A related set of questions arises regarding the medical secrets of deceased presidents. For instance, several US presidents have been rumored to have sired illegitimate children. The possibility that President Grover Cleveland fathered a boy, Oscar, with a woman named Maria Crofts Halpin made the chant “Ma, Ma, where’s my pa?” a rallying cry of the 1884 election campaign. President Warren G. Harding’s reputation was tarnished by the posthumous accusation, leveled by Nan Britton in The President’s Daughter (1927), that the married Harding was the father of her daughter, Elizabeth Ann. For many years, surviving relatives of Harding disputed Britton’s claim. However, DNA testing in 2015 firmly established a close genetic link between both sets of heirs, solving a long-standing historical mystery.
Not all interest in the DNA of historical figures relates to paternity. A prominent California cardiologist and medical historian, John Sotos, has made a plausible case that Abraham Lincoln suffered from a rare genetic disorder, multiple endocrine neoplasia, type 2B. DNA testing on surviving Lincoln artifacts, such as the now-bloodstained cloak he wore to Ford’s Theatre on the night of his assassination, might shed light on this hypothesis and might explain Lincoln’s psychological state in the later years of his public service, but the owners of these artifacts have proven reluctant to permit such testing. Revealing the secrets of past presidents may clarify the historical record, but might also have an impact on living relatives—such as the discovery that the family might still carry a genetic disorder. Another factor in the ethics of revealing secrets related to deceased political leaders might be whether survivors knew the deceased figure personally or hold some other direct connection to him. As time passes, under this latter standard, the claims of survivors will become more tenuous.
While the specific ethical questions Dr. Eckleburg faces will arise rarely, the broader implications for public trust in physicians are significant. Few people will likely withhold confidences from their psychiatrists for fear that they will be used against them in a presidential run, but many patients outside the public eye might withhold information if they fear their secrets could be shared with others.
Individuals with bipolar disorder, when appropriately treated, can live extremely productive lives, and many such individuals hold high positions in the public sector. Rather than breach the candidate’s confidentiality, another approach might be for Dr. Eckleburg to reach out to the candidate and his current physicians directly—to ascertain whether he is truly untreated or is merely deceiving the public about his treatment. If the candidate is untreated and dangerous, a reasonable case could then be advanced for revealing the diagnosis to the public. The argument for breaching confidentiality is far weaker if the candidate is merely lying, which, unfortunately, places him in the company of many other politicians.
6
“The Worst Patient Ever”
Dr. McKenna runs a dialysis clinic. His clinic provides life-prolonging artificial kidney treatments to hundreds of patients each week. Most are very appreciative. Lucinda is the rare exception. She is, in the words of Dr. McKenna’s head nurse, “the worst patient ever.” Lucinda often appears at the clinic drunk, or high on cocaine. Even when she arrives clean and sober, she frequently hurls racist and anti-Semitic comments at the staff and at other patients. On several occasions, when she was upset, she pulled dialysis tubing out of the arm of the patient in the neighboring bed, so now she must receive treatment alone in the far corner of the clinic under the watch of a nursing assistant. She refuses a psychiatric referral, but she does not appear to Dr. McKenna to be mentally ill, merely an extremely unpleasant person. Still, multiple efforts by Dr. McKenna over two years have failed to achieve a working relationship with Lucinda.
One afternoon, when she feels the staff has kept her waiting for treatment too long, Lucinda topples several chairs in the waiting area and breaks a glass coffee table. Dr. McKenna has had enough; he decides that he will no longer provide treatment for Lucinda. However, with her history, it’s possible that no other hospital or clinic will assume care for her. Without dialysis, she will eventually die.
Is it ethical for Dr. McKenna to give Lucinda notice that he will stop providing dialysis for her in six months, whether she can find another dialysis provider or not?
Reflection: Patient Conduct
Physicians in private practice have broad latitude to choose which patients they treat, as long as they do not discriminate on the basis of protected statuses like race or religion. This freedom is subject to the criticism that physicians are generally sheltered from market forces by the government—through various mechanisms (e.g., limitations on medical-school class sizes and residency positions, retraining requirements for physicians educated abroad, etc.) that keep the number of doctors artificially low and, hence, fees artificially high. Having the talent to practice medicine is not enough to acquire a medical license or hang up a shingle; one must also meet lengthy and complex credentialing requirements designed to constrain entry into the field. Since doctors do not operate in a free market, but rather as part of a protected guild, some commentators argue they should have charitable service obligations connected to their licensure. However, no such mandates exist. This contrasts with the duty of hospitals, which under the Emergency Medical Treatment and Labor Act (EMTALA) of 1986, must stabilize every patient who comes through their doors.
Once a patient is already under the care of a particular physician, certain safeguards do exist to shield that patient from abandonment. As a general principle, a doctor can “fire” a patient as long as she affords the patient reasonable time and opportunity to find another provider. In psychiatry, for instance, six months is generally considered an ample interval to arrange alternative care. Usually, doing so is not difficult. Yet some patients, for a variety of reasons, will face practical challenges in managing such a transition. Sometimes, a patient’s mental status or healthcare literacy will prove so limited that she cannot be expected to find a new provider on her own. A patient suffering from dementia, for example, should not be asked to seek a different neurologist unaided. Under such circumstances, the original provider may be expected to assist with the transfer of care.
A very small number of patients find no alternative options. In one high-profile 2009 case, Grady Memorial Hospital in Atlanta closed a dialysis clinic that served many undocumented immigrants who were ineligible for treatment elsewhere. The ensuing court battle saw some of these patients repatriate, others move to states with more lenient Medicaid policies, and a few rely on hospital emergency rooms for urgent dialysis. In California, a dialysis patient with severe addiction and behavioral problems, Brenda Payton, was “fired” by her dialysis clinic for unruly behavior, even though no other provider would accept her. A California appeals court ruled in favor of her doctors in 1982. While such a precedent is not legally binding outside of California, it may offer guidance to courts in other states.
Whatever Dr. McKenna ultimately decides about Lucinda, he can take comfort in knowing that courts and professional associations, while they generally look unfavorably upon doctors who abandon patients recklessly or for pecuniary gain, have historically been sympathetic in cases where a patient’s conduct was both egregious and relentless.
7
“I’d Never Actually Do It, But …”
A new patient, Danny, comes to Dr. Maturin, a family medicine physician, complaining that he is having trouble sleeping, is frequently agitated, and cannot concentrate at work. In explaining his symptoms to her, Danny starts to describe his sexual fantasies involving his seventeen-year-old stepdaughter. He reveals that he sometimes gets up at night and watches her as she sleeps. He also mentions that he daydreams about lying down next to her and fondling her breasts. “I don’t think I’d actually do anything,” says Danny. “I’m ninety-nine percent sure.” He later says, “You won’t tell anyone about my fantasies, will you? If my wife knew, she would leave me—and I do love her very much, even if I am unhappy with our sex life.”
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br /> Doctors in Dr. Maturin’s state are expected to report a “reasonable suspicion” of child abuse or neglect to the state’s child welfare agency.
Should Dr. Maturin report Danny’s conduct, knowing that the state will investigate and that Danny’s wife will likely learn of his fantasies?
Reflection: A Doctor’s Duty to Report
Although reports of child abuse have peppered medical literature as far back as the nineteenth century, the issue did not receive widespread attention among physicians until the publication of a groundbreaking paper, “Battered Child Syndrome,” by pediatrician C. Henry Kempe, radiologist Frederic N. Silverman, and psychiatrist Brandt F. Steele in 1962. Their paper galvanized the public. By 1967, every state had passed a mandatory-reporting statute, requiring physicians to disclose suspected abuse. The federal government passed its own law, the Child Abuse Prevention and Treatment Act (CAPTA) in 1974, making state reporting requirements a prerequisite for certain federal funds. Many statutes require healthcare providers—and others involved in childcare, such as teachers and social workers—to report a reasonable suspicion of abuse or neglect, leaving to the state authorities the responsibility of determining whether mistreatment actually occurred. Such mandatory disclosure differs from rules regarding other forms of abuse. In some states, for example, physicians not only face no requirement to report spousal abuse, but they are prohibited from doing so. The reason advanced for this distinction is that battered adults can make their own decisions regarding the risks and benefits of reporting mistreatment, while children are not yet able to do so.
The definition of child abuse is clear at the extremes; on the cusp between abuse and discipline, however, a gray area exists. The public became privy to this liminal space in the controversy surrounding Minnesota Vikings running back Adrian Peterson, who faced criminal charges in 2014 for whipping his four-year-old son with a switch. The football star maintained that such punishment was within the community standard, but ultimately pled no contest to a misdemeanor assault charge. Corporal punishment remains legal in nineteen states, and in 2014 Deborah Kotz reported in the Boston Globe that as recently as 2012, “77 percent of men, and 65 percent of women agreed that a child sometimes needs a ‘good hard spanking.’ ” Certain cultural practices can also be mistaken for abuse, including “cupping” and “coining”—alternative medical therapies that leave temporary marks on the skin. The challenge in potential child-abuse cases is that underreporting places children’s lives in danger but overreporting runs the risk of significantly damaging innocent families. The investigation process, which often involves removing children from their parents’ homes, is not benign.
Danny has placed Dr. Maturin in a difficult spot by revealing his fantasies. On the one hand, he has not yet acted on them—and may never do so. Dr. Maturin must decide whether the 1 percent chance that her patient reports that he might act on these fantasies at some hypothetical point in the future constitutes a “reasonable suspicion” of child abuse. If Dr. Maturin believes so, she must report Danny. Mandatory-reporting laws are per se rules, which afford no discretion. On the other hand, considerable subjectivity—and, hence, discretion—exists in determining whether Danny’s behavior meets the “reasonable suspicion” standard. So despite mandatory-reporting laws, physicians often still find themselves bearing the weight of such no-win decision-making.
8
Sleeping with the Doctor
Rita is a fifty-seven-year-old woman in outpatient therapy with a veteran psychiatrist, Dr. Stockmann. Rita is a shy and anxious divorcée who often describes herself as being “insignificant” or “worthless,” and states that she has always been inhibited about sexual involvement. In fact, she reveals to Dr. Stockmann that she has had only one fulfilling romantic relationship in her entire life. Fifteen years ago, she had gone to a different outpatient psychiatrist, Dr. Praetorius, for treatment of her social anxiety. After a month of weekly therapy, Dr. Praetorius said to her: “I can’t continue to treat you, because I find you too attractive. But I would love to start seeing you romantically.” The pair then dated clandestinely for two years, until Dr. Praetorius broke off the relationship. Rita believes that he “fell in love” with another patient, although she cannot prove this. She has no regrets about her relationship with Dr. Praetorius, except that it ended, and demands that Dr. Stockmann not share her secret.
Sexual relationships between psychiatrists and patients or former patients are considered malpractice and often result in the physician losing his or her license. Dr. Praetorius was a leading psychiatrist in the community, but he has recently retired. He continues to serve on various committees and advisory boards, although he is no longer treating patients.
Should Dr. Stockmann report Rita’s allegations to the state medical board, despite her insistence that he not do so?
Reflection: Doctor-Patient Attraction
Ethical norms and many state laws prohibit sexual relationships between healthcare providers and their patients. For instance, California bans marital and family therapists from having such relationships until two years after treatment has ceased. The American Psychological Association’s Ethics Code similarly forbids relationships between psychologists and patients for at least two years after their last professional contact—and even then, such relationships are permitted only under the “most unusual circumstances” where the psychologist can establish that there has been no exploitation. The rules governing psychiatrists in the US are even more stringent: they may never have sexual relationships with people they have treated. States have refused to carve out exceptions, even for providers who marry patients long after treatment terminated. The argument for a blanket per se rule is that such relationships inherently “mismanage the transference” between doctor and patient—a fancy way of saying that, even after psychotherapy ceases, doctor and patient are never equals.
Rules governing psychiatrist-patient sex were far more fluid until the 1970s. Many prominent figures in the psychiatric field, including Carl Jung and Bruno Bettelheim, are alleged to have had affairs with their patients; a 1972 study by psychiatrist Sheldon H. Kardener found that 10 percent of Los Angeles psychiatrists admitted to sexual relations with individuals under their care. The American Psychiatric Association did not formally prohibit such relationships until 1973. Only with the case of Roy v. Hartogs in 1975 (later the basis for the NBC movie Betrayal, starring Rip Torn and Lesley Ann Warren) did the profession fully turn against doctors like Renatus Hartogs, who was accused of using his office as a pickup lounge. Yet such conduct persists: former APA president Jules Masserman was sued in the 1980s by four former patients for sexual misconduct; psychiatrist Jack Gorman, the president of Harvard’s McLean Hospital, surrendered his license in 2007 following such an affair.
Most psychiatrists and ethicists now view therapist-patient sex as unethical—although some disagreement remains regarding relationships with former patients pursued after a lengthy passage of time. The issue of romantic relationships with the close relatives of patients has also become a concern, with at least one state medical board penalizing the practice. Most states require physicians to report knowledge of the misconduct of colleagues; much of the time, if one discovers a fellow psychiatrist is sleeping with a patient, one has a moral obligation to report that transgressor to the state. Yet the situation is more difficult in cases such as Rita’s, where Dr. Stockmann has learned of the alleged conduct during the course of therapy, and where the patient is actively discouraging him from taking any action.
Physicians have considerable leeway in breaching confidentiality to prevent serious future dangers to the health or safety of others. If Dr. Praetorius were still treating patients, Stockmann might face a difficult task of determining whether protecting the public from his renegade colleague would justify the damage he might cause to his therapeutic relationship with Rita. As Dr. Praetorius is not actively engaged in patient care anymore, the risk to the public appears much lower. (Of course, Dr. Praetor
ius might still return to practice someday.) Under such circumstances, most—but not all—ethicists would argue against divulging Rita’s secret. At the same time, Dr. Stockmann may wish to work with his patient to persuade her to take the matter to the licensing board on her own, an act which might both serve justice and prove therapeutic.
9
A Physician with a Dark Past
As an eighteen-year-old, Hugh became involved with a neo-Nazi street gang and eventually killed a member of a rival gang in a shoot-out. He was convicted of voluntary manslaughter and served three years of a fifteen-years-to-life sentence before a judge freed him on a technicality. During his time in prison, Hugh earned a GED; after his release, he worked his way through college and graduated with high honors in biology and physics. He is now twenty-seven and wants to become a physician. He takes the MCAT—the admissions test for medical schools—and receives nearly a perfect score. In his applications, he explains that he regrets his past actions and rejects any affiliation with white supremacism.
If not for his criminal past, Hugh would almost certainly gain admission to an excellent US medical school. While many states do not permit convicted felons to practice medicine, because Hugh committed his crimes prior to medical school admission, it is possible that a state would defer to the judgment of the medical-school admissions process in determining his eligibility to practice. If Hugh graduates from medical school, he may become a licensed physician.
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