Around the world, hearts were broken when news came that the conjoined Bijani twins had died on the operating table. Having lived in tortured unity for 29 years, they traveled from their native Iran to Singapore for the surgery meant to set them free. The doctors who performed it were devastated. When you lose a patient, particularly when the patient dies at your own hand, the heartbreak mixes with unbearable guilt. The doctors are asking themselves the same question everyone else is asking: Should they have done it?
The doctors certainly knew the risk. They knew that, with the women’s shared circulatory systems, the risk was great. They might have underestimated the technical challenges, but they did not deceive their patients. The sisters, highly educated and highly motivated, knew full well the risk of never waking up from the surgery.
Indeed, they never did. Should the surgeons have attempted such a risky procedure on patients who were not dying, and, in fact, were not even sick?
For all the regrets and second guesses, it is hard to see how the answer could have been anything but yes. The foundation of the medical vocation is that the doctor is servant to the patient’s will. Not always, of course. There are times when the doctor must say no. This was not such a time.
Consider those cases in which outside values trump the patient’s expressed desire. The first is life. Even if the patient asks you to, you may not kill him. In some advanced precincts—Holland and Oregon, for example—this is thought to be a quaint idea, and the state permits physicians to perform “assisted suicide.” That is a terrible mistake, for the state and for the physician. And not only because it embarks us on a slippery slope where putting people to death in the name of some higher humanity becomes progressively easier.
Even if there were no slippery slope, there is a deeply important principle at stake: Doctors are healers, not killers. You cannot annihilate the subject you are supposedly serving—it is not just a philosophical absurdity, it constitutes the most fundamental violation of the Hippocratic oath. You are not permitted to do any harm to the patient, let alone the ultimate harm.
There are other forms of self-immolation, less instantaneous and less spectacular, to which doctors may not contribute. Drug taking, for example. One could say: The patient wants it, and he knows the risks—why not give him what he wants? No. The doctor is there to help save a suffering soul from the ravages of a failing body. He is not there to ravage a healthy body in the service of a sick and self-destructive soul.
Doctors are not just biotechnicians. They must make judgments about, yes, the soul. Before serving a patient’s will, doctors have to decide whether it is perverse and self-destructive. One has to ask what kind of plastic surgeon would repeatedly do his work on Michael Jackson. Or on the Manhattan socialite, known now as the cat woman, who had her face tweaked so many times that it changed inexorably into that of a feline.
Do sex-change operations fall into this category? Some doctors believe that prospective transsexuals really are born into the wrong body; the surgery is therefore corrective. Others argue with equal force that gender dysphoria, as it is known, is a psychiatric affliction and that mutilating the body to fit the afflicted psyche is to inflict a double injury on the patient. The area is gray enough, and the controversy serious enough, to leave the matter, as we have, to the conscience of the individual physician.
But we ought never leave the decision to the individual physician when we come to the two redlines: no assistance in self-destruction (whether gradual or immediate) and no assistance in mutilation.
That is all, however. Beyond that, the patient is sovereign and the physician’s duty is to be the servant. Which is why the doctors in Singapore were right to try to separate the twins. They were not seeking self-destruction; they were seeking liberation. And they were trying to undo a form of mutilation imposed on them by nature. The extraordinary thing about their request was that it was so utterly ordinary. They were asking for nothing special, nothing superhuman, nothing radically enhancing of human nature. They were only seeking to satisfy the most simple and pedestrian of desires: to live as single human beings.
The twins suffered from an error of nature, a mistake in individuation. They were asking for nothing more than the possibility of solitude. To risk everything for this was perfectly rational—indeed, an act of nobility and great courage. Their doctors were assisting heroism, not suicide. They should feel no guilt, only sorrow that victory once again went to nature, in all its cruelty.
Time, July 21, 2003
About a decade ago, a doctor friend was lamenting the increasingly frustrating conditions of clinical practice. “How did you know to get out of medicine in 1978?” he asked with a smile.
“I didn’t,” I replied. “I had no idea what was coming. I just felt I’d chosen the wrong vocation.”
I was reminded of this exchange upon receiving my med-school class’ 40th-reunion report and reading some of the entries. In general, my classmates felt fulfilled by family, friends and the considerable achievements of their professional lives. But there was an undercurrent of deep disappointment, almost demoralization, with what medical practice had become.
The complaint was not financial but vocational—an incessant interference with their work, a deep erosion of their autonomy and authority, a transformation from physician to “provider.”
As one of them wrote, “My colleagues who have already left practice all say they still love patient care, being a doctor. They just couldn’t stand everything else.” By which he meant “a never-ending attack on the profession from government, insurance companies, and lawyers…progressively intrusive and usually unproductive rules and regulations,” topped by an electronic health records (EHR) mandate that produces nothing more than “billing and legal documents”—and degraded medicine.
I hear this everywhere. Virtually every doctor and doctors’ group I speak to cites the same litany, with particular bitterness about the EHR mandate. As another classmate wrote, “The introduction of the electronic medical record into our office has created so much more need for documentation that I can only see about three-quarters of the patients I could before, and has prompted me to seriously consider leaving for the first time.”
You may have zero sympathy for doctors, but think about the extraordinary loss to society—and maybe to you, one day—of driving away 40 years of irreplaceable clinical experience.
And for what? The newly elected Barack Obama told the nation in 2009 that “it just won’t save billions of dollars”—$77 billion a year, promised the administration—“and thousands of jobs, it will save lives.” He then threw a cool $27 billion at going paperless by 2015.
It’s 2015 and what have we achieved? The $27 billion is gone, of course. The $77 billion in savings became a joke. Indeed, reported the Health and Human Services inspector general in 2014, “EHR technology can make it easier to commit fraud,” as in Medicare fraud, the copy-and-paste function allowing the instant filling of vast data fields, facilitating billing inflation.
That’s just the beginning of the losses. Consider the myriad small practices that, facing ruinous transition costs in equipment, software, training and time, have closed shop, gone bankrupt or been swallowed by some larger entity.
This hardly stays the long arm of the health-care police, however. As of January 1, 2015, if you haven’t gone electronic, your Medicare payments will be cut, by 1% this year, rising to 3% (potentially 5%) in subsequent years.
Then there is the toll on doctors’ time and patient care. One study in the American Journal of Emergency Medicine found that emergency-room doctors spend 43% of their time entering electronic records information, 28% with patients. Another study found that family-practice physicians spend on average 48 minutes a day just entering clinical data.
Forget the numbers. Think just of your own doctor’s visits, of how much less listening, examining, even eye contact goes on, given the need for scrolling, clicking and box checking.
The geniuses who rammed this through undoubtedly thought they were rationalizing health care. After all, banking went electronic. Why not medicine?
Because banks deal with nothing but data. They don’t listen to your heart or examine your groin. Clicking boxes on an endless electronic form turns the patient into a data machine and cancels out the subtlety of a doctor’s unique feel and judgment.
Why did all this happen? Because liberals in a hurry refuse to trust the self-interested wisdom of individual practitioners, who were already adopting EHR on their own, but gradually, organically, as the technology became ripe and the costs tolerable. Instead, Washington picked a date out of a hat and decreed: Digital by 2015.
As with other such arbitrary arrogance, the results are not pretty. EHR is health care’s big-government boondoggle. Many, no doubt, feasted nicely on the $27 billion, but the rest is waste: money squandered, patients neglected, good physicians demoralized.
Like my old classmates who signed up for patient care—which they still love—and now do data entry.
The Washington Post, May 29, 2015
Surgeons in West Virginia have gone on strike to protest the exorbitant cost of malpractice insurance. Good for them. Don’t talk to me about the ethics of doctors going on strike. So long as they agree to treat emergency cases, they have as much right to strike as anybody else. The premise of a free market is that people can withhold their labor if they find the conditions under which they work intolerable.
Many doctors do. Many, especially those in the inherently risky specialties, such as surgery or obstetrics, have been forced out of business by malpractice premiums or hounded out by malpractice litigation. A totally irresponsible legal system, driven by a small cadre of lawyers who have hit the mother lode, has produced perhaps the most dysfunctional medical-liability system in the world. Juries hand out millions of dollars not just for lost earnings but also in capricious punitive damages in which the number of zeros attached to the penalty seems to be chosen at random.
As a result, innocent doctors who have devoted their lives to their patients are required to spend tens, even hundreds, of thousands of dollars a year on insurance. In effect, we are making doctors give up an entire chunk of each year laboring just to work off their insurance premiums. Why? To cover for the few offenders in their midst. To compensate the lucky few victims who stumble upon the most profligate juries. And, most important, to make a few trial lawyers very, very rich. (Herewith the requisite full disclosure: I am a doctor, though I no longer practice.)
This is not a hard problem to fix. Tort reform is not rocket science. A reasonable bill passed the House of Representatives just last year but died in the Senate, where the trial-lawyer lobby rules. The elements of a fix are simple: no limit on plaintiffs’ lost earnings or other costs, a reasonable cap on pain and suffering ($250,000 in the House bill), a similar cap on punitive damages, serious penalties for frivolous lawsuits.
For years, such remedies have had a tough time getting through legislatures, which are—surprise!—peopled overwhelmingly by lawyers. That is why you have never heard of a lawyers’ strike. Lawyers have assured themselves pretty good working conditions. Some of my friends who graduated with me from medical school in the mid-’70s are working 50 to 60 hours a week, almost as hard as they did as interns, just to make ends meet: to pay their rent and nurses and other office expenses on the highly reduced reimbursements they get from HMOs, Medicare and Medicaid. And then a huge part of what is left over goes to pay for malpractice insurance.
But the frustration of doctors is more than a matter of money. The real blow to the profession has been the assault on autonomy. Physicians spend endless days and long years acquiring an extraordinarily specialized skill and then find themselves being told by some 23-year-old HMO administrator a thousand miles away how many minutes they can spend with a patient, how long they can keep him in the hospital and what kind of treatment they are allowed to give him. The introduction of managed care may be societally necessary to keep down costs. But we should at least recognize its cost to the dignity and effectiveness of the profession it regulates. Forgive my obsession here, but lawyers would never put up with faraway bureaucrats dictating their methods and setting their fees.
A doctor wants to strike no more than does a textile worker. But the malpractice burden—indeed, the malpractice threat—is the final assault on the implicit contract society makes with its healers: You give up the best decade of your youth, your 20s, to treat the sick and learn your craft, and we will allow you to practice it with autonomy, dignity and the kind of security—and freedom from capricious victimization—that, oh, say, lawyers enjoy.
Of course there will be medical errors. And there will be medical malefactors. The bad doctors need to be found, punished, defrocked. But why should their sins be paid for by the good doctors among them?
The current system is crazy, ruinous and unfair. And it is easily changed. By lawyers.
Time, January 13, 2003
It seems elementary, but a science—like the Party—must have unity, at least in the fundamentals. Chemistry cannot have two periodic tables. Physics will not permit believers in 19th-century ether. Alchemy is not an elective at MIT.
Indeed, perhaps the most important event for the development of a science is the dying away of its schools. Biology could not mature if split between Darwinian and Lamarckian schools of heredity. It was not until that battle was settled—the Lamarckians fell on their swords and were carted away—that biology could take off as a science.
Which brings us to psychotherapy, the science of the talking cure, now turning a ripe 100. Psychotherapy has had quite the opposite development. It opened for business, as it were, a century ago next spring, when Sigmund Freud opened his consulting room at Berggasse 19. What began in one great mind and one great room has proliferated wildly into…well, let the Great Phoenix Gathering tell the story.
A few weeks ago in Phoenix an extraordinary conference was held to mark the anniversary of the opening of Freud’s office. It was called, optimistically, “The Evolution of Psychotherapy.” Seven thousand psychotherapists showed up to see and hear the largest assembly of gurus in history.
It was the greatest concentration of psychotherapeutic talent to gather in one place since Freud dined alone. The leaders of every major school, more than two dozen in all, were there. Rollo May, Bruno Bettelheim, Virginia Satir, R. D. Laing, Carl Rogers. They represented every technique: Freudian therapy, family therapy, behavior therapy, existential therapy. Even Thomas Szasz was there, representing, I suppose, pseudo-therapy, since he believes that mental illness is a myth. (Szasz once outlined his approach to the patient who comes to him and says he is Jesus: “I say he is lying.”) For a science, evolution means development toward some deeper unity. This jamboree of jousting sects and one-man shows might more properly have been called the devolution of psychotherapy. It showed what these hundred years have wrought: “a babel of conflicting voices,” to quote Joseph Wolpe, a founder of behavior therapy.
Psychotherapy has come upon this state of confusion because, true to its healing, understanding soul, it permits too few deaths among its schools. It is incapable of killing its own. Psychotherapy is dying of dilution.
So what? Business is good and the intellectual ferment brings new techniques (“a new crop every year from California,” noted Wolpe wryly) to serve new patients. Who cares whether psychotherapy is a science? Let’s see. A few intellectual purists. A few nostalgics, who respect Freud’s original vision of psychoanalysis as a scientific technique.
Oh, yes. And one 800-pound gorilla: the insurance companies. As psychotherapy grew more popular, it grew more expensive for insurers. By the mid-’70s, with every psychotherapy school claiming incomparable (in both senses of the word) results, and with bills mounting and premiums rising, insurers began cutting coverage. But finding no way to separate the elite from the quacks, they cut the subsidy to all the schools.
Fifteen years ago in Washington, you could get insurance to cover 80% of unlimited psychotherapy. Around then, when I told a psychiatric colleague (at the time, I was a psychiatrist) that I would be coming to Washington to work for the government, he smiled and said, “Now you can get the Big Tune-up.” I was puzzled. He explained: With insurance paying 80% and no limit on visits, why not go for it: five-days-a-week psychoanalysis. Redo the engine.
I answered that my engine felt okay, and I did not want anyone poking around under the hood. But today it wouldn’t matter. The Big Tune-up is gone. You can barely get a lube job. Insurers have generally cut coverage to 50%, with severe limits on visits.
As long as psychotherapies resist pressure to produce scientific evidence that they work, the economic squeeze will tighten. After all, if psychotherapy is really an art, it should be supported by the National Endowment, not by Blue Cross.
The first to face economic extinction will be the longer-term therapies, such as, ironically enough, Freudian analysis. Where it ends, though, is not clear. My hope is that society will not totally abandon support for psychotherapy as a form of treatment. In my own experience, some psychotherapies (behavior therapies, in particular) helped my patients, some dramatically. But mine is anecdotal evidence, and there is not a school that cannot produce a bagful of glowing affidavits. What is needed is real science.
Unfortunately, psychotherapy shows little sign that it is inclined to reverse the direction of its disastrous anti-scientific evolution. Phoenix didn’t help. In fact, it makes clear that, as an intellectual and perhaps soon as an economic enterprise, psychotherapy in its 100th year is deep into its twilight.
The Washington Post, December 27, 1985
In the liberal remake of Casablanca, the police captain comes upon the scene of the shooting and orders his men to “round up the usual weapons.”
It’s always the weapon and never the shooter. Twelve people are murdered in a rampage at the Washington Navy Yard, and before sundown Senator Dianne Feinstein has called for yet another debate on gun violence. Major opprobrium is heaped on the AR-15, the semiautomatic used in the Newtown massacre.
Turns out no AR-15 was used at the Navy Yard. And the shotgun that was used was obtained legally in Virginia after the buyer, Aaron Alexis, had passed both a state and federal background check.
As was the case in the Tucson shooting—instantly politicized into a gun-control and (fabricated) Tea-Party-climate-of-violence issue—the origin of this crime lies not in any politically expedient externality but in the nature of the shooter.
On August 7, that same Alexis had called police from a Newport, Rhode Island, Marriott. He was hearing voices. Three people were following him, he told the cops. They were sending microwaves through walls, making his skin vibrate and preventing him from sleeping. He had already twice changed hotels to escape the men, the radiation, the voices.
Delusions, paranoid ideation, auditory (and somatic) hallucinations: the classic symptoms of schizophrenia.
So here is this panic-stricken soul, psychotic and in terrible distress. And what does modern policing do for him? The cops tell him to “stay away from the individuals that are following him.” Then they leave.
But the three “individuals” were imaginary, for God’s sake. This is how a civilized society deals with a man in such a state of terror?
Had this happened 35 years ago in Boston, Alexis would have been brought to me as the psychiatrist on duty at the emergency room of the Massachusetts General Hospital. Were he as agitated and distressed as in the police report, I probably would have administered an immediate dose of Haldol, the most powerful fast-acting antipsychotic of the time.
This would generally have relieved the hallucinations and delusions, a blessing not only in itself, but also for the lucidity brought on that would have allowed him to give us important diagnostic details—psychiatric history, family history, social history, medical history, etc. If I had thought he could be sufficiently cared for by family or friends to receive regular oral medication, therapy and follow-up, I would have discharged him. Otherwise, I’d have admitted him. And if he refused, I’d have ordered a 14-day involuntary commitment.
Sounds cruel? On the contrary. For many people living on park benches, commitment means a warm bed, shelter and three hot meals a day. For Alexis, it would have meant the beginning of a treatment regimen designed to bring him back to himself before discharging him to a world heretofore madly radioactive.
That’s what a compassionate society does. It would no more abandon this man to fend for himself than it would a man suffering a stroke. And as a side effect, that compassion might even extend to potential victims of his psychosis—in the event, remote but real, that he might someday burst into some place of work and kill 12 innocent people.
Instead, what happened? The Newport police sent their report to the local naval station, where it promptly disappeared into the ether. Alexis subsequently twice visited VA hospital ERs, but without any florid symptoms of psychosis and complaining only of sleeplessness, the diagnosis was missed. (He was given a sleep medication.) He fell back through the cracks.
True, psychiatric care is underfunded and often scarce. But Alexis had full access to the VA system. The problem here was not fiscal but political and, yes, even moral.
I know the civil libertarian arguments. I know that involuntary commitment is outright paternalism. But paternalism is essential for children because they don’t have a fully developed rational will. Do you think Alexis was in command of his will that night in Newport?
We cannot, of course, be cavalier about commitment. We should have layers of review, albeit rapid. But it’s both cruel and reckless to turn loose people as lost and profoundly suffering as Alexis, even apart from any potential dangerousness.
More than half of those you see sleeping on grates have suffered mental illness. It’s a national scandal. It’s time we recalibrated the pendulum that today allows the mentally ill to die with their rights on—and, rarely but unforgivably, take a dozen innocents with them.
The Washington Post, September 20, 2013