Mitchell Goldstein, MD, MBA, CML, Lily Martorell, MD, T. Allen Merritt, MD, MHA

In academic neonatology, as in any profession, individuals seek a sense of belonging, opportunities for growth, and a feeling of being valued. However, the reality is that these aspirations are often elusive. Many professionals have encountered situations where they feel mistreated—whether someone else is receiving undue credit or taking advantage of circumstances at another’s expense. These experiences prompt a deeper reflection on the concepts of fairness and justice, which, despite their frequent conflation, are far from synonymous.

Justice, as a concept, is rooted in legality and structured ethics. The term derives from the Latin iustus, meaning “lawful” or “rightful;” it has maintained a firm association with legal and ethical codes throughout history. In contrast, fairness originates from the Old English fæger, which initially meant “beautiful” or “pleasant” before evolving into a broader concept of equity and balance. While justice aligns with objective principles and established frameworks, fairness is relative and considers the unique needs and circumstances of all parties involved. (1)

In neonatology, the distinction between fairness and justice plays out in ways that can shape careers, institutions, and, ultimately, patient care. Consider a scenario where their institution acknowledges a young researcher’s groundbreaking work, but the credit is publicly attributed to a more senior colleague. From a legal standpoint, this may not constitute an injustice if there is no formal intellectual property violation. However, from a moral and professional perspective, such an outcome feels deeply unfair, and the impact on the individual’s career trajectory can be profound. (2)

Similarly, justice might dictate that a clinician who inadvertently breaches an obscure hospital policy faces formal disciplinary action. However, fairness would recognize the mitigating factors: Was the rule well-communicated? Was the clinician acting in good faith to provide the best possible care? The balance between adhering to just policies and ensuring fair treatment is delicate, and failing to navigate it properly can lead to a work environment rife with resentment and disengagement. (3)

Alexander Hamilton famously asserted that “the first duty of society is justice.” He could have chosen the word “fairness,” but he did not—because fairness, while desirable, is not an absolute principle. It is fluid, dependent on perspective, and occasionally at odds with justice. (3) This tension is particularly evident in academia, where hierarchical structures often dictate who is recognized, rewarded, or reprimanded.

The reality is that reconciling fairness and justice is as challenging as achieving perfect sensitivity and specificity in a clinical test. The ideal scenario—where both align perfectly—is aspirational but often impractical. Instead, institutions and leaders must consciously strive for a balance, ensuring that just decisions are tempered with fairness and that fairness does not undermine necessary structures of justice. (2, 4, 5)

For academic neonatology to thrive, there must be an ongoing dialogue about how decisions are made and their implications for those affected. Mentorship, transparency, and institutional accountability can help bridge the gap between what is just and what is fair, fostering a culture where professionals feel valued and are treated with integrity. Ultimately, the pursuit of fairness and justice is not about achieving perfection—it is about ensuring that when the two diverge, efforts are made to navigate their complexities with wisdom and ethical consideration. (6)

Maintaining this balance becomes even more crucial in the ever-evolving landscape of neonatology, where cutting-edge research, clinical care, DEI, and education intersect. This is a significant investment—not only for the individuals navigating their careers but also for the patients and families who depend on a well-functioning, ethically sound system. (1, 5, 7, 8)

One practical approach to mitigating the disparity between fairness and justice is cultivating an environment where open discussions about ethical dilemmas are encouraged. Professional development programs should integrate training on ethical decision-making, conflict resolution, and bias awareness to ensure leaders at all levels can recognize and address potential inequities before they become systemic issues.

Additionally, fostering a culture of acknowledgment and recognition can help rectify some of the fairness gaps that naturally arise in hierarchical institutions. Institutions should consider structured credit-sharing mechanisms for research contributions, transparent promotion and evaluation processes, and clear, well-communicated policies that minimize ambiguities leading to perceived injustices. (5)

At its core, academic neonatology is driven by compassion and a commitment to improving the lives of the most vulnerable patients. It stands to reason that the principles guiding our professional interactions should reflect these same values. While challenging, striving for fairness and justice in tandem is a task worth undertaking for the benefit of both the field and the individuals within it. (4, 9)

References:

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2. Haines VY, 3rd, Patient D, Guerrero S. The fairness of human resource management practices: an assessment by the justice sensitive. Front Psychol. 2024;15:1355378. Epub 2024/04/10. doi: 10.3389/fpsyg.2024.1355378. PubMed PMID: 38596324; PubMed Central PMCID: PMCPMC11002264.
3. Gresh R. What’s the Difference Between “Fair” and “Just”? https://wordsmarts.com/fair-and-just/: wordsmarts; 2025 [cited 2025 3/1/2025]. Available from: https://wordsmarts. com/fair-and-just/.
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7. Campagna V, Mitchell E, Krsnak J. Addressing Social Determinants of Health: A Care Coordination Approach for Professional Case Managers. Prof Case Manag. 2022;27(6):263-70. Epub 2022/10/08. doi: 10.1097/ NCM.0000000000000590. PubMed PMID: 36206117.
8. Williams KJ, Nicklin JM. Reactions to others’ mistakes: an empirical test of fairness theory. J Psychol. 2009;143(5):53358. Epub 2009/12/01. doi: 10.3200/JRL.143.5.533-558. PubMed PMID: 19943403.
9. McKenzie N, Dorsey C, Guerrero S, Donington J, Alverdy J, Nordgren R, et al. Enhancing equity in academic surgery promotion practices. Surgery. 2025;180:109023. Epub 2025/01/22. doi: 10.1016/j.surg.2024.109023. PubMed PMID: 39837048.