Serious Ethical Violations in Medicine: A Statistical and Ethical Analysis of 280 Cases in the United States From 2008–2016

James M. DuBois, Emily E. Anderson, John T. Chibnall, Jessica Mozersky & Heidi A. Walsh (2019) The American Journal of Bioethics, 19:1, 16-34.
DOI: 10.1080/15265161.2018.1544305

Abstract

Serious ethical violations in medicine, such as sexual abuse, criminal prescribing of opioids, and unnecessary surgeries, directly harm patients and undermine trust in the profession of medicine. We review the literature on violations in medicine and present an analysis of 280 cases. Nearly all cases involved repeated instances (97%) of intentional wrongdoing (99%), by males (95%) in nonacademic medical settings (95%), with oversight problems (89%) and a selfish motive such as financial gain or sex (90%). More than half of cases involved a wrongdoer with a suspected personality disorder or substance use disorder (51%). Despite clear patterns, no factors provide readily observable red flags, making prevention difficult. Early identification and intervention in cases requires significant policy shifts that prioritize the safety of patients over physician interests in privacy, fair processes, and proportionate disciplinary actions. We explore a series of 10 questions regarding policy, oversight, discipline, and education options. Satisfactory answers to these questions will require input from diverse stakeholders to help society negotiate effective and ethically balanced solutions.

A Drug Trial’s Frayed Promise

By Katie Thomas
The New York Times
Originally published April 17, 2015

Here is an excerpt:

The University of Minnesota’s clinical trial practices are now under intense scrutiny. In February, a panel of outside experts excoriated the university for failing to properly oversee clinical trials and for paying inadequate attention to the protection of vulnerable subjects. The review, commissioned by the university after years of criticism of its research practices, singled out Dr. Schulz and his department of psychiatry, describing “a culture of fear” that pervaded the department.

In March, after another critical report by Minnesota’s legislative auditor, the university announced that it would halt all drug trials being conducted by the psychiatry department until outside experts could review them. And this month, the university announced that Dr. Schulz would step down as head of the psychiatry department. The dean of the medical school, Dr. Brooks Jackson, said in a statement to reporters that Dr. Schulz’s decision “was completely his own” and that he would “remain a valued member of our faculty.”

The entire article is here.

Denying Problems When We Don’t Like the Solutions

By Duke University
Press Release
Originally published November 6, 2014

Here is an excerpt:

A new study from Duke University finds that people will evaluate scientific evidence based on whether they view its policy implications as politically desirable. If they don't, then they tend to deny the problem even exists.

“Logically, the proposed solution to a problem, such as an increase in government regulation or an extension of the free market, should not influence one’s belief in the problem. However, we find it does,” said co-author Troy Campbell, a Ph.D. candidate at Duke's Fuqua School of Business. “The cure can be more immediately threatening than the problem.”

The study, "Solution Aversion: On the Relation Between Ideology and Motivated Disbelief," appears in the November issue of the Journal of Personality and Social Psychology (viewable here).

The entire article is here.

Punishment and Blame within Criminal Justice

By Hanna Pickard
Flickers of Freedom
Originally posted January 21, 2014

Here is an excerpt:

As well as working clinically with patients, I’m also currently developing a training for prison officers, to teach them how to distinguish responsibility from blame in theory and in practice, as part of an initiative to increase awareness and skills working with personality disorder (PD) and promote a more rehabilitative environment within prisons. On a purely personal note, going into prisons has been hard. Over time I’ve become much less scared, but I still can’t bear being locked in, dependent on the officers and their keys to get out. Every time I go, I can’t quite believe we’ve ended up doing this to people, no matter what they’ve done. So I certainly think there’s reason to re-think radically the entire system, on multiple grounds. However the training I’m developing and the theoretical work that underpins it aims to be pragmatic rather than revolutionary – and that’s what I’m going to blog about today. No utopian ideals!

We currently spend millions and millions imprisoning offenders. Meanwhile there’s some real and plenty of anecdotal evidence that one of the best ways to increase re-offending is to put people in jail – arguably, you really couldn’t design a better environment to entrench criminality if you tried. Yet 66% of male offenders and 50% of female offenders have PD – they have many of the same mental health problems and psycho-socio-economic backgrounds as patients in the community who we know we can help in Therapeutic Communities and other forms of treatment program.

The entire blog post is here.

Responsibility and Blame in the Clinic

By Hanna Pickard
Flickers of Freedom
Originally posted January 17, 2014

Here is an excerpt:

But we can really help these patients if we adopt a stance that I call “Responsibility without Blame”. Here’s what this means. The problem behaviour is voluntary. Patients with PD are not mentally ill and they know as well as most of us do what they are doing when they act. They have choice and control over their behaviour at least in the minimal sense that they can refrain – which they will often do if sufficiently motivated.  That does not mean that refraining is easy.  Here a little more background is important: PD is associated with extreme early psycho-socio-economic adversity. Most patients come from dysfunctional families or they may have been in institutional care. Rates of childhood sexual, emotional, and physical abuse or neglect are very high. Socio-economic status is low. Additional associated factors include war, migration, and poverty. Problem behaviour is often a learned, habitual way of coping with the distress caused by such adversity, and patients may have hitherto lacked decent opportunities to learn alternative, better ways of coping. So, until the underlying distress is addressed and new ways of coping are learned, restraint is hard.

The entire blog post is here.

Zero Degrees of Empathy

From the RSA, 21st Century Enlightment
RSA Homepage
Originally published July 6, 2011

Professor Simon Baron Cohen presents a new way of understanding what it is that leads individuals down negative paths, and challenges all of us to consider replacing the idea of evil with the idea of empathy-erosion.

‘Everyday Sadists’ Among Us

By Jan Hoffman
The New York Times
Originally published September 16, 2013

Here is an excerpt:

Those who enjoy inflicting at least moderate pain on others, directly or vicariously, mingle with us daily. Think mean girls, taunting a classmate to commit suicide. Or the professor who grills a squirming, clueless student, lips curled in a small, savage smile.

Delroy L. Paulhus, a psychology professor at the University of British Columbia, calls such people “everyday sadists.”

“They exist on a spectrum,” he said. “It could be at a hockey game and your guy is pummeling the opponent into hamburger and people are standing up having orgasms, to taking revenge on those you think deserve it, to schadenfreude.”

But acknowledging that sadists regularly cross our paths is unsettling, said Scott O. Lilienfeld, a professor of psychology at Emory University, who studies personality disorders. “We prefer to think, ‘There’s sadists, and then there’s the rest of us.’ ”

The entire story is here.

Psychopathic criminals have empathy switch

Psychopaths do not lack empathy, rather they can switch it on at will, according to new research.

By Melissa Hogenboom
Science reporter, BBC News
Originally published July 24, 2013

Placed in a brain scanner, psychopathic criminals watched videos of one person hurting another and were asked to empathise with the individual in pain.

Only when asked to imagine how the pain receiver felt did the area of the brain related to pain light up.

Scientists, reporting in Brain, say their research explains how psychopaths can be both callous and charming.

The team proposes that with the right training, it could be possible to help psychopaths activate their "empathy switch", which could bring them a step closer to rehabilitation.

The entire story is here.

Can You Call a 9-Year-Old a Psychopath?

By Jennifer Kahn
The New York Times
Originally published May 11, 2012

One day last summer, Anne and her husband, Miguel, took their 9-year-old son, Michael, to a Florida elementary school for the first day of what the family chose to call “summer camp.” For years, Anne and Miguel have struggled to understand their eldest son, an elegant boy with high-planed cheeks, wide eyes and curly light brown hair, whose periodic rages alternate with moments of chilly detachment. Michael’s eight-week program was, in reality, a highly structured psychological study — less summer camp than camp of last resort.

Michael’s problems started, according to his mother, around age 3, shortly after his brother Allan was born. At the time, she said, Michael was mostly just acting “like a brat,” but his behavior soon escalated to throwing tantrums during which he would scream and shriek inconsolably. These weren’t ordinary toddler’s fits. “It wasn’t, ‘I’m tired’ or ‘I’m frustrated’ — the normal things kids do,” Anne remembered. “His behavior was really out there. And it would happen for hours and hours each day, no matter what we did.” For several years, Michael screamed every time his parents told him to put on his shoes or perform other ordinary tasks, like retrieving one of his toys from the living room. “Going somewhere, staying somewhere — anything would set him off,” Miguel said. These furies lasted well beyond toddlerhood. At 8, Michael would still fly into a rage when Anne or Miguel tried to get him ready for school, punching the wall and kicking holes in the door. Left unwatched, he would cut up his trousers with scissors or methodically pull his hair out. He would also vent his anger by slamming the toilet seat down again and again until it broke.

The entire story is here.

Calling for an End to Phony Military Discharges

Letter to the Editor

New York Times

Originally published March 3, 2012

To the Editor:

“Branding a Soldier With ‘Personality Disorder’ ” (front page, Feb. 25) scratched the surface of an important military scandal.

I have been investigating personality disorder discharges for the last six years. In that time, I’ve interviewed dozens of physically wounded soldiers who were booted from the military with a phony “pre-existing personality disorder,” which prevents the soldiers from receiving disability and medical benefits. They even have to give back a chunk of their signing bonus.

Soldiers severely wounded in combat are finding out on their final day in uniform that they will never get disability benefits — and they now owe the military thousands of dollars.

I have also interviewed military doctors about being pressed by their superiors to misdiagnose wounded soldiers. One doctor told me of a soldier who came back with a chunk missing from his leg. His superior pressured him to diagnose that injury as personality disorder.

The numbers in this scandal are staggering. Since 2001, the military has discharged more than 31,000 soldiers with personality disorder, at a savings to the military of over $17.2 billion in disability and medical benefits.

Barack Obama had been at the forefront of this issue. As a senator, he put forward a bill to halt all personality disorder discharges. But as commander in chief, he has done nothing to halt these fraudulent dismissals.

The American people should confront the president and the Republican presidential candidates with this question: As commander in chief, what actions will you take to keep these phony personality disorder discharges from devastating another military family?

JOSHUA KORS

New York, Feb. 26, 2012

The writer is a freelance reporter.