Jekyll and Hyde in Medical Practice

 I've written many times about how doctors who exploit patients sexually can provide excellent care to and be idolized by their other patients. I just learned from my friend Dr. Brian Hurwitz that the same can be true for doctors who murder their patients!

I first met Brian when I spent three months at the King's College London Centre for Medical Law and Ethics in 1992. He was doing an MA at the Centre, and allowed me to spend a fascinating day with him in his general practice surgery. For the past ten years he's been D'Oyly Carte Professor of Medicine and the Arts and Director of the Centre for the Humanities and Health at King's College.

Brian sent me a not-yet-published chapter he's written about Dr. Harold Shipman, the GP who was ultimately found to have been a serial killer who murdered more than 250 of his patients. The chapter included this remarkable quote from the son of one of the patients Dr. Shipman was found to have murdered:

I remember the time Shipman gave to my Dad. He would come around at the drop of a hat. He was a marvellous GP apart from the fact that he killed my father.

Shipman never admitted his guilt and refused to talk with psychiatrists, as did his surviving family. He committed suicide in prison in 2004. Although many colleagues and members of the community where he practiced noted strange occurrences in Dr. Shipman's practice, no one was prepared to draw the retrospectively obvious conclusion - a trusted, beloved physician was killing his  patients!

I think the best comment about people like Shipman comes from "The Shadow," an old time radio detective whose adventures I followed as a child. (The Shadow had the gift of invisibility.)

Who knows what evil lurks in the hearts of men? The Shadow knows!

Who's taking care of Mom?

The July Journal of the American Geriatric Society has a disturbing article - "Hiring and Screening Practices of Agencies Supplying Paid Caregivers to Older Adults."

Researchers at Northwestern School of Medicine posing as prospective clients seeking a caregiver for an elderly adult relative, contacted 180 agencies and asked about hiring, screening, and supervisory practices. Their findings aren't pretty!

67% of the agencies required experience, but this was often assessed by self-report. 62% checked references. 92% checked criminal background within the state, but no agencies checked other states, meaning that someone who had been convicted elsewhere would appear to have a clean record. English language proficiency was assessed via the interview, and no agencies assessed health literacy (ability to understand physician recommendations, dosage schedules, and so forth). 31% conducted drug screening. 7% verified citizenship or visa status. Training and supervision were very limited. The researchers conclude:

The screening and training practices in use by caregiver agencies are highly variable and often of poor quality. Using an agency to hire paid caregivers may give older adults and their families a false sense of security regarding the background and skill set of the caregivers.

Home care for the elderly has the makings of a perfect storm. It brings together vulnerable elderly with a marginalized population of poor, often immigrant, workers. This is a setup for exploitation - sometimes of the elderly by the "caretaker," and sometimes of the caretaker by the agencies that hire them.

When my father, who lived 1,000 miles from where I was, lost his vision and entered the early stage of cognitive decline, my cousin needed a place to live and moved in with him. He provided eyesight, companionship, and driving. My father provided lodging and paid for food. It was a true win/win situation.

But this kind of good luck is the exception, not the rule.  Agencies, like the 180 surveyed in the study, are filling a vacuum in our fragmented society. Unfortunately, as the study reveals, being hired by an agency is not a reliable stamp of approval.

Teaching Ethics in High School and Middle School

I'm in Vermont at the Bread Loaf School of English, a Middlebury College program in which the students, primarily high school and middle school English teachers, can get a Master's degree in the course of five summers. My wife has been teaching here every summer since 1992 and I've been enjoying the potential for (a) telecommuting and (b) swimming and hiking in Vermont.

This year the Bread Loaf program has a new format for elective workshops, and I'm doing one next Friday on teaching ethics in high school and middle school. I've never taught at that level, but I've taught medical ethics at Harvard Medical School for many years, and I wanted to see whether and how that experience could be extended to pre-college English classes. I hope the participants learn as much as I have in preparing for the workshop.

Since the content of the medical school course isn't relevant for pre-college English classes, I dissected out the underlying goals I have for the medical students. I identified five:

1. Strengthen ability to identify ethical issues, ideally combined with a zest for tackling these issues – a capacity that can be called “moral imagination” or “moral sensitivity.”
2. Impart systematic approaches to resolving ethical questions – approaches, not answers.
3. Enhance skills and attitudes that promote considering the views of others in a respectful manner – listening to those we’re talking with and, imaginatively, to the views of other stakeholders to the issue. 
4. Cultivate the habit of using our own "gut" reactions as “data” for ethical reflection, not necessarily as “truth.” This doesn’t come naturally to most adults, and is even more challenging for adolescents. 
5. Enhance capacity to reason to a justifiable conclusion and articulate the rationale for our conclusions.

In preparing for the workshop I came upon the work of Tom Wartenberg, Professor of philosophy at Mount Holyoke college, who teaches a course in which undergraduates (a) examine children's books through the lens of articulating the implicit philosophical content of the stories and (b) train to lead discussions for fifth graders at a nearby charter school. (The website is very worth a visit.) In an interview he described his objectives for elementary school children as essentially the same as my objectives for Harvard Medical students. His aim is to teach children how to "philosophize," not about the content of philosophy per se. The children dove into the discussions with the same gusto that makes teaching the course to medical students such  a privilege and pleasure.

Apart from the specific content focus of ethics education, the attitudes and skills required for reasoning about ethical issues are the fundamental requirements for democratic participation. I'll depend on the teachers who participate in the workshop for ideas on whether and how including ethics in high school and middle school English classes is (or is not) a promising practice in an era dominated by standardized testing.

Sexual Intimacy in the Nursing Home

The most recent issue of the Journal of Medical Ethics has an excellent article from the Centre for Evidence-Based Aged Care in Australia - "Dementia, sexuality and consent in residential aged care facilities."

The authors' argue that "while we must abide by laws regarding consent and coercion, in general we [in the West] expect to be able to engage in sexual behaviour whenever, and with whomever, we choose." In their view, nursing homes should allow for sexual intimacy and interfere only for clearly defined reasons, rather than treating sexuality as a special privilege that must be earned by requiring both parties to "prove" decisional competence, and, often, to require permission from families.

The authors are drawing on the concept of "dignity of risk." Meaningful life entails taking risks. If we agree with John Stuart Mill that as long as individuals are (a) not causing harm to others and (b) understand the nature and consequences of their proposed actions ("decisional competence"), then(c) their liberty should not be constrained. The authors recognize, but do not discuss in depth, the challenge of assessing "competence" in the presence of dementia. To my reading they underestimate the potential risks, as when one party erroneously believes that the other is their spouse or partner. But they're right that we tend towards excessive prudishness with regard to sexuality in our parents and grandparents.

This was the explicit focus of teaching when I was a medical student. We were in our 20s, so patients in their 70s and 80s were the age of our grandparents. When teaching us how to take a medical history our instructors warned us that we might feel uncomfortable asking about sex with patients in that age range. They reminded us that we were doctors-in-training learning a medical role, not prurient children or grandchildren peeking through keyholes into a bedroom.

My father was something of a ladies man. He outlived three wives and, over the years, I was aware of a number of his girlfriends. In the final months of his life he suffered from dementia and heart failure, along with blindness, and was in a nursing home. On a visit that turned out to be just two days before his death, we returned to his room to find an elderly woman lying on his bed. I said in what must have been a saccharine-toned voice "this is my father's bed." She responded, with a mischievous smile and a twinkle in her eye, "I know."

Knowing that flirtation was alive and well so near the end of my father's life is a happy memory for me!

(The full article is only available by purchase, but a free abstract is available here.)

Teacher/student sex

I spent four happy years (9th to 12th grades) at the Horace Mann School in New York, and was startled by a New York Times article in June titled - "Prep School Predators: The Horace Mann School's Secret History of Sexual Abuse." The author, Amos Kamil, had researched the piece for more than a year and had interviewed more the 100 former students and teachers.

The article describes how several teachers in the 1980s and 1990s were well known for "hitting" on students. The article discusses in detail three who preyed on boys. One, possibly two, committed suicide after finally being dismissed. But the sexual exploitation had gone on for many years. It's hard to believe that the administration was unaware of what was happening. The author himself was invited to the home of Inslee Clark, the head of school, and, although underage, was given alcohol, at a small dinner that included one of the teachers known for hitting on boys.

In the world of organizational ethics there's a saying: if the CEO isn't "chief ethics officer" as well as "chief executive officer," don't waste your time on organizational ethics. Leaders set the moral tone of organizations by what they practice, not what they preach. Clark's alcohol-laced dinner suggests that he was setting an atmosphere that tolerated what in the medical world is called "boundary violations."

There's a structural similarity between the doctor/patient relationship and the teacher/student relationship. We give doctors and teachers authority and respect for helping us cultivate our capacities for health and wisdom. We expect them to focus on the needs of their patients and students, and to put their own private desires into the background. Sexual interest isn't a violation of that trust. Overt behavior is.

Neither I nor my best friends from high school had any knowledge of teacher/student sexual relationships, but we were at Horace Mann 25 years before the period the article discusses. But Tek Young Lin, a new teacher in our days, now 88, acknowledged that he had sexual relationships with students in the 1960s and 1970s. Tek was a Buddhist and a beloved English teacher. I remember him as a charismatic, profoundly educative person. The candor I remember him for was reflected in the interview he did with the New York Times:

 "in those days, it was very spontaneous and casual, and it did not seem really wrong...if I had in any way harmed them, hurt them, I am truly, truly sorry. I hope if they have been hurt, they will overcome that hurt, and I should be very happy to help in any way I can." 

 The fact that a beloved teacher could also be an exploiter is consistent with comments made on this blog by former patients of physicians who'd lost their licenses for boundary violations. It's clear that teachers, like doctors, who violate boundaries with some, may provide superb education to others.

An article in yesterday's New York Times reports that alumni are unhappy with what to them seems like a "cold" reaction on the part of current leadership. I'd felt the same way. The disappointing public comments probably reflect the misguided legal advice the school administration was given - to say nothing that could be used against the school in court. This is what lawyers used to advise physicians in situations of bad outcomes. That defensive approach is now seen to be (a) inhumane and (b) bad strategy for preventing malpractice litigation.

I take three lessons from these unhappy stories about my high school. First, we humans are open to a wide range of feelings and fantasies. In relationships like teacher/student and doctor/patient we should expect that the full range of emotions can enter in (on both sides). Professional education should help us become better self-observers and self-managers, so that we can govern ourselves in accord with our professional responsibilities. Second, leadership matters. Inslee Clark set a permissive example. Likewise, in years past, leaders in medicine did the same. Medical leaders hushed up allegations against colleagues, just as bishops did with offending priests. Finally, when a problem hits the fan, respond as Tek Young Lin did, not as past medical leaders and bishops did - take responsibility for the situation, apologize, and make amends when possible.

(For the initial article about "Prep School Predators" see here. For the article about my teacher Tek Young Lin, see here. For yesterday's article about alumni reaction to how the school is handling the situation, see here.)