How Ethical is Ethical Enough?

How Ethical is Ethical Enough?

January 2019

Assessing when an ethics violator can safely return to practice

Lawyers take the bar exam. Physicians take the United States Medical Licensing Examination (USMLE). These and similar tests ensure that practitioners meet the high standards of their chosen profession before they are allowed to practice.

But what happens when someone who has passed the qualifying test fails to live up to the ethical standards of their profession? In 2004, the National Board of Chiropractic Examiners (NBCE) created a multiple-choice test for state regulatory boards to use when a chiropractor had been disciplined for an ethics violation. When other professional groups expressed interest in a more sophisticated version of the test, the NBCE worked with a psychometrician to develop the Ethics and Boundary Assessment Services (EBAS) exam, now used by 40 state medical boards.

As mentioned earlier, EBAS covers the five areas of greatest interest to boards: boundary violations, fraud, professional standards, unprofessional conduct and substance abuse. Following an approach often used to assess moral reasoning in professional ethics classes, EBAS presents carefully crafted scenarios in each of the five areas. Test takers write essays in response to each scenario, identifying the ethical issues involved, when the licensee in the story breached professional standards and what consequences could arise as a result of the violation. The applicant is also asked to propose actions that would resolve the problem and prevent its recurrence, and in the last section of the essay, explain how the violation harmed the community and why it is considered an ethical violation.

While the test is now taken using a computer, each essay is scored individually by seven different graders, all of whom have board experience (the current pool of 43 graders includes board members, executive directors and board attorneys). The graders are intensively trained and are given detailed rubrics that tell them what to look for. These rubrics help the graders identify important patterns. In the fraud section, for example, a test taker may say the licensee should fire their billing manager. If the graders find that tendency to blame other people weaving through the other essays, said EBAS executive director Stacey Kjeldgaard, “They pick up on that. They can tell the person is not willing to take ownership, and is always blaming someone else.” Others show genuine remorse and understanding of how the patient and others in the scenario were harmed.


In general, the EBAS exam is used to assess a person’s fitness to practice. In the majority of cases, said Kjeldgaard, people are asked to take the test after receiving remedial education, sometimes as a kind of final exam before being allowed to return after a suspension or revocation. In these cases, the test helps assess what the person has learned.

But there are times when boards use the test in place of remedial education, said Stephen Schenthal, MD, PBI’s founder. He thinks that’s misguided. “Someone who has committed an ethics violation has already failed the test. A well-written essay cannot undo that fact,” he said.

“It’s the difference between hot and cold ethics,” explained Schenthal. “A person may understand the ethical issues intellectually and be able to explain them clearly in a cold state, sitting quietly at a computer. But if they have committed a violation in the heat of the moment, something else is going on. And it’s important to figure out what that is,” he said. “That is the point of remedial education, for people to confront their own demons.”