Sunday, December 16, 2007

Ethics-Easier Said than Done

Although I consider myself a good general physician, as well as being very good in my chosen specialty, I am neither a psychiatrist nor a pediatrician. Since this blog deals a lot with issues concerning autism, I don't usually put on my "doctor" hat here. But sometimes some subjects get to me not just as the parent of my autistic son, but also as a physician.

The recent episode of the NYU Child Study Center's (together with its director, Dr. Harold Koplewicz) "Ransom Notes" campaign raises serious ethical concerns that I think need to be addressed. Kristina Chew over at Autism Vox summarized many of the excellent responses by the autism community to these ill conceived ads. I'm going to address this purely from the perspective of a fellow physician.

I have always considered the ability to practice medicine a privilege that is granted me by society. Having been granted that privilege, I, like all physicians, have certain responsibilities towards not only my own patients, but also to society in general.

The American Medical Association, as one of the major professional associations of physicians in the US, publishes Principles of Medical Ethics which all physicians are expected to adhere to. I'd like to take a few minutes here to review some of what is stated in that document. Here's one section that I found:

E-9.123 Disrespect and Derogatory Conduct in the Patient-Physician Relationship

The relationship between patients and physicians is based on trust and should serve to promote patients’ well-being while respecting their dignity and rights. Trust can be established and maintained only when there is mutual respect.

Derogatory language or actions on the part of physicians can cause psychological harm to those they target. Also, such language or actions can cause reluctance in members of targeted groups to seek or to trust medical care and thus create an environment that strains relationships among patients, physicians, and the health care team. Therefore, any such conduct is profoundly antithetical to the Principles of Medical Ethics. ...

On its website NYU's Child Study Center (CSC) gives good lip service to subscribing to the above principle:

Our key goals include:

* Increasing the body of scientific knowledge about child mental illness
* Eliminating the stigma of being or having a child with a psychiatric disorder
* Improving the practices of professionals serving children
* Influencing child-related public policy

How does that square with the "Ransom Notes" campaign, where they have ads such stating things like:

We have your son.

We will make sure he will
not be able to care for
himself or interact socially
as long as he lives.

*This is only the beginning.


Now I might expect something like the above ad twenty years ago, or perhaps now from someone who is totally ignorant regarding current concepts in autism. But from a major medical center's Department of Child Psychiatry? Never. Such rhetoric is blatantly wrong, totally derogatory, and sure to increase discrimination against all autistics. To hide behind a justification of "increasing awareness" is disingenuous at best, and outright lying at worst.

The "Ransom Notes" campaign is all about publicity. Whether it's viewed as primarily advertising for NYU's CSC (which I do), or as a public service message, the following section of the AMA's Principles of Medical Ethics addresses this point.

E-5.02 Advertising and Publicity

...Aggressive, high-pressure advertising and publicity should be avoided if they create unjustified medical expectations or are accompanied by deceptive claims. The key issue, however, is whether advertising or publicity, regardless of format or content, is true and not materially misleading. ...

Again, the gross factual inaccuracy of the description of autism renders this ad unethical.

When it comes to Psychiatry, the World Psychiatric Association also has some things to say regarding ethics. This comes from them commenting on psychiatrists and the media:

• Psychiatrists addressing the media. The media has a key role in shaping the attitudes of the community. In all contacts with the media psychiatrists shall ensure that people with mental illness are presented in a manner which preserves their dignity and pride, and which reduces stigma and discrimination against them. An important role of psychiatrists is to advocate for those people who suffer from mental disorders. ...

Keep the above in mind while reading this:

We have your daughter.

We are making her wash her hands until
they are raw, every day.

This is only the beginning.


We have taken your son.

We have imprisoned him in
a maze of darkness
with no hope of ever
getting out. Do nothing
and see what happens.


Preserving dignity and pride? Reducing stigma and discrimination? Not in my book.

Now from Googling Harold Koplewicz and reading about him, before this I wouldn't have thought him a bad guy. He's written several books, including one titled "It's Nobody's Fault:New Hope and Help for Difficult Children and Their Parents". He's a Vice Dean, Full Professor, and Department Chairman at a prestigious university, and has received numerous awards from various groups, and has appeared often on mainstream media. He's not some fly by night practitioner of woo that I would expect such claptrap from.

But now I'm going to address the good doctor directly.

Harold, I may be a simple country doctor in flyover country, but I gotta tell ya. Your reputation alone isn't going to get you thru this one. It's time to "man up", take the hit, and admit that you got this whole campaign totally wrong. Everyone can make a mistake, and you made a big one. Being "edgy" doesn't cut it when the ads going out in your name are full of untruths and are frankly unethical in their demeaning portrayal of those with a variety of conditions. Accept responsibility, apologize sincerely, and go on. Do so, and people will listen and be willing to start a dialogue with you. Keep delaying, and this will only get bigger. You've succeeded in uniting and galvanizing widely disparate groups of people against this campaign, and secondarily against you.

Be the physician your record would indicate you have been. Do the right thing.


Anonymous said...

Excellent post. One of the best ones I've read on the subject and much more likely to persuade a fellow physician in my opinion.

kristina said...

The last paragraph is worth its weight in internet traffic (I don't think that makes sense, but I think you get what I mean).

Anonymous said...

This is easily the best post on this matter that I have seen thus far. Thank you.

Bearing upon the issue of ethics, I was surprised to discover yesterday that Koplewicz co-authored the rather notorious Paxil Study 329 for Glaxo Smith Kline, thus helping the pharma juggernaut to bury crucial data concerning the dangers of the drug, inflate estimates of its effectiveness, and thus misrepresent its value as a treatment to government, doctors, patients and the general public.

Hardly a coincidence that Paxil has been among the most profitable pharmaceutical products in the history of health care. And, oddly enough, it turns out that the ad agency, BBDO, which produced the NYU "Ransom Notes" campaign also represents GSK.

Earlier, in watching this debacle unfold, I wanted to be fair and allow for the possibility of good intentions, even despite the outlandish nature of the campaign. Now I'm forced to conclude that my patience and restraint, along with that of so many other concerned citizens, has been sorely misplaced. And I'm willing to bet, sadly, that there is simply no appeal, however polite or rationally compelling, that can reawaken him to his ethical obligations.

I hope I'm wrong.

But at this point, I see little hope for satisfactory resolution short of harsh censure by the medical establishment, and perhaps legal as well. And worst of all, owing to the overwhelming power of the key players in this matter, I see little hope of any significant resolution at all, amicable or otherwise.

Casdok said...

Yes excellent post!

Daisy said...

Thank you for your articulate statement. Well said -- as father and as physician.

Bev said...

Very well said. Thank you, Joe.

michele_k said...

An excellent post. It really shines a light on the matter of ethics and this campaign. Thank you.

VAB said...

Well though out and well stated! It also seems to point the way as to the next steps to be taken in correcting this wrong.

abfh said...

Great points, and very well stated! I wonder if any complaints have been filed with New York's medical board? Anyone know?

Sharon McDaid said...

Thanks for writing this fantastic post Joe. I hope the other doctor pays attention to your well made points.

Niksmom said...

Thanks for this very thoughtful post. I hope it garners the attention it deserves. Thought about sending it to the NY Times as a letter to the editor or as an editorial/opinion piece?

Jenny said...

Thank you from me, too. I hadn't thought about this in this manner. it doesn't really leave Dr. Kopleweicz and his friends a leg to stand on. They are totally out of line with this ad campaign.

kristen spina said...

Kind of sheds a whole new light on how wrong this campaign is. Thanks for a thoughtful and well-done post.

Ange said...

Agree. Great post.

Anonymous said...

NEXT STEPS - they are not hearing us

They have not responded to our requests to pull the campaign and it sounds like we are really emboldening Harold Koplewicz and his boss, Robert Grossman, appears to be letting Koplewicz see the campaign through. I found some contacts that are over both of their heads and we need to promote a major emailing, writing and phone calling campaign to Medical Center Board Chairman Kenneth Langone, NYU President John Sexton, and NYU Trustee Chairman Martin Lipton. Here is their contact info; PLEASE help get the word out.

Kenneth Langone, Board Chairman
New York University Medical Center
(212) 421-2500
375 Park Avenue, 22nd Floor
New York, NY 10152

Martin Lipton, Board of Trustee Chairman
New York University
(212) 403-1200
51 West 52nd Street, 29th Floor
New York, NY 10019

John Sexton, President
New York University
(212) 998-2345
70 Washington Square South, 12th Floor
New York, NY 10012

Patrick said...

Well said.

Now, I wonder if one has multiple conditions (as I do) that he/they are Stigmatizing/ Slandering/ Libeling if I could get multiple returns from any class action that may arise.

Club 166 said...

Thanks to everyone for your comments. I am writing letters and considering how to proceed from here. I agree that so far it seems that our voices have not been heard (or at least not taken seriously).


Jen P said...

Joe, I really appreciate this post and your pov. I have physicians in my family and I think they will like to see you perspective so if I may I will add you to my blogroll.

I just sent the link to my networking group president. When I made the announcement this morning they were all disgusted. Thanks for stopping by my post and leading me to your blog.

Marla said...

Wow! This is a truly amazing post. I think it is the best I have read covering this topic. I love your letter to the doctor directly.

Anonymous said...

Fabulous post! Sorry I missed it earlier. I think your particular professional insight carries a lot of weight. I would be glad to hear more in this vein, as you feel your limitations-by-specialty allow. (I mean really, it's so good to hear someone say they are not an expert in something out of their specialty, for a change!)