Hana Hooper was just shy of 19 and had recently started college when she received a devastating diagnosis: she was dying. An echocardiogram had revealed signs of an enlarged heart chamber, its walls stretched dangerously thin. The diagnosis was end-stage dilated cardiomyopathy. In simple terms, Hana needed a new heart—and fast.

To survive long enough to get a transplant, Hana required a "bridge to transplant" surgery to place a device in the left ventricle of her failing heart to help it keep pumping. Her worried parents, Ali and Patrick Hooper, arranged for her to undergo the surgery at the University of Washington Medical Center, a prestigious hospital in their home state.

However, shortly after the procedure was performed by esteemed cardiac surgeon Dr. Nahush Mokadam in January 2017, it became clear something had gone wrong. Hana suffered a stroke, slipped into a semi-coma, and lost her sight.

Her parents later alleged in a lawsuit that Mokadam had used an unconventional surgical technique that put Hana at higher risk for a stroke without informing them in advance. They claimed that, to cover up his wrongdoing, the doctor blamed the surgery’s problems on an unexpectedly "significant amount of plaque" he encountered in Hana’s aorta and subsequently removed her from the transplant eligibility list. When the family sought a second opinion, Mokadam allegedly threatened to tell other transplant programs that Hana was not suitable for a new heart.

"Dr. Mokadam lied about his operative findings and sought to prevent Hana from obtaining a life-saving heart transplant," Hana and her parents asserted in a legal notice preceding their lawsuit.

Mokadam referred questions about the case to his lawyer, who declined to comment.

The allegations of alarming misconduct have never made headlines, and the university hoped they never would. After more than two years, the case was settled in March 2023 with a $12 million payment and neither Mokadam nor the university admitting wrongdoing. However, the university included a confidentiality clause, also known as a nondisclosure agreement (NDA), instructing the Hoopers "not to publicize the names or identities of the defendants" or "any description of their conduct."

NDAs are widely used by major corporations and wealthy celebrities to make accusations go away, but their use by taxpayer-funded institutions like public hospitals raises significant ethical questions. Lawyers and scholars particularly question NDAs at public hospitals since they receive tax dollars and are subject to transparency laws.

“The information they’re hiding is publicly available, so confidentiality is just a barrier they’ve set up for victims,” said Paul Luvera, a now-retired trial lawyer in Washington state who opposes the routine use of NDAs. “It’s an intimidation clause.”

From 2015 to early 2023, the University of Washington Medical Center and other UW-affiliated hospitals and clinics included confidentiality clauses in 70 of the 89 settlement agreements negotiated. These NDAs require victims and their families to keep silent about their claims, the amounts they were paid, or both, as a condition of settlement.

As a result, the public has been kept in the dark about allegations of egregious medical mistakes and serious misconduct at Washington’s largest taxpayer-funded hospital system. Payments to settle cases with confidentiality requirements ranged from $2,000 to $14 million.

One such settlement involved a newborn who suffered severe brain damage because doctors allegedly failed to properly monitor his heart rate during childbirth, resulting in a $14 million payout. Another case saw a man die after doctors allegedly misdiagnosed and improperly treated a cancerous mass in his face and neck, leading to a $6 million settlement. A girl was left with permanent cognitive disabilities after a doctor who operated on her face allegedly left bone fragments in her skull, causing a catastrophic stroke, resulting in an $11 million payout.

Susan Gregg, a spokesperson for UW Medicine, stated that the accusations leading to these confidential settlements "may not be factually accurate." Gregg added, "Like many healthcare organizations, including publicly owned organizations, UW asks for confidentiality in order to achieve finality and certainty when a claim concludes."

However, the use of confidentiality to hide allegations of malpractice is widespread. Lawyers and scholars argue that NDAs at public hospitals are particularly problematic because these institutions receive taxpayer funding and should be subject to transparency laws.

“The reality is that unless there’s specific legislation that mandates openness and prevents secrecy, then there’s going to be secret settlements and protective orders that prevent the public from knowing there’s a physician with repeated mistakes or a hospital with repeated failures,” said Richard Zitrin, a University of California-San Francisco law professor who has helped draft anti-secrecy legislation for decades.

Despite the lack of a law in Washington state explicitly banning NDAs in medical malpractice settlements, some lawyers doubt the university can enforce its confidentiality requirements. Joel Cunningham, a former defender of the university and other public hospitals who now specializes in suing them, said he "never understood how public hospitals could really enforce these agreements."

Most plaintiff attorneys interviewed said they disliked NDAs but sometimes agreed to confidentiality with the university if they believed it was in their client's best interest or if the client wanted to keep certain details private, such as the settlement amount.

"Personally, I don’t believe nondisclosure agreements are good for society," said Mike Wampold, an attorney in Seattle. "But I’m not a legislator making public policy. I’m a lawyer representing an individual client."

And that’s what Wampold did when Ruby Blondell decided to talk to NBC News. Blondell’s husband, Douglas Roach, had pursued a lawsuit against the University of Washington Medical Center after discovering that a critical lesion in his lungs, flagged by a radiologist in 2012, had not been communicated to him or his primary care physician. Roach was diagnosed with terminal cancer five years later. The university settled the case for $5 million without admitting wrongdoing.

Blondell said her husband pursued the lawsuit as an act of love—to ensure she’d be financially secure after he died. "We couldn’t afford our house without his income," she said. "And Douglas loved this house."

The settlement included a confidentiality clause, but Blondell worried that the incident would be "swept under the rug." "I just always heard that these kinds of things usually did come with a confidentiality agreement," she said. "I just thought it was par for the course."

The NDA kept the settlement out of the headlines. But Blondell interjected: "I probably wouldn’t have minded it being public if in return we got accountability."

In a separate case, Susanna Grieser and her husband, Mark, opted to break their silence. In November 2016, Susanna went to the UW School of Dentistry to get a broken tooth removed. A student dentist convinced her that she also needed a right molar pulled, assuring Susanna the procedure would be "easy." However, during surgery, the student and an older male faculty dentist struggled to remove the molar. Susanna, who was partially sedated, felt intense pressure as the student jammed bone graft material into her exposed tooth socket.

Over the next few months, Susanna experienced constant, debilitating pain. She avoided opening her mouth or touching her face, spoke little, ate only mashed foods, rarely slept, and routinely missed work. She even fantasized about driving into oncoming traffic.

After the Griesers filed a notice of claim in 2018, the university eventually paid them $600,000 and forgave some bills. Confidentiality only came up after the deal was struck—when the couple saw a clause in their settlement document. Though he ultimately signed it, Mark objected to its inclusion.

"My firm belief is that I have a duty as a citizen to speak out about this to protect my fellow citizens," said Mark, 66, a semi-retired accountant. "I’m not afraid to speak up," said Susanna. "I don’t want this to happen to anybody else."

The details of Susanna’s care were reviewed as part of a state health department investigation. Dillon, the oral surgeon who later treated Susanna, described the university dentists’ failure to suction out bone graft material as "a medical error." None of the dentists who treated Susanna were fined or disciplined by the state. The university cooperated with the state investigation and reviewed Susanna’s care under "the UW School of Dentistry’s quality improvement program."

Patrick Malone, a Washington, D.C.-based lawyer who has written extensively about the legal ethics of using NDAs, reviewed the university’s boilerplate confidentiality clause and said it violates model ethics rules that encourage transparency in claims and defenses. "There are a number of jurisdictions that have said it’s unethical for a lawyer to hide, under the guise of confidentiality, any of the public facts of a case," Malone said.

Several local and state bar associations have adopted advisory opinions or rules against lawyers using NDAs, and a handful of state laws forbid them under certain circumstances. California prohibits NDAs in sexual abuse settlements. Florida bans "concealing information" in settlements of claims "against the state," including malpractice cases at public hospitals. And a law passed 30 years ago in Washington state outlaws confidentiality agreements if they keep secret "hazards to the public"—but it doesn’t specify medical malpractice.

Despite the lack of a law in Washington state explicitly banning the use of NDAs in medical malpractice settlements or by public institutions, five lawyers who’ve settled cases with the university in recent years told NBC News they are doubtful that it can enforce its confidentiality requirements.

Hana Hooper, now 26, received a new heart in 2018 after a different UW heart surgeon, Dr. Daniel Fishbein, rejected Dr. Mokadam’s assertion that excessive plaque in Hana’s main cardiac artery made her ineligible for a transplant. Fishbein arranged for Hana to get second opinions at two out-of-state hospitals. Both relisted Hana as a top priority for transplant. She got her new heart