Tuesday, June 29, 2010

Gay Bashing, 12 Step Privacy, and Journalistic Ethics

Lavender, "Minnesota's GLBT Magazine," recently created a firestorm of ethical controversy when it published an article outing a Lutheran Pastor known for tirades against homosexuality as a gay person struggling to remain chaste.

Reverend Tom Brock, Associate Pastor at Hope Lutheran Church in Minneapolis, regularly denounced homosexuality on his daily radio program. Last summer, when another branch of the Lutheran Church began to discuss the possibility of ordaining gay and lesbian clergy in committed relationships, a tornado tore off the roof of the meeting hall. Reverent Brock interpreted this as a message from God, condemning the idea of ordining non-chaste gays. Until recently his preaching about the tornado could be seen on youtube.

When it was rumored that Reverend Brock was attending a support group for men struggling against homosexual desire, Lavender sent John Townsend, an "undercover" reporter, into the group. Townsend reported on what Reverend Brock said in the group - most notably, about his experience on a preaching mission to Slovakia: "I fell into temptation. I was weak. That place has this really, really weird, demonic energy. I just got weak, and I had been so good for a long time. Things had been going so well for a long time. There’s a lot of gypsies there."

Clearly Brock is one of the many hypocrites who publicly attack the rights of homosexuals while secretly living a homosexual life. He's entitled to deal with his own sexuality in whatever way he chooses (as long as he is not harming others), but once he takes a public anti-gay stand and claims to know God's will his own conduct is fair game. The Lavender article was exposing a duplicitous public figure, not outing a private person. I see no basis for faulting Lavender's revealing these facts about Reverend Brock.

But what about going into a 12 step meeting on false pretenses and reporting on what transpired? Lavender published where the meeting occurred, what time it started, the name of the priest who led it, and unattributed comments from other participants. This was wrong. The participants are entitled to privacy, which is part of the ethos of 12 step programs.

The Lavender article is a vintage good versus good ethical dilemma. Scrutinizing public figures who denounce others is valid journalism - a public good. But privacy for a support group turned to in good faith by people doing the best they can in their lives is also a good thing.

The situation calls for a nuanced moral response. We should thank Townsend and Lavender for taking the issue of the integrity of public figures seriously. But we should chastise Townsend and Lavender for violating the legitimate expectations of the participants in the support group.

It's much easier, though, to see situations as all black or all white. That, alas, is the direction public and political discourse are taking.

Wednesday, June 23, 2010

Torturing the Frail Elderly

"My Father's Broken Heart," Katy Butler's remarkable account of the last years of her beloved father's life, renders the dynamics of medicine run amok as well as anything I've read.

Jeffrey Butler, a retired Wesleyan University professor, was a healthy 79 year old, until he suffered a severe stoke in 2001. Sadly, his vigorous efforts at rehabilitation yielded little benefit. In 2002 he told Katy he believed his wife, her mother, would have been better off if he had died - "she'd have weeped the weep of a widow...and then she would have been alright."

But when he experienced a painful inguinal hernia, the cardiologist who was asked to clear him for surgery recommended a pacemaker for a slow heartbeat. Katy's father had rejected a similar proposal before the stroke, but now he was no longer able to decide for himself. After a brief discussion with the cardiologist, Katy's mother, concerned about his pain from the hernia, and unaware of alternatives, agreed. The cardiologist did not talk with their beloved primary care physician, who knew the couple well, would have counseled against the implant, and could have suggested a temporary external pacemaker for the surgery.

Jeffrey Butler continued to decline with progressive dementia and blindness. Ultimately his wife, with the full support of their three children, asked to have the pacemaker turned off. There was no doubt that this is what Jeffrey would have wanted.

But the cardiologist who had urged the implant refused, on moral grounds. He later told Katy "it would have been like putting a pillow over your father's head." Even when Jeffrey contracted pneumonia being treated with comfort measures alone, but no antibiotics, the cardiologist's colleague refused to turn off the pacemaker, saying "he might die immediately," which would, of course, had been Jeffrey's wish, had he been able to express it.

The cardiologists, claiming the moral high ground, showed less understanding of patient autonomy and informed consent than my first year Harvard Medical School ethics class did.

I have the privilege of teaching a group of brilliant, committed primary care residents. From that perspective the tragedy of Jeffrey Butler's care is that the conveyor belt of medical technology took over his care without consulting with his own primary care physician. I have no doubt that the cardiologists believed themselves to be doing the right thing for Mr. Butler, even though they weren't. Medicare incentives, alas, richly rewarded the unwanted overtreatment, and the installed pacemaker kept Jeffrey Butler's body alive long after the person he had been was dead.

Last summer the duplicitous opponents of health reform attacked the idea of supporting conversations about patients' wishes for late life care as "death panels." But stories like the one Katy Butler tells about her father shows how the status quo leads to real torture.

Thursday, June 10, 2010


The onlinecollegesanduniversities website cited this blog as one of the "top medical ethics blogs." A number of my own favorites are listed as well, and I found some interesting new links on the list.

Monday, June 7, 2010

Doctor-Patient Sex - Is There a Duty to Warn the Patient's Spouse?

Justice Nicholas Colabella recently ruled in Levine v Werboff that an aggrieved husband is entitled to bring suit against his wife's psychiatrist.

Carl Levine alleges that Werboff had unprotected sex with his wife without revealing that he was infected with the herpes virus and without using precautions to prevent transmission. Levine claimed that as a result of Werboff's actions his wife contracted herpes and passed on the infection to him.

Werboff argued that Levine did not have standing to sue him. Judge Colabella disagreed. Here's the judge's reasoning:

1. New York Public Health law - "makes it a misdemeanor for a person, knowing himself to be infected with an infectious sexually transmitted disease, to have sexual intercourse with another."

2. Although judges are concerned about expanding the scope of duties, "there is nothing unfair about extending such a duty to a spouse of the infected person."

3. The judge, however, rejected Levine's effort to charge Werboff with malpractice - "the doctor-patient relationship that is the basis for a malpractice claim was between defendant and plaintiff's wife, not plaintiff."

I found nothing in Judge Colabella's decision that attributed a greater duty to Dr. Werboff than to any person with herpes alleged to have infected Levine by infecting his wife. But my hunch is that the Judge was influenced by the fact that a psychiatrist has a well-known and unambiguous ethical commitment not to have sexual relations with a patient. This means that if Dr. Werboff had such a relationship with Levine's wife, he was committing a seriously unethical act quite apart from transmitting herpes.

The question of how far to extend a physician's scope of duty is challenging. If a patient on a medication falls asleep in his car and injures a pedestrian, can the injured pedestrian sue the physician? (I discussed this issue in a previous post about Coombs v Florio, a Massachusetts case.) But in the Levine case, the alleged action was a gross violation of medical ethics and a potential basis for malpractice action, should Levine's wife choose to complain. From the perspective of ethics as well as law, Judge Colabella got it right!

Saturday, June 5, 2010

Consumers Don't Believe in Evidence-Based Medicine

An article published online by Health Affairs is more frightening than a horror movie for those of us who try to bring reason to bear on health policy and the health system:
The key finding from focus groups, interviews, and the online survey is that there is a fundamental disconnect between the central tenets of evidence-based health care and the knowledge, values, and beliefs held by many consumers. For health care experts, variation—in quality among health care providers, the evidence base regarding therapies, and the effectiveness and cost-effectiveness of treatment options—is a well-established fact of the health care delivery system, documented extensively in the published literature and well understood after years of careful study. Yet such concepts are unfamiliar to many Americans and may even seem threatening, to the extent that they raise unwelcome questions about the quality of medical care that people receive.
The majority of consumers believe that all care meets minimal quality standards, that more care means higher quality care, that newer care is better care, that treatments costing less are inferior, and that medical guidelines "represent an inflexible, bargain-basement approach to treating unique individuals."

The news for health reform could hardly be worse! Reformers and consumers are talking different languages - the language of rationality and the language of faith. But the findings shouldn't surprise us. Since the time of Hippocrates we humans have schooled ourselves into a trusting worship of the healers. That faith helps us ward off the terror engendered by our awareness of vulnerability and mortality.

At the level of clinician-patient interaction, it's possible to bridge the gap. I frequently said to patients suffering from depression some version of - "Of course none of us can be a hundred percent certain about the future...but that said, I'm sure we can make this depression go away." Or, as a wise and caring oncologist said to a dear friend of mine at the point when the chemotherapies he was master of had come to an endpoint - "X, the best thing I can do for you now is to give you a hug" - a "treatment" he promptly delivered!

Consumer skepticism about evidence-based medicine reflects our effort to deal with mortality, not stupidity. To effect change health care professionals and policy leaders need to learn how to explain the importance of practice variation, comparative effectiveness research, and all the other wonky concepts those of us concerned with health reform are so fond of, in ways that respect our human need for solace in the face of finitude and vulnerability.

I've often used the example of how the wise oncologist dealt with my friend with medical students. He applied evidence-based technologies in prescribing therapies that prolonged my friend's life. But when life prolongation was no longer possible, he remained in the role of reassuring healer and provided a different form of evidence-based practice - laying on of hands in the form of a hug, and a commitment to be part of my friend's life to the end.

Wise clinicians understand and apply the aphorism "To cure sometimes, to relieve often, to comfort always." For the public to develop more belief in evidence-based medicine it will have to develop a stronger faith that our health system will "comfort always."

Tuesday, June 1, 2010

Child Pornography, Law, and Ethics Education

A recent New York Times article about federal judge Jack Weinstein's view that the law requiring mandatory sentences for possession of child pornography is "unnecessarily cruel" raised three important points about ethics and ethics education for me.

  1. The relationship between law and ethics. In ethics discussions with students and practicing physicians, participants often start by asking "what is the law?" My response is always the same. "First let's decide what we think is the right thing to do. Then we can ask about the law." If the law disagrees with our conclusion, that's a reason to reassess our analysis. After all, the law reflects society's view of how we should govern ourselves. Maybe our reasoning was wrong.

    But maybe the law is wrong. Judge Weinstein abhors child pornography. But he believes that many of those prosecuted for possession of pornographic images do not present a risk to children, and that mandatory long term prison sentences are sometimes unjust. The judge now proposes to tell the jury what kinds of mandatory sentences guilty verdicts will require, so that the juries will consider the punishment as well as the crime.

    This is not a typical court practice. Whether the judge's view of the degree of threat possession of child pornography poses or does not pose to children is correct, he'd making an important distinction between law and ethics.

    Law tells us what's legal, but not necessarily what's right.

  2. Wishful thinking about human nature and the effectiveness of "treatment." In a recent case, Judge Weinstein did impose the mandatory five year prison sentence. But he wasn't happy about it - "This is an unnecessarily harsh and cruel sentence under the circumstances. This defendant requires treatment and a stable life outside of prison..."

    A social worker who wrote in response to the article spoke in a similarly optimistic way about mental health assessment and treatment:
    For some, if not most, collectors, child pornography films are a relatively harmless way of dealing with feelings of sexual attraction to minors. Such individuals would not think of actually touching a child inappropriately.

    For others, however, the viewing is a step on the way to actually performing the acts they view. To imprison the former group is a waste of taxpayer money; for the latter group, imprisonment is essential, and sentencing laws should be based not on a fixed time period but on the likelihood of repeating the abuse upon release.

    To distinguish between those who will and those who will not move on to abuse of children, the court should request assessment by mental health professionals. Such assessment is also needed for the decision whether to release the prisoner.
    But as Hamlet said to Horatio - "There are more things in heaven and earth than are dreamt of in your philosophy." Human nature is too complex and mysterious for our mental health categories to comprehend and reliably manage. We don't have effective treatments for sexual offenders, and our ability to predict dangerousness is limited at best. Recommending treatment reflects an admirably optimistic view of the fundamental goodness of our species, but it's not an evidence-based proposal. Ethics isn't just about values - it's about facts as well!

  3. Emotion and moral judgment. The NYT article also tells about Judge James Graham, who sentenced a 67 year old man who had suffered a stroke to one day in jail, plus restrictions on computer use and registration as a sex offender. Judge Graham was quoted as follows:
    When you have to sit there on the bench and look at someone like my stroke victim and say, 'I have to send this man to prison for six years,' it just doesn’t feel right....It’s not right.
    In the Harvard Medical School class on medical ethics that just ended, I encouraged students to be very attentive to what they felt as they reflected on ethical matters, since emotional responses are relevant to our moral assessments. But we need to step back from those feelings to decide whether they reflect moral intuitions we should endorse or prejudices we should reject.

    That's how I interpret Judge Graham's comment. The initial "it just doesn't feel right" reflects his emotional reaction. His repetition, after a momentary pause - "it's not right" - reflects, I believe (and hope) his assessment of the initial "moral intuition."