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Hearing that the highest tiers of European royalty and government officials have been toppled for their association with Jeffrey Epstein, I can’t help but look closer at home and abroad. It’s hard to avoid uncomfortable comparisons.

In the U.S., we’ve seen a lower tier of elite face consequences, such as Peter Attia and Larry Summers, who were spared termination but were able to resign. For the rest, it’s been a familiar playbook. When powerful people are accused of misconduct or even abuse, institutions move to containment — not transparency.

The piecemeal release of the Epstein files reflects a familiar pattern: complaints and claims are made, evidence exists, but access is controlled. Accountability stalls.

While the Constitution promises equal protection under the law, that protection comes through the courts and via its agents — attorneys. Juries decide on innocence or guilt, and then determine financial damages.

In America, harm is monetized.

It follows, then, that those who wield money and power can buy protection within the legal system. How can we forget OJ Simpson’s stable of lawyers, the best money could buy, nicknamed the “Dream Team.”

With financial resources and access to elite legal representation, those accused of wrongdoing are able to turn the pursuit of justice into a negotiation. Civil settlements, nondisclosure agreements (NDAs), and confidential arbitration dominate. As such, judgment and public accountability can be avoided or deferred.

Examples abound. Roger Ailes was well known for his prolific use of NDAs at Fox News, and Harvey Weinstein avoided consequences of his actions for years, showing how money and power can make even the most egregious allegations against him disappear.

Left unaddressed in those cases in which perpetrators are not brought to justice is the magnitude of the impact on victims.

My career as an emergency physician and public health expert has centered on the vulnerable and at-risk. I have seen the long arc of trauma — through physical, mental, and behavioral health manifestations in my patients, most especially those who suffered adverse childhood events (ACE).

Ranging from anxiety and depression to sleep disturbances, neurologic impact, chronic illness, and substance use, the consequences are long-standing and pervasive. This doesn’t include the depth of impact on what are known as the social determinants of health — job stability, housing stability, economic possibilities, and other nonmedical factors that can shape a patient’s well-being. The damages of trauma are not measurable in simple dollars.

Power is often leveraged through coerced silence.

Studies have shown that more than one-third of the U.S. workforce has been subjected to NDAs for workplace-related harassment, sexual misconduct, and employment discrimination. The National Women’s Law Center found NDAs isolate victims, shield serial predators, and allow harassment to persist.

The Equal Employment Opportunity Commission (EEOC) notes significant underreporting in the workplace, where research suggests as many as 85% don’t report sexual harassment, and 94% of people don’t report discrimination.

Years ago, a woman I was treating for opioid use disorder confided in me after holding me at reticent arms’ length for weeks. I noted a subtle change, where her steely gaze was replaced by downcast eyes. She whispered, “I want to tell you something.” She went on to recount how she had been sexually assaulted on more than one occasion by someone who was supposed to help her.

She hadn’t told anyone out of fear. She felt trapped. After our session, I immediately sprang into action to alert authorities as a mandatory reporter and put mechanisms in place to keep her safe — especially for possible retaliation.

Days later, when I saw her next, she was sobbing uncontrollably. I feared the worst until she finally whispered, “Thank you for believing me.”

For the minority who do speak up, the consequences can be overwhelming. Speaking truth to power is fraught with danger that is rarely just legal. A victim’s credibility is often structurally discounted — framed as financially motivated, vindictive, or selfish.

That skepticism is unevenly applied. Institutions often require overwhelming proof of undeniable and well-documented harm, while at the same time, extend presumption and patience to those with power. Countless examples illustrate how anchor institutions often circle the wagons to protect an accused, but leave the person harmed to fend for themselves.

Lawyers and others are often forthcoming with victims about the risks of pursuing legal action. The list is long: litigation costs, reputational damage, professional blacklisting, social ostracism, and family exposure.

The most common EEOC complaint is for retaliation, often in response to reporting harassment or discrimination internally within the workplace. People who report transgressions have faced career derailment and other penalties, perhaps most famously demonstrated by Lilly Ledbetter, whose landmark U.S. Supreme Court case prompted new standards for fair wages.

Despite Ruth Bader Ginsburg’s encouragement to challenge laws in court, it seems difficult for many to understand why someone might invoke the protections of our laws or work to establish safety and fairness for others. For the many who don’t have wealth or power as buffers, silence is survival — not consent.

Europe does not always operate in a way Americans would consider fair or just. But in the last few weeks, we’ve seen that government officials and the highest-ranking citizens seem to be held to a higher standard than their counterparts in the U.S.

There is a cultural expectation that power increases responsibility.

The British monarchy and government have repeatedly centered the survivors in their response to questions and probes: “Our thoughts are with the victims.”

Cynically, this could be a convenient deflection, but practically, it keeps the focus on those who have been hurt and wronged. It sets the tone from the top and normalizes compassion and empathy for victims over perpetrators.

In America, power often confers insulation. In Europe, there is instead greater reputational consequence. That kind of accountability conveys justice precisely because it cannot be insured against. It changes the incentives.

In Europe, they have fired the men who were involved with Epstein. In America, we have allowed them to step down, resign, or retire quietly.

Will we allow power to protect itself more reliably than it protects the vulnerable — especially children?

The enduring failure we are seeing play out is a collective nonconsequence for those who sit the highest among us. Accountability collapses where power concentrates.

At the same time, lest we forget, it was the demands from everyday Americans that led to the release of the Epstein files. The public brought this issue to the forefront.

We can use this moment to force change.

If we demand extraordinary proof from victims, we must demand extraordinary transparency from power. If we believe authority confers responsibility, then ethical standards must be enforced. Boards, professional societies, and institutions cannot simply issue statements of values; they must act when those values are breached.

Accountability cannot remain optional for the powerful. As voters, donors, consumers, and leaders, we decide what we will reward. We can insist that reputation reflect conduct. We can demand that rules travel upward, not only downward. We can see justice as an integral part of our democracy, and each of us equally deserving.

As a society, we can be clear on whose harm matters. That choice is ours.

Priya E. Mammen is an emergency physician, healthcare executive, and public health specialist who helps the nation’s most impactful companies integrate clinical integrity at scale.