of physicians today.

Dr. Zimbardo describes heroic actions and selfless heroic deeds subjecting the hero to physical or societal harm. In reviewing his book, I understand that by refusing to go along with a practice that was harming patients and refusing the chairmanship was a heroic act. But since I did not change things, I could not be called a hero. An outside agency, at a time when outside agencies seldom reviewed programs, shut the program down. The outcomes were that bad.

I carry in my phone the statistics of that time decades ago to remind me of the importance of my defiance.

One final thought. In the novel Detroit Heroic my protagonist talks of his literary hero, Joseph Conrad’s Lord Jim. Jim, in an act of cowardice, or confusion, or complicity, commits a deviation from maritime law and ethics. He abandons a sinking ship, leaving 300 passengers to drown. The ship does not sink, the passengers are saved. Jim is discovered and disgraced and lives the rest of his life seeking redemption. My question is: if the 300 pilgrims had drowned, would Jim have felt compelled to live a life of redemption or, like those protected by a cover-up, gone on as if nothing had happened?

My protagonists in Detroit Heroic risk their lives and bring about change. They are heroic and heroes.