Sunday, March 21, 2010

Doctors, morality and behavior: where is the moral compass?

In their New York Times article on March 1, 2010, about “Doctors without Morals”, Leonard S. Rubenstein and Stephen N. Xenakis contrast the investigation into the Bush administration lawyers involved in the authorization of torture (who they feel were let off much too easily, with an assessment of “poor judgment”, not professional misconduct) with the complete lack of investigation into the doctors and psychologists who participated in the torture itself, as well as the CIA’s Office of Medical Services that investigated the activities when they were questioned by the agency’s Inspector General, and found that, well, everything was ok.

According to Justice Department memos released last year, the medical service opined that sleep deprivation up to 180 hours didn’t qualify as torture. It determined that confinement in a dark, small space for 18 hours a day was acceptable. It said detainees could be exposed to cold air or hosed down with cold water for up to two-thirds of the time it takes for hypothermia to set in. And it advised that placing a detainee in handcuffs attached by a chain to a ceiling, then forcing him to stand with his feet shackled to a bolt in the floor, ‘does not result in significant pain for the subject.’” Waterboarding, when limited to “12 applications over two sessions within 24 hours, and to five days in any 30-day period,” was ok.

The questions is “Who are these people? Other questions, such as “How did they get to be doctors?”, “How can they sleep at night?”, “How can they have been put in charge of this?”, and “How come they still are allowed to practice medicine?” Most important is “Why was there no investigation?” Doctors are investigated by their state licensing boards and others all the time. They can lose their licenses for minor drug offenses, and are subject to severe restrictions and monitoring for risky behaviors involving drugs or alcohol, even if no actual patient was hurt (yet). They can be, and are, sued for all sorts of things, sometimes real malpractice, sometimes in the hope, by patient and lawyer, that they or their insurance company will agree to a monetary settlement in order to avoid the time, pain, and expense of a trial, even when they are not guilty. They are subject to fraud investigations by Medicare, sometimes found liable for honest mistakes.

But actually condoning and designing and implementing torture on actual people with actual damage? Apparently, if done by the CIA, not even worthy of investigation. It is absolutely intolerable and outrageous. Another question is “how did people get this way?” Are they born without moral compass? Were they ethical health professionals who just got so carried away by being part of the CIA that they lost their way? Is the role of the Office of Medical Services particularly despicable because it involved time and thought and did not occur in the health of the moment? I think another question we have to ask is whether we have tolerated less severe moral lapses in physicians that have made this a slippery slope rather than a fall off a cliff.

Where is the dividing line between ethical and unethical behavior in physicians and other health professionals? Clearly, to most of us, it lies somewhere this side of doing or condoning torture (except to the folks involved in the torture directly, in the Office of Medical Services who ok’ed it, and in the licensing and disciplinary boards within and outside of government who have not investigated). But what about facilitating and performing capital punishment? All reputable medical societies say it is unethical for physicians to be involved, but obviously the government authorizes and pays those who do. What about taking bribes from drug companies for using and endorsing their products? The issue of physicians’ conflict of interest has certainly been in the news, but bribes? Well, if I’m a realtor who gives you a present for having listed your house with me, that isn’t a bribe, since it is your money at risk. If I am a company who gives you, as a legislator, money for voting on a public works project that benefits the company, that is a bribe, since it involves the public’s money for which you have fiduciary responsibility, not your own. I would suggest that pharmaceutical and medical device companies give gifts to physicians not so they individually will use their products, but so they will recommend, or even more actually prescribe them, to patients. This is a bribe.

What else besides gifts from drug and device makers, from pens to large corporate board fees, from free samples to tips to resorts, might challenge the morality of physicians?

And, in the particular case of the torture-doctors: Rubenstein and Xenakis say, “This is an unconscionable disservice to the thousands of ethical doctors and psychologists in the country’s service. It is not too late to begin investigations. They should start now.”



john lunstroth said...


What you are seeing is partially the result of the incredible success by the medical profession of the acquisition and protection of the social authority of physicians, and partially the result of a national security apparatus doing what national security apparatuses do in emergencies when given a blank check written on paper of fear …

Very few bioethicists or doctors, even the ones in the article, are willing to go so far as to assert that the violations by physicians of laws against torture are violations of law and that they should be sent to prison. That, after all, is what happens to people who commit crimes. Rather, the discourse is one of “ethics” and “discipline.” Boards of medical examiners cannot send errant doctors to jail. So, if you wish to see some kind of justice, then start by advocating for the idea doctors are subject to the law, not to the vague and indeterminate “ethics.”

You are probably unaware that there was an effort to seek local discipline of a Guantanamo doctor (Captain John S. Edmondson), but since the medical boards of CA and SC would not act without a complaint by the employer (the military), then it would not act on its own, or on the complaint of a citizen. The problem is in the idea the medical profession can regulate itself.

The jurisdictional and other problems with military doctors are quite complex because medicine, like other professions, is regulated on a state by state basis.

You act surprised that doctors can do such things, but clearly the medical profession is well aware of comprehensive ethical problem with medical education, although it is in denial about the cause … it cannot train for ethics because 1) doctors do not do wrong, “do no harm”; and 2) it has no model of the human being in which morality is scientifically recognized.

Doctors are absolved of wrongdoing by tort reform, and by the judgments of such illustrious bodies as the IOM, which has opined that the real source of medical error is in the systems in which doctors work. This means the only source of discipline of doctors is the medical boards, and they are notoriously weak.

If the best thing about medicine is its link with science, and the dominant understanding of the person in the life sciences is that the person is a complex biochemical machine, then the medical scientist is not treating a moral entity, but a machine developed through evolution. This mechanical view is potentiated and magnified through the idea of evidence-based medicine. EBM at once removes professional judgment from the physician, and adds to his social authority with its claim to be objective and scientific.

In this context, torture for a physician may not be harder than it is for anyone else - it takes special training in guarding prisoners to learn not to do it (see Zimbardo prison experiment conducted for the Navy). But, lest I sound insensitive to the plight of the military physician, you must recognize that the problems faced by military docs is very complex ethically, not to mention legally. Doctors and other health workers can be involved in torture in numerous ways, not all of which are easily categorizable as torture, but which do get picked up under the idea of complicity. I refer you to the British Medical Association handbook: The Medical Profession & Human Rights, in which the problems are laid out in some detail.

Xenakis has been bold and outspoken, and that is a good thing. What is needed is not investigations by the medical profession, because it is incompetent to deal with the problem. Lawmakers have to draft a law that examines the details, and draws some bright lines. Otherwise, we should be arguing that docs, regardless of the complexity of their role, should simply be locked up for being involved at all in breaking the law. That is not so hard to say really.

Josh Freeman said...

Great comment.
If I "act surprised", however, I call that editorial license, or sarcasm.

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