Guest pen
In medicine, the morally unthinkable is too easily normalized
Many of the most egregious ethical abuses of recent decades have occurred at medical centers with prominent bioethics programs.
This is how I remember it: the year is 1985 and some medical students are gathered around an operating table where an anesthetized woman has been prepared for surgery. The gynecologist in charge asks the group: “Has everyone palpated a cervix yet? This is your chance to do it.” One after another, we took turns inserting two gloved fingers into the unconscious woman’s vagina.
Had the woman consented to a pelvic examination? Did she know that when the lights went out she would be treated like a clinical practice dummy and a succession of untrained hands would feel her genitals? Don’t know. Like most medical students, I simply did what I was told.
Last month, the U.S. Department of Health and Human Services issued new guidance requiring written informed consent for pelvic exams and other intimate procedures performed under anesthesia. Much of the impetus behind this initiative came from dismayed medical students who find these pelvic exams unacceptable and mustered the courage to speak out.
I don’t know if the guideline will really change clinical practice. Medical traditions have a reputation for being difficult to eradicate, and academic medicine does not easily tolerate ethical dissent. I doubt the medical profession can be trusted to reform itself.
What drives one individual to oppose deceptive, exploitative, or harmful practices when everyone else thinks they are okay? For a long time, I assumed that saying “no” was primarily a matter of moral courage. The pertinent question was this: if you witness wrongdoing, will you have the courage to report it?
But then I started talking to internal sources who had reported abusive medical research. I soon realized that I had overlooked the importance of moral perception. Before you decide to report irregularities, you must be able to recognize them.
This is not as simple as it seems. Part of what makes medical training so unsettling is how often you find yourself in situations where you don’t really know how to behave. Nothing in your life up to that point has prepared you to dissect a corpse, perform a rectal examination, or deliver a child. Never before have you seen a psychotic patient sedated against her will and tied to a bed or a brain-dead body fresh from a hospital room to have her organs harvested for transplant. Your initial reaction is usually a combination of revulsion, anxiety and self-consciousness.
Taking up medicine is like moving to a foreign country where you don’t understand the customs, rituals, manners or language. Your main concern upon arrival is how to fit in and avoid offending. This is what happens even if local customs seem backward or cruel. What’s more, this particular country has an authoritarian government and a rigid status hierarchy in which dissent is not only discouraged, but also punished. Living happily in this country requires convincing yourself that any discomfort you feel comes from your own ignorance and lack of experience. Over time, you integrate completely. You may even laugh at how naive you were when you arrived.
Very few people hold on to that discomfort and learn from it. When Michael Wilkins and William Bronston began working at Willowbrook State School on Staten Island as young doctors in the early 1970s, they found thousands of mentally disabled children condemned to the worst conditions imaginable: naked children rocking and moaning in puddles of his own urine on concrete floors; an overwhelming stench of disease and filth; a research unit where children were deliberately infected with hepatitis A and B.
“It truly was an American concentration camp,” Bronston told me. However, when he and Wilkins attempted to recruit doctors and nurses from Willowbrook to reform the institution, they faced indifference or hostility. It seemed as if no one else on the medical staff could see what they saw. It wasn’t until after Wilkins went to a journalist and showed the world what was happening behind the walls of Willowbrook that something began to change.
When I asked Bronston how it was possible for doctors and nurses to work at Willowbrook without seeing it as a crime scene, he told me that it all started with the way the institution was structured and organized. “Physician-insured, administered and validated,” he said. Medical professionals simply conform to the status quo. “You adapt to the program because that’s what they hire you to do,” he said.
One of the great mysteries of human behavior is how institutions create social worlds where unthinkable practices become normalized. This is as true of academic medical centers as it is of prisons and military units. When we’re told about a horrible medical research scandal, we assume we’d see it the way whistleblower Peter Buxtun saw the Tuskegee syphilis study: as abuse so shocking that only a sociopath could miss it.
However, this is rarely the case. It took Buxtun seven years to convince others that these were abuses. For other whistleblowers it has taken even longer. Even when the outside world condemns a practice, medical institutions often insist that what is happening is that “outsiders” don’t really understand it.
According to Irving Janis, a Yale University psychologist who popularized the notion of groupthink, the forces of social conformity are especially powerful in organizations driven by a deep sense of moral purpose. If the organization’s goals are virtuous, its members consider it wrong to put obstacles in the way.
This observation helps explain why academic medicine not only defends researchers accused of wrongdoing, but sometimes also rewards them. Many of the researchers responsible for the most notorious abuses in recent medical history, such as the Tuskegee syphilis study, the Willowbrook hepatitis studies, the Cincinnati radiation experiments, and the Holmesburg prison studies, continued to receive professional praise even after the abuses had already been reported.
It is well known that the culture of medicine is resistant to change. During the 1970s, the solution to medical wrongdoing was thought to be formal ethics education. Major academic medical centers began establishing bioethics centers and programs throughout the 1980s and 1990s, and today virtually every medical school in the country requires ethics training.
However, it is debatable whether that training has had any effect. Many of the most egregious ethical abuses of recent decades have occurred at medical centers with prominent bioethics programs, such as the University of Pennsylvania, Duke University, Columbia University, and Johns Hopkins University, as well as my own institution, the University of Minnesota.
It is understandable to conclude that the only way the culture of medicine will change is for the changes to be imposed from outside: by oversight bodies, legislators, or litigators. For example, many states have responded to the controversy over pelvic exams by passing laws prohibiting the practice unless the patient has given explicit consent.
You may find it difficult to understand how pelvic exams performed on unconscious women without their consent can seem like anything more than a terrifying invasion. However, a central objective of medical training is to transform sensitivity. They teach you to fortify yourself against your natural emotional reactions to death and disfigurement; to let go of your usual views on privacy and shame; to see the human body as something to be examined, tested and studied.
One danger of this transformation is that you may see your colleagues and superiors do horrible things and be afraid to report them. But the subtler danger is that you no longer consider what they are doing horrible and end up thinking, “This is how it’s done.”
By recognizing and discussing these issues within the medical community, we can work towards a more ethical and compassionate practice. The normalization of unethical practices must be challenged, and true reform must be implemented.