Wednesday, March 21, 2012

Bioethics and Psychiatry, British Columbia

A young physician joined a research facility.  A number of physicians worked there. The head physician had been 'star' in his day. His research was mostly on new medications. He was well financed by  one drug company in particular.  The trouble was getting patients enough for his drug studies.
He and some of his colleagues addressed this problem by 'broadening  the "diagnosis".  Though the disease category wasn't 'cancer' it could well have been. To recruit more people for his research he included people who would not traditionally have been said to have 'cancer'  These "healthy' recruits would further 'dilute' the side effects of the medication and allow for better outcomes.  It did subject a whole lot of people to unnecessary toxicity though and in addition could cause some people without other disorders to be given simply the wrong treatment thereby missing the right treatment for their 'correct' diagnosis.
The young researcher was suspicious of this and raised his concerns early. The head researcher explained this away and used a lot of 'attitude' and 'dominance' behaviour to make his point. This of course concerned the young physician even more because people who depend on the gun don't usually have any better argument.
Using the 'local' research criteria the young researcher diagnosed a man with the condition.  The man was indeed sick with this particular condition that could affect his judgement. He was offered a position in the research trial.  When he balked the head physician came and essentially sold the man on the research.
In selection for research people can be recruited for pay, or be offered a position, or have the pros and cons explained and an advocate or family member included to help in the decision. The young physician having had some research experience before joining this community had been exposed to a much different and  more 'patient centered' approach to selection.
In this community however  there seemed to be a real 'drive' to get patients enrolled in programs.  At the time the young physician never thought that there might be incentives associated with this. He'd worked in sales to pay his way through undergraduate studies and he actually saw patients being 'sold' on being part of research that really wasn't likely to benefit them and might well not provide any benefit for the world as a whole. The interactions were distinctive to those trained in process.
Of course this is also all hypothetical and fictitious. In medicine it's said that hindsight is a proctoscope that's 100% perfect only because it's in the hands of assholes.
That the man would be treated with the research drug and die as a result of the wrong diagnosis and wrong treatment could well have happened to anyone. Medicine isn't an exact science.  Mistakes occur and only after death does one recognise the errors.
Usually after death, though,  especially suspicious deaths, there isr a post mortem. This can be a physicai post mortem done by a pathologist and it can also be a psychological post mortem done by the staff. The head physician ensured that neither was done confirming the young man's concerns.
The young man followed the old man's directions because he was  senior and more experienced. The young man  never even speculated that there was conflict of interest.
The experimental drug didn't work.  The research failed.  The man died.  Usually, having an experimental drug is sufficient cause for more intensive investigation of the factors leading up to death.
The young physician had  pleaded with the older more experienced physician but had been  silenced repeatedly. The young physician questioned the diagnosis and questioned keeping the man in the double blind research trial because he was clearly deteriorating and death was imminent.  In those days the young physician was known for being very diplomatic and respectful of authority as the young and highest trained from the finest institutes are.
He'd never encountered such a problem before and didn't know what further he could do.  There was no one, he believed, more senior he could take his concerns to. Further the young man had already been told that that he wasn't considered a good  '  team player".  Being a 'team player' was indeed the highest praise one received in this hospital research institute and perhaps this community at large. .
He sadly learned later from other researchers  that there were many discrepancies and other deaths had occurred . No one spoke up because that was considered unprofessional. The doctors in this community appeared to put the greatest emphasis on professionalism and a lesser emphasis on such matters as patient life and death, , truthfulness, transparency, patient advocacy, patient's rights or any number of considerations that might well have contributed to saving  the man's life.
Further, there was no place in the university for anyone who bucked the system. The hierarchy in research was sacrosanct and the grand man was politically well connected. This hierarchal problem is central to 'systems research' and the study of why corruption is so wide spread in some communities.  For example, the success of the Japanese car industry at one point was the result of a letter box which was solely read by the CEO of the company and open to be used by all employees. Prior to that innovation in the 'system' was blocked by middle management and yukuza who simply removed any one who suggested change in the existing system.
The reformer is the enemy of anyone who benefits from the status quo.  Only the CEO and Board were specifically interested in the quality of Japanese cars because of world wide competitiveness whereas the lower level managers were only interested in their jobs remaining unchanged with all the privileges and perks in tact.
The young man wanted to do something but exhausted all avenues except whistleblowing. Whistleblowing is not taken lightly by professionals.  It's essentially committing suicide to bring attention to someone being murdered.  It's like Tibetan monks who pour gasoline on themselves and ignite it.  Whistleblowying in Canada is routeinely punished.  In British Columbia whistleblowing is crucified. So it was not something to be done lightly.
The young man in the end had  refused to  make the unsavoury decisions alone and insisted that the old man attend the patient and give the orders publicly rather than the young man doing what he no longer believed in alone and in silence.  The old man was furious with the young man for this refusal to cooperate but saw the patient and publicly gave the order which caused the patients death.
The patient died.
The young man not trusting the older , came into the hospital and copied  the file.  The next day he learned that the old man was saying that the patient had died through an error of the young man's.  Further, the chart was suddenly missing and the orders of the old man were expunged from existence. The research assistant later said that the research data was all re written too.  It had been done before when people had died she told him.  Crying she said I can't say anything because he'd ruin my career if I objected.  He learned that several of his colleagues had been directly involved in this sort of thing unbeknowst to him.
Everyone has heard the adage, you can't make an omelette without breaking a few eggs.  No one higher in the food chain was ever concerned about such matters because they had their own skeletons in their closets to worry about.
The young man simply left the hospital. He didn't want to have anything more to do with the old man or with the colleagues whose behaviour, specifically sins of omission, contributed to the deaths of patients. As he put it, "I just wanted to play hockey. I didn't know that I'd joined a bush league run by the mafia. " He never lost his love of hockey though.
He later learned that the research funding had further caused the senior man to have a conflict of interest because there was serious support for a particular outcome measure in the research.  Alot of money apparently was involved not in finding  if the drug was good or not but solely in proving this drug was good and extending it's distribution potential.  The particular drug company involved did not itself have a good reputation.
The young man did not know any of the history of the trend of the very government  appointed beaurocrats to choosing sketchy low cost  suppliers rather than reputable institutions.  Deaths of patients could therefore be likened to the crashes of airplanes that occured increasingly because maintenance was being done by low cost knock offs rather than the specified parts the manufacturer required for wings and engines.  A patient's death could always go by quietly but airplane crashes attracted attention.
The difficulty for young doctors  in primitive barbaric systems is that they are so dependent on the context of their situation and lizards have long been known to eat their young whereas mammalian species usually care for theirs.
The young researcher left the hospital  and returned to general practice.
He was subsequently approached by a  former senior colleague to come forward and speak out against the head and tell the truth about the death of the patient,he was was less than keen.  He felt he was out of that system and had nothing further to contribute.  .  The colleagues who approached him and begged him for his assistance  said that they could not do it as their careers and positions with the university would be jeopardized if they did.  They said that the old man was crazy and killing people and it was his duty to stop the carnage because he had the evidence and could make the complaint.
He discussed this request with a colleague.  The colleague said simply, "I've known that man who wants you to do this  for many years. He's a psychopath.  He is playing on your goodness and doesn't care for anyone but himself. He lacks empathy. He hasn't the capacity for love. He's a chameleon but he's still a lizard. "
Women doctors who he'd formerly worked with also approached him and begged him to help them, his female colleagues.
So he wrote the letter.
The letter caused the head doctor to lose his position. He was deposed by a jury of his peers who felt his behaviour was wholly 'unprofessional'. .
The young physician was never forgiven.  The other senior colleagues who'd 'used' him went on to high position. The woman colleagues never looked him in the eye again. ..
At the time the young physician thought there was still nobility in his colleagues  and that he was duty bound to stop the unnecessary death which was continuing. At the time he never suspected that the persons who were asking him to make the supreme sacrifice  were indeed only hoping to get the old man's position.  He personally knew of no conflict of interest that he had.  Thanks to his teachers and his family and their values he was quite simply most interested in doing what he thought was right, helping out and helping ensure better health care for patients specifically and in general.   Otherwise  he happy to be hunting and fishing and working in his private practice. He figured he'd do research elsewhere if the opportunity arose but he wasn't going to do research locally given the lack of regulation and the tendency of governing bodies to either be themsevles corrupted or simply wholly negligent.
The longer he was in the community the more of a political Sodom and Gomorrah it appeared.
It was at this time that national and international regulatory bodies were refusing to certify the provincial institutions in general. The greatest calamity of the decade was that the Vancouver Stock Exchange lost it's license to practice due to gross corruption. The business community en mass was considered so criminal it lost the right to self government. For years thereafter it only ran with supervision of the Toronto Stock Exchange.  The government in general was notorious for questionable practices which explained why everyone called this the 'wild west'.  A day didn't go by in his office where some patient wasn't being harmed by some group of shysters and their government affliliates like those in the infamous 'leaky condo fiasco'.
Even when MLA  Moe Sihota caught the Attorney General and Premier doing dirty deals over their cell phones, the Premier and Attorney General tried to have Moe Sihota arrested for 'eavesdropping'.  They subsequently brought in a law that would severely punish anyone who exposed graft in government. I was shocked that those caught red handed seemed quite content to accuse the accuser. It was with great admiration I watched Moe Sihota avoid imprisonment.  What seemed significant was that no particular 'party' was alone in dirty tricks.
Everyone was complicit at the time in no end of lawlessness that was occuring partly because of the great growth in the city and province and because of the wealth that was flowing through the great port. The principal agricultarl trade of the community was marijuana and all manner of individuals in all levels of government were somehow involved in the multi billion dollar industry.  The city was further one of the principal avenues of heroin into the US with millions of dollars of profits dispersed through the community.
The logging companies were clear cutting and lying about replanting but at least paying taxes whereas non tax paying  fat cat marijuana criminals were planting acre large plantation in the clear cuts left by the logging companies .
The business of the administration and promotions were made for those who would 'turn a blind eye'.
Conflict of interest was the norm. Further, greed was the community pathos.  With rising costs of living and declining pension potential everyone seemed to be scrambling and no one was interfering in how their neighbour went about survival. Mad men and mad women dominated the landscape.
What was interesting was that they didn't tend to go to church as much after their deeds of dubious treachery and barbarianism, they as often as not showed their hypocricy by seeking social support for their age old villainy in psychological and philosophical theories that would justify their venomous behaviour.  Social darwinism was all the rage along with pursuit of happiness at all costs.  In this age of narcissism there were all manner of drugs illicit and medicinal which could be guaranteed to remove any insomnia or depression that might have once made guilt and shame more unbearable. Sympton management was all the rage.
The young man thought that his colleagues  decisions  to remain mum, and protect their careers, appeared to him to suggest they were like  thieves in a den, not willing to question a thief among them, All manner of shady things had been going on at the time which he'd found offensive but none had caused the unnecessary death of a patient.  So he wrote the  letter which was used by the hospital and university authorities to depose of the  great man.
What the young man didn't know about office politics was that he was just a tool in a greater conflictt, carelessly and stupidly used to remove an opponent.  The puppet master, another drunk and thug, didn't win the gambit but someone else became head.  That person was not necessarily any better or any more caring of patients.
The old man was in retrospect just declining and scared, anxious about money and aging, clinically out dated and irresponsible. In the grand scheme of things using the retrospectoscope of highsight, he was really the best of a very bad lot.  The young man regretted seeing him brought down even if it was the right thing because this old stag was really just surrounded by wolves.  The wolves took over then and things went even worse. It wasn't for another several years before a head was chosen who actually took their Hippocratic Oath seriously and research and the hospital began to function once again somewhat as a 'patient centred' facility.
In a way the old man was like  a King Lear. In other ways he was a MacBeth. Seeing him go was like watching a Zorba the Greek episode with all the clawing old ladies and lesser rat like people grabbing the remains of what he had left. Years later the young man was sorry he'd hurt the older man simply  because he was so much better than what immediately had followed.  Further as he grew to know those who'd pressured him to come forward he realized he had indeed fallen in with worse than theives.
He' d learned however that he could depose a metaphorical Hitler.  He was like David in the Bible who could relatively easily depose a Goliath but it was much more complicated when he had to deal with Saul.   The problem wasn't just single men in his mind but rather all the alliances.  He described his predicament  as not being able to deal with the   NEST.  To explain this he'd say,  if the allies or even the Germans themselves had assassinated Hitler, it was just possible that Goebbells or Eichman would have taken  his place.  Quite possibly they'd have been worse.
The idea that removal of a leader meant better things was only a communist idea from the failed machinations of Marxism.  Revolution didn't improve things but rather as likely made things worse. Like the Beatles he'd all along sung, "We don't want a revolution" but somehow through his inability to see the Saul in a person he'd thought a friend he'd betrayed his own personal principles alligning with a project which was intrinsically ungodly from the start.
Years later one of the gang would suggest he needed to study ethics and professionalism.  By then he knew that God had a great sense of irony.
Professionalism was loyality to the group and the group's good cause. The difficulty with professionalism was specifically that it was so similiar to  tribalism. The German Army was the most professional soldiers of history yet the cause they served changed from what was called higher " kultura" or culture to low culture.  The lower unit of any society after family is  tribe.  It's a gang.  It's a self serving entity that defines all outsiders as the enemy.  Historically a profession was a subsection of society that served its membership and the greater needes of the society as a whole.  Tribes care not for society as a whole and like gangs serve only themselves.
The young man only stayed with the team because he thought it better than the alternative gang.  Professional soldiers were said to be superior to the mob because of the discipline and allegiance. But it was a Prime Minister of England who said " I don't need you to agree with me when I'm right, I need you to agree with me when I 'm wrong." That's the nature of the party system of the government.  It's especially dangerous when it devolves from professionalism into tribalism.
A National Post editorial put forward the question "What is the difference today between a Canadian Political Party and the Hell's Angels?"  This was a question that didn't need to be asked 20 years ago but was clearly one being asked today.
In medicine the doctor owed allegiance first to his Oath and his profession.  His oath was first 'Do no harm' and that the "patient should come FIRST:'.  The Beurocrats were very good at platitudes and 'saying the right thing'.  Georgia Strait newspaper  annually made a joke of banning the words over used by beaurocracy as 'buzz words' and 'politically correct' hypocrisy. There was a serious disconnect between the words and behaviours of some individuals and especially the institutions which promoted them.
By use of the corporate and beurocratic term,  'terms of reference' all investigation into any malfeance limited  their 'apparent' culpability, accountability and responsibility. Hence even  a massacre commission might insist that it was only called to judge the death of one person in a massacre when that sole person alone  had in fact, as the subsequent report showed, died of natural causes.  By limitting 'terms of reference' the commission didn't have to account for the countless machine gunned bodies.
The young physician had seen too much unnecessary death and in the end was labelled a whistle blower. He'd stopped many individual deaths. by speaking up.  His 'sacrifice' individually had been in countless lost nights of sleep, personal threats to himself,  endless hours of research and consultation with others, and immense loss of income all to conclude that the 'NEST' seemed the same as when Kafka described it as the "Castle". He had played the Glass Bead Game and become Magister Ludi but to no avail.  The best he could do was indeed simply the 'next right thing'.
Talking with the deacon of the Queen's church in Buckingham he was told by this old white haired poet, "I finally learned that there's all the money in the world to help the sheep that survive the fall from the top of the cliff as long as you don't do anything about the hole in the fence up there.  And God forbid you don't say anything about the people pushing the sheep off the cliff."
Today he was looking for a bioethicist who had sacrificed his career to save the life of one man.  From what he'd read so far philosophers learned far more from the death of Socrates than Christians learned from the death of Jesus.  He wasn't sure though they had anything to offer in tying action to word because everyone was so very good at paying lip service and no one seemed willing to pay the blood price.

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