Two bulletins crossed my desk this morning. In one, a child urgently needing convulsive therapy had to go to court to get it. In another, an Afghan family was baffled by “informed consent.”
In our desire to force doctors to be professional we’ve created a web of inappropriate rules that serves patients ill and poisons the doctor-patient relationship.
Consider the legal restrictions on convulsive therapy for children and adolescents: In some states you can get it only via the courts (or as in California and Texas you practically can’t get it at all, so restrictive are the rules).
Why is this?
It’s because well-meaning legislators, seeking to protect children from the “shock-docs” made getting permission from the court compulsory. The child psychiatrists and pediatricians were seen as the enemies of the children, the lawyers and judges as the friends. So to get ECT, you have to go into court well lawyered-up. This is very expensive and time-consuming. A child who is pounding his head against the wall – and who will respond to ECT -- will be brain-damaged long before the judge’s ruling.
In this morning’s email, the judge was actually quite accommodating, and, my correspondent writes, “when the parent showed videos and then removed the patient’s equipment [to keep him from hitting himself], his attorney actually started crying. These legal folks were unaware that individuals can suffer from such behavior.”
The judges themselves are often bewildered by these petitions and understand nothing of medicine. They often cannot even pronounce the names of the drugs used in ECT, such as succinylcholine, the muscle relaxant. Yet the law says they have to approve the drugs too! And in a few months the whole charade starts all over again, as new “permission” is necessary. We don’t do this with penicillin, and ECT is the penicillin of psychiatry.
Consider “informed consent.” It’s supposed to protect patients from Nazi medical experiments. Hey, that was 200 years ago! We don’t do those anymore. Patients must now “be consented” – as the expression goes – to everything. It has become a meaningless ritual, and actually protects the doctors themselves more against lawsuits than the patients against abusive medical practice.
And every time a physician or a nurse shoves a consent form across the table to a patient or their family, the doc is thinking, “These people could mean trouble.” The reflexes on both sides of the table that these consent forms arouse are toxic and anti-therapeutic. This hurts the care of patients, who once thought of physicians as their protectors rather than as malignant devils in white coats.
I learned this morning that in one academic medical center on the East Coast, an Afghan family found all the permissions and rules baffling. Every time the doctor would phone for a new “informed consent” to change medication for their son, the boy’s father “would chastise me,” said the physician, “and ask me why in the world I was contacting him. He knew nothing about medications or psychiatry, and just wanted me to prescribe what was necessary.”
Poor simpleton! He didn’t understand that the rules were supposed to protect him and his family against doctors wildly out of control who were scheming against their patients. But thank God that we have the lawyers and the medical ethicists on hand to insert themselves in the doctor-patient relationship and tell everyone what to do.
“You’ve sworn the Hippocratic Oath, doctor?” Doesn’t matter. We’ll make doubly sure you don’t put anything over on your patients.
Both sets of regulations – on ECT and on informed consent – are based on the assumption that physicians must be forced by law to behave professionally. And if we don’t have legal oversight, the doctors will act in their patients’ worse interests by shocking them senseless or taking Josef Mengele – the Nazi horror doctor – as a role model.
Before the Second World War, physicians enjoyed extraordinary community stature. The doctor trudging through the snowy night in a house call was seen as the epitome of humanitarian selflessness. That we have this senseless, purposeless web of regulation now is a testimony to have far medical prestige has sunken. The patient’s best friend is now the lawyer and the hospital “ethicist.”