Mind-Body Dualism

In every generation since Richard Cabot initiated medical social work at the Massachusetts General Hospital in 1905, humane physicians and medical ethicists have inveighed against mind-body dualism and mechanistic approaches to medicine. But dualism and a decidedly second class citizenship for mind have had remarkable staying power. Powerful preaching on behalf of an integrated view of our human species and elegant conceptualizations like George Engel's biopsychosocial model have not slain the dualistic dragon.

But dualism and neglect of mind may finally be on the way out. Our capacity to look inside the skull with magnetic resonance imagining is bringing about the change.

An article by Matcheri Keshavan and colleagues - "Neuroprotective Effects of Cognitive Enhancement Therapy Against Gray Matter Loss in Early Schizophrenia" - in the July issue of the Archives of General Psychiatry, reports on a two year study in which patients early in the course of schizophrenia but already significantly impaired were randomized to "cognitive enhancement therapy," an integrated approach to the remediation of cognitive impairment in schizophrenia that uses computer-assisted neurocognitive training and group-based social-cognitive exercises, or "enriched supportive therapy." All patients were treated with antipsychotic medications.

Not surprisingly, patients who received the cognitive enhancement therapy showed gains in cognitive and social function. But MRI studies over the course of two years showed significantly greater preservation of grey matter in several areas of the brain and increased grey matter in some key locations. In other words, a psychosocial intervention caused physical changes in the brain.

As an undergraduate studying philosophy and psychology I learned the riddle: "What's mind? It doesn't matter. What's matter? Never mind!" But studies like the one Keshavan reports show that words and thoughts are not wimpy ephemera compared to "the real thing" (drugs). They show up in our wiring and have the power to generate physical changes as well as emotional reactions.

Creating a better balance between mechanical intervantions with drugs, devices and other technologies and the interactive, interpersonal components of medicine won't come about easily. Too many economic interests are at stake in our worship of mechanism and contempt for mind. But the combination of a heightened understanding of the power of mind and dissatisfaction with the soul-less health system we've created will be a powerful force for change.

Judge Vaughn Walker's Decision about California Proposition 8

I recently read all 136 pages of Judge Vaughn R. Walker's decision in which he found that California's Proposition 8 is unconstitutional. Prop 8, enacted by a 52 to 48 percent margin in 2008 consists of 14 words: "Only marriage between a man and a woman is valid or recognized in California."

Judge Walker was nominated to the court by President Reagan in 1987. Ironically, his nomination stalled in the Senate Judiciary Committee. Because he had represented the U.S. Olympic Committee in its suit of the proposed "Gay Olympics" over use of the Olympic name, Walker was regarded as "insensitive to gays." President George H.W. Bush renominated him to the Federal District Court in Northern California in 1989, and he was unanimously confirmed.

Judge Walker's opinion made me proud of the U.S. Here is the gist of his extended analysis:

The evidence shows that the movement of marriage away from a gendered institution and toward an institution free from state-mandated gender roles reflects an evolution in the understanding of gender rather than a change in marriage. The evidence did not show any historical purpose for excluding same-sex couples from marriage, as states have never required spouses to have an ability or willingness to procreate in order to marry. Rather, the exclusion exists as an artifact of a time when the genders were seen as having distinct roles in society and in marriage. That time has passed...

Plaintiffs do not seek recognition of a new right. To characterize plaintiffs’ objective as “the right to same-sex marriage” would suggest that plaintiffs seek something different from what opposite-sex couples across the state enjoy —— namely, marriage. Rather, plaintiffs ask California to recognize their relationships for what they are: marriages...

The evidence at trial shows that domestic partnerships exist solely to differentiate same-sex unions from marriages. A domestic partnership is not a marriage; while domestic partnerships offer same-sex couples almost all of the rights and responsibilities associated with marriage, the evidence shows that the withholding of the designation “marriage” significantly disadvantages plaintiffs...

In the absence of a rational basis, what remains of proponents’ case is an inference, amply supported by evidence in the record, that Proposition 8 was premised on the belief that same-sex couples simply are not as good as opposite-sex couples. Whether that belief is based on moral disapproval of homosexuality, animus towards gays and lesbians or simply a belief that a relationship between a man and a woman is inherently better than a relationship between two men or two women, this belief is not a proper basis on which to legislate...

The evidence shows conclusively that Proposition 8 enacts, without reason, a private moral view that same-sex couples are inferior to opposite-sex couples...“[L]aws of the kind now before us raise the inevitable inference that the disadvantage imposed is born of animosity toward the class of persons affected.”). Because Proposition 8 disadvantages gays and lesbians without any rational justification, Proposition 8 violates the Equal Protection Clause of the Fourteenth Amendment.

...Proposition 8 was premised on the belief that same-sex couples simply are not as good as opposite-sex couples. Whether that belief is based on moral disapproval of homosexuality, animus towards gays and lesbians or simply a belief that a relationship between a man and a woman is inherently better than a relationship between two men or two women, this belief is not a proper basis on which to legislate.

Two of my good friends in high school killed themselves in their 20s. Despair and shame about their sexuality was a major factor in their deaths. A college friend who spent several painful years trying to turn himself into a heterosexual described how at our 25th reunion he went to a dance sponsored by the gay and lesbian student association. Seeing gay and lesbian couples dancing together made him cry for the time he had wasted in the closet. One of my best friends in medical school was a closeted gay man. I can remember his terror that if he was "found out" his medical career would be ruined before it started. And in my psychiatry residency (in the mid 1960s) we were taught that if a gay or lesbian patient did not want to work on changing their sexual orientation there was no point in undertaking psychotherapy!

I found Judge Walker's opinion inspiring - not because of soaring rhetoric (there isn't much) - but because of the systematic way in which he considers the factual basis for prohibiting same sex couples to marry. He finds the arguments on behalf of prohibition lack any plausible basis in fact, and concludes that Prop 8 is based on the kind of faulty moral outlook that contributed to the deaths of my high school friends, that terrified my friend in medical school, and that I encountered in the teaching we received in residency.

I hope that over time Judge Walker's decision proves to be the final stake in the heart of our malignant history of anti-homosexual social prejudice.

Doctor-Patient Sex and Quality of Care

The Providence (Rhode Island) Journal blog reported that Dr. Brian Kwetkowski, a family physician, relinquished his medical license after it was revealed that he had conducted a three-year affair with a patient. The affair started when the patient was 19.

I found the comments about the blog post fascinating. I've copied them here, with my own comments written in bold italics:

Ernie said: "Doctors have affairs with their patients all the time in soap operas. Dr. Kwetkowski should apply as a soap opera actor now that he's done this in real life." (I don't follow soap operas, but it would be interesting to know how these affairs are handled. Is the exam room presented as an acceptable boy meets girl/boy meets boy/girl meets girl venue? If so it would make for good soap drama but terrible public education about professional ethics.)

Providence said: "Why did the guy have to turn in his license? She was over 18 - old enough to consent to a relationship. Maybe that "relationships" law needs to be reconsidered. Doctors can fall in love with patients, can't they?" (Providence is right - Doctors can fall in love with their patients, with "can" meaning that (a) love feelings occur and (b) love feelings aren't morally reprehensible. The moral issue isn't what a physician feels, but what the physician does. I agree with Providence that a 19-year old is entitled to "consent" (or to "initiate"). But in my view, and the prevailing view of the medical profession and licensure boards, the physician is not allowed to be part of a sexual relationship with a patient.)


A Patient said: "my opinion to this is (and I have every right to it! - that the female patient is and was an adult when this started and this obviously was consensual. I hate the fact that I'm loosing the one doctor that really meant a great deal to me and my family all because of this. How many doctors or any other professionals out there has had an affair, big friggin'deal! It's their life and they shall do with it as they will, who are we to judge?? It is none of our business. That mother should just deal with the fact that her daughter did this as an adult and mommy should have dealt with the daughter. What skeletons are hiding in your closet? Shall someone probe into your life? Or is mommy just looking for a financial boost in her bank account?" (Dr. Kwetkowski's patient makes several important points here: (1) If we knew the facts we might conclude that the affair was indeed consensual. It would be condescending to assume that the affair must have been exploitative. (2) The patient sees no basis for the ethical perspective I argued for in a recent post - that sexual relationships with patients are wrong quite apart from whether the patient is harmed. The patient appears to be putting what I see as a professional relationship that entails distinctive obligations into the framework of market exchange between consenting adults, within which anything the two parties agree to is OK. (3) The patient invokes a teaching I agree with - "let he or she who is without sin cast the first stone." I do not conclude from the fact of the affair that Dr. Kwetkowski is an evil human being, but I do conclude that he violated his ethical responsibilities as a physician. (4) The patient reports having received excellent care from Dr. Kwetkowski. There's no reason to doubt this.)

Linda Tente said: "Dr. Briam Kwetowski is my phsician. He has been my doctor since 2001. He is the most efficient, knowledgeable, honest, trustworthy, caring humanitarian and family doctor anyone could know. I can't imagine having anyone else as my doctor. I don't know the circumstances that put him in this awkward position, but I do know the public does not have to be protected against him. My God he saves lives and families. He heals and protects his patients. Who of us has lived our lives without personal indiscretions? This does not impact his ability to uphold the Hippocratic oath. Dr K hold your head high. I am sure once all the details are disclosed you will be vindicated. Me and my family cannot wait for this to be cleared up and you return to your office. I am proud to know you and be your friend as well as one of your loyal patients. Stay well!" (This is a very important comment. It amplifies the previous patient's praise of Dr. Kwetkowski. There's no reason to doubt that a physician who, like Dr. Kwetkowski, violates the prohibition of sexual relationships with patients might provide superb care to his other patients. Apparently that was true for Dr. Kwetkowski.)

I don't know if Dr. Kwetkowski has lost his license on a permanent basis. If I had been on the Rhode Island Board of Licensure I would have wanted to know more about the history of his practice. Was this affair a solitary event, or did he have a pattern of sexual involvement with patients? If it was a pattern I would have favored permanent loss of licensure. If it was a single event, if his practice performance was otherwise commendable, and if other factors suggested that he was capable of upholding professional expectations in the future, I would have been open to a time-limited suspension of licensure, followed by a supervised return to practice.

Medicalizing Normal Grief

I've never met Allen Frances, whose distinguished psychiatric career has included chairing the DSM IV Task Force and the Department of Psychiatry at Duke. But I've admired him ever since reading an article he wrote in 1981 - "No Treatment as the Prescription of Choice" - in which he discussed the range of human situations that involve distress or odd behavior but should not be brought under the microscope of psychiatric treatment.

Today Dr. Frances has an Op Ed in the New York Times that challenges the way the American Psychiatric Association draft of DSM V is construing the relationship between grief (a "normal" process) and major depression (an "illness"). My admiration for his lucidity and good sense holds steady. Here's the gist of his argument:

Suppose your spouse or child died two weeks ago and now you feel sad, take less interest and pleasure in things, have little appetite or energy, can’t sleep well and don’t feel like going to work. In the proposal for the D.S.M. 5, your condition would be diagnosed as a major depressive disorder.

This would be a wholesale medicalization of normal emotion, and it would result in the overdiagnosis and overtreatment of people who would do just fine if left alone to grieve with family and friends, as people always have. It is also a safe bet that the drug companies would quickly and greedily pounce on the opportunity to mount a marketing blitz targeted to the bereaved and a campaign to “teach” physicians how to treat mourning with a magic pill.

...Because almost everyone recovers from grief, given time and support, this treatment would undoubtedly have the highest placebo response rate in medical history. After recovering while taking a useless pill, people would assume it was the drug that made them better and would be reluctant to stop taking it. Consequently, many normal grievers would stay on a useless medication for the long haul, even though it would likely cause them more harm than good.

The bereaved would also lose the benefits that accrue from letting grief take its natural course. What might these be? No one can say exactly. But grieving is an unavoidable part of life — the necessary price we all pay for having the ability to love other people. Our lives consist of a series of attachments and inevitable losses, and evolution has given us the emotional tools to handle both...It is essential, not unhealthy, for us to grieve when confronted by the death of someone we love.

...Turning bereavement into major depression would substitute a shallow, Johnny-come-lately medical ritual for the sacred mourning rites that have survived for millenniums. To slap on a diagnosis and prescribe a pill would be to reduce the dignity of the life lost and the broken heart left behind. Psychiatry should instead tread lightly and only when it is on solid footing.

Wise thoughts, wonderfully well articulated!

Accountable Care Organizations and Medical Ethics In New Hampshire

The action in health reform has passed to the states.

Twenty states, nineteen of them led by Republican Attorney Generals cultivating future election prospects, are hoping to return to the past, and are fighting a rear guard action against the federal reform law. (See here.)

Others, like New Hampshire, are moving forward.

In July, Governor John Lynch announced a five year pilot program to move the state away from fee-for-service reimbursement by establishing five accountable care organizations in different parts of the state. Here's what the Governor had to say about launching the ACO experiment:

"Right now, we're not spending our health care dollars the right way and through this pilot project we are going to work together in New Hampshire to change that. Our current health care system rewards providers for seeing as many patients as possible. We're going to change that. Under this pilot project, we are moving to a system where health care providers will profit from spending time with their patients and keeping them healthy - and that's the way it should be. This Accountable Care Health Organization Pilot Project seeks to be competitive in getting a piece of incentive grants in the federal Obama health care reform law to reward providers that bend the cost curve.

Two years ago, I challenged health care and insurance industry leaders to work with us to develop a New Hampshire solution for improving quality and reducing the growth in health care costs. Everyone at the table recognized that our current health care system was not working for business, for providers or patients. That's why we are taking action to change our health care system now, the New Hampshire way, by working together."

The key phrase in the Governor's comments is "working together." Improving our health system requires a population health perspective and new forms of collaboration among stakeholders. Reform isn't rocket science, but it requires cooperation and substantial political courage. That's what the tea leaves suggest is happening in New Hampshire. The provider community, citizen health organizations, employers, health insurers, and the University of New Hampshire Institute for Health Policy and Practice are all part of the initiative.

The first year of the five year pilot is devoted to planning. I expect that anticipating the ethical opportunities and challenges of the ACO structure will be part of the planning process. Heather Staples, who supports the ACO pilot on behalf of the New Hampshire Citizens Health Initiative, pointed the way to the ethics discussion:

"Right now, we pay for care when someone shows up. We don't pay for care when they don't ever come in. What we want is for people to be managed in a thoughtful way outside of when they come into the emergency room."

Having health and health care "managed in a thoughtful way" is exactly what the health system needs. But different parties will hold different perspectives on the right way to manage. Physicians will want wider information about their patients. Insurers will want to be able to reach out to the insured population. Employers will want to encourage employees to be active on behalf of their own health. And each of us, as individuals, will have our own views about privacy and the relationships we want to have with our physicians, insurers and employers.

In the 1990s, the U.S. asked insurers to take the lead in having health care "managed in a thoughtful way." The experiment blew up because we didn't have all stakeholders at the table for open deliberation about competing values. New Hampshire, with its strong tradition of respect for individual autonomy (the state motto is - "Live free or die"), isn't going to repeat the mistake we made with managed care 1990s style!

Justice and Full Vindication for Whistleblowing Nurses

In February I wrote about how physician Rolando G. Arafiles, hospital administrator Stan Wiley, and Winkler County (west Texas) Sheriff Roberts tried to intimidate and prosecute two whistleblowing nurses who complained about the care Dr. Arafiles was providing. (See here and here.)

It took the jury one hour to acquit the one nurse who was brought to trial. (Charges against the other were dropped before the court date.)

The nurses then sued the hospital, Dr. Arafiles and Mr. Wiley for vindictive prosecution and denial of First Amendment rights. This week the defendants settled out of court for $750,000. In the meanwhile, the Texas Board of Medicine has charged Dr. Arafiles with numerous violations.

The two nurses have not been able to find other jobs. But Dr. Arafiles is still employed by the unrepentant hospital.

Steven Slater, Air Travel, and Organizational Ethics

One day after Jet Blue flight attendant Steven Slater cursed out a passenger, grabbed a beer, and then bolted from the plane by sliding down the emergency exit chute after the passenger (a) took his out luggage too soon, (b) didn't follow Slater's directive to stay seated and (c) let the overhead compartment door fall onto Slater's head, Slater has become an international celebrity.

Apparently the chute could have injured or even killed anyone who was standing under it if it came down on top of them, so what Slater did was recklessly dangerous. But Jesse James and other folk heroes actually murdered people, which makes Slater more deserving of folk stardom than they were. A Facebook legal defense fund for Slater is raising money hand over fist.

Airline passengers and flight attendants see themselves as fellow victims of airline efforts to cut costs. High unemployment means that flight attendants have fewer job choices, and a poor transportation system reduces choices for passengers. Everyone feels trapped and helpless. That's where Steven Slater comes in. He refused to be helpless and bucked the system in dramatic fashion.
Twenty-seven years ago in "The Managed Heart: Commercialization of Human Feeling," Arlie Hochschild described how flight attendants were trained to "produce" positive emotions on the job. It's much harder for attendants to do that under current working conditions. There's no established code of conduct for passengers, but passenger civility is also down.

The social compact around airline travel is badly frayed. Slater's theatrical exit from the Jet Blue flight won't change the price of fuel or other aspects of airline economics, but it may be a wake-up call for airline personnel management.

Many years ago I was chairing a meeting of 10-15 people in my office. My phone rang, and when I picked it up a colleague immediately started to harangue me about a trivial problem. I forgot that I was leading a meeting, yelled "don't you dare talk to me like that," and slammed the phone down. Later I told a colleague how disturbed I was to have erupted that way. My wise colleague said - "it was really a good thing - people will say 'Sabin is usually a reasonable and fair-acting guy, but every now and then he goes ballistic if he's pushed too hard, so keep yourself in line!'"

Reasoned, evidence-based argument is the preferred way to point out organizational failures and promote change. But change doesn't come easily. Organizational ethics also needs Steven Slaters who go over the top in a way that's hard to ignore.

(For the original New York Times story, see here.)

Mental Health Parity Won't Work Without Ethical Managed Care

It's hard to tell the "good guys" from the "bad guys" in implementing the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act.

The act, signed into law by President Bush in October 2008, requires employers with more than 50 employees who offer health insurance that includes mental health, to cover mental health and addiction conditions on the same terms as medical/surgical conditions. The law rectifies clinically unwise and ethically unjustifiable insurance practices I experienced from early in my practice.

In the 1970s I was responsible for an inpatient psychiatric unit at a public hospital. Nearby private hospitals regularly transferred patients to us after twenty-nine days, one day before they hit the insurance limit of thirty days. We called that "dumping." And when I moved to the Harvard Community Health Plan HMO we worked within the typical limit of twenty outpatient visits per year.

In some ways the limit stimulated efficiency and creativity. Along with others we pioneered time-limited therapies. I had the privilege of developing an outpatient program for patients with chronic psychiatric illnesses built around a flexible "continuing care" group. But for many patients the limit didn't allow patients to achieve outcomes reasonable to hope for in a society as wealthy as ours.

Advocates fought for "parity" with medical/surgical coverage. Their argument was straightforward. Mental health and substance abuse conditions caused suffering and disability comparable to medical/surgical conditions. Effective treatments were available. Selectively disadvantaging mental health care could not be justified on clinical or ethical grounds.

The bugaboo was cost. Employers and insurers feared that mental health and addiction care would be a bottomless pit. But when President Clinton required the Federal Employees Health Benefits Program to provide parity, costs did not soar. (see here) Managed care became the advocates' best friend!

Managed mental health care, which made parity possible by showing that costs could be contained to an acceptable level, is the focus of the implementation fight. The implementation rules can be found in an arcane forty-three page document, but the fight is over these fifty-seven words:

Any processes, strategies, evidentiary standards, or other factors used in applying the nonquantitative treatment limitation to mental health or substance use disorder benefits in a classification must be comparable to, and applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used in applying the limitation with respect to medical surgical/benefits in the classification.

Clinicians hate "nonquantitative" management techniques like closed networks, requirements that less costly therapies be tried first, and recurrent treatment reviews. But management techniques like these, which are not used to the same extent in medicine/surgery, made parity possible. Advocates now argue, however, that parity means similar care management techniques, not just similar benefits in the insurance contract.

This argument risks an employer backlash:

Woodman's Market, a grocery store chain that employs 2,800 people and is based in Janesville, Wis., is among [the employers considering dropping mental health coverage].

"We can't have an open checkbook," company vice president Clint Woodman told the Capital Times in Madison.

"If an employee went to a psychiatrist and ran up a million dollars, it would come out of our pockets," he said.

When asked about an employee who incurred similar expenses after a cancer diagnosis, Woodman said in the Capital Times: "Cancer is different. That's an identifiable physical situation."

Paradoxically, a tough-minded manager would say - "The advocates are right. Mental health and medicine/surgery should be managed by the same means. Since health costs are out of control, let's bring the tougher mental health approach to medicine and surgery!"

This won't happen. We tried widespread third party managed care in the 1990s, and while it slowed the cost trend for a few years, providers and the public rebelled, and we chucked the approach, except in mental health.

The big picture of what we need to do is clear. Providers, as through "Accountable Care Organizations," must take more direct responsibility for cost management along with care management. And patients who want more choices than that system allows should have those choices available, but at their own expense.

"The Kids are All Right" and Doctor-Patient Sex

A few days ago my wife and I saw the new film "The Kids are All Right" at the charming little (100 or so seats) Savoy Theater in Montpelier, Vermont. It's an engaging, funny-but-serious family comedy, centered on Nic (Annette Bening) and Jules (Julianne Moore), a middle-aged lesbian couple, their children - 18-year Joni (Mia Wasikowska) and 15 year-old Laser (Josh Hutcherson) - and Paul (Mark Ruffalo), their sperm-donor father. The kids set the plot in motion by making secret contact with Paul. The rest is a form of chaos, misunderstanding, conflict and reconciliation most folks who've been in a long term relationship will recognize.

I'm not going to review the film, but I promise that you'll enjoy it. (If you want more than my word, here are links to reviews in the New York Times and the New Yorker.)

What struck me as relevant to medical ethics was a moment when the five characters are having dinner. Paul asks Nic and Jules how they met. We already know that Nic, the bread winner, is a hard-working, rigid, wine-loving OB/GYN, while Jules is the slightly flaky and lost homemaker. It turns out that they met in the UCLA emergency room. Nic was a resident doing an ER rotation. Jules was a sexy young student scared because her tongue was numb. (We're left to imagine what she'd been doing with her tongue.) Nic cures her with a Valium and some teasing. The rest is history. Joni and Laser groan - they've heard the story so many times.

(FYI, in the 1960s I did a year of medical internship at UCLA. I remember a UCLA student a bit like Jules who came to the ER in her pink undies with chest pain that I was wise enough to recognize as a panic attack.)

So is anything wrong here? Nic and Jules are an attractive, responsible couple, bringing up attractive, responsible kids. They're screwed up, but only in the way most people are. One would be happy to have them as friends.

The prevailing fashion in medical ethics is to dwell on "unequal power relationships," "transference," "idealization of the doctor," "rescue fantasies," and the likelihood of doing harm to the patient, as the rationale for precluding moving from the exam room to the bedroom.

But there's no reason to doubt that a romantic relationship that started in a doctor-patient context could work out just as well (or badly) as relationships that start in all the other "normal" ways relationships get going. Love entails risks, but that's not unique to romance between doctors and patients. I learned that from seeing "South Pacific" as a kid when I heard Emile (Ezio Pinza) sing "Some Enchanted Evening" after meeting Nellie (Mary Martin). There would have been no more reason to warn Nic and Jules about getting involved after they met in the ER than if they'd met at a GLBT mixer or had been fixed up on a blind date.

Here's what might have transpired if Nic had consulted me after she'd met Jules in the UCLA ER:

Nic: Jim, I want to ask your advice. Last night in the ER I met a girl who seemed exactly right for me. Her name is Jules. She's smart, pretty, sexy, and we really hit it off. I really want to date her. It may sound crazy, but I can picture spending my life with her and having kids with her..."

Jim: Nic - you've told me that you feel ready to settle down when you meet the right person. If we had a crystal ball it might tell us that you and Jules were made for each other and would live happily ever after. Of course it might say something different, but that's always the case. I feel sad saying this, but I don't think you should contact her. There are two big reasons. First, Jules came to the ER because she was scared about her tongue and trusted us to look after her. Patients tell us secrets they haven't told anyone else, and let is touch them in ways we'd never let strangers touch us. You did a great job relieving Jules's symptoms and helping her understand what was going on. To carry out our responsibilities and do things like you did, we physicians need to be trusted. If patients don't trust us to respect boundaries and stay in our professional role they won't open up the way Jules did with you and we won't be able to help them the way you did for Jules. Second, part of our vocation is to put patients first. A relationship with Jules might work out well, but it might not. If you'd met her in a bar or at a party I'd congratulate you and say "good luck - go for it!" But you met her as a doctor, so primum non nocere applies. You wouldn't prescribe a medicine for Jules that might break her heart, so you shouldn't "prescribe" a relationship that could do that!

My guess is that Lisa Cholodenko, the director and co-author of "The Kids are All Right," put in the ER detail to show that Nic is a romantic at heart, not just a rigid, up-tight scold. If I can find Cholodenko's email address I'll send her the post and ask her.

WikiLeaks and Medical Ethics

WikiLeaks, the secure website that publishes documents leaked by whistleblowers, has been front page news since it published 92,000 secret Pentagon documents from Afghanistan. Its founder - Julian Assange - is a fascinating person. He, and the WikiLeaks venture, have a lot to teach about organizational ethics. (My information and quotes come from a terrific New Yorker article about Assange by Raffi Khatchadourian.)

My goal for this blog (and for much of my work) is the same as Assange's - to improve the ethical performance of organizations and public agencies. But our world views and methodologies are so different that I fear Assange would describe me as he described physicists at a conference he attended - "sniveling fearful conformists of woefully, woefully inferior character."

I operate from the quality improvement perspective - the belief that most people in health care want to do the right thing, but may be impeded by faulty systems, which include intellectual/ethical constructs as well as production processes. My methodology is analysis, teaching, and advocacy.

Assange's world view is much darker. Here's how Khachadourian describes it:

He [came] to understand the defining human struggle not as left versus right, or faith versus reason, but as individual versus institution. As a student of Kafka, Koestler, and Solzhenitsyn, he believed that truth, creativity, love, and compassion are corrupted by institutional hierarchies, and by “patronage networks”—one of his favorite expressions—that contort the human spirit. He sketched out a manifesto of sorts, titled “Conspiracy as Governance,” which sought to apply graph theory to politics. Assange wrote that illegitimate governance was by definition conspiratorial—the product of functionaries in “collaborative secrecy, working to the detriment of a population.” He argued that, when a regime’s lines of internal communication are disrupted, the information flow among conspirators must dwindle, and that, as the flow approaches zero, the conspiracy dissolves. Leaks were an instrument of information warfare.

Assange learned this outlook early. His mother "believed that formal education would inculcate an unhealthy respect for authority in her children and dampen their will to learn." She told Khatchadourian "I didn't want their spirits broken." When Assange was eleven his mother separated from his stepfather, who she feared was part of a dangerous cult. "Assange recalled her saying, 'Now we need to disappear,' and he lived on the run with her from the age of eleven to sixteen." By the time Assange was fourteen they had moved thirty-seven times.

Assange's mission is to expose injustice, and injustice is everywhere. Because he sees injustice and exploitation as the basic truth about the world, the default position for organizations and governments, he rejects the Hippocratic injunction to "first, do no harm." His precept is "first, fight tyranny!"

His mission is to expose injustice, not to provide an even-handed record of events. In an invitation to potential collaborators in 2006, he wrote, "Our primary targets are those highly oppressive regimes in China, Russia and Central Eurasia, but we also expect to be of assistance to those in the West who wish to reveal illegal or immoral behavior in their own governments and corporations." He has argued that a "social movement" to expose secrets could "bring down many administrations that rely on concealing reality—including the US administration."

Assange does not recognize the limits that traditional publishers do. Recently, he posted military documents that included the Social Security numbers of soldiers, and in the Bunker I asked him if WikiLeaks’ mission would have been compromised if he had redacted these small bits. He said that some leaks risked harming innocent people—"collateral damage, if you will"—but that he could not weigh the importance of every detail in every document. Perhaps the Social Security numbers would one day be important to researchers investigating wrongdoing, he said; by releasing the information he would allow judgment to occur in the open.

To those for whom harm perpetrated against individuals by government and large organizations is the default expectation, primum non nocere is Pollyanna foolishness.

Assange's ethic is that of public health, not clinical medicine. His passion is for social justice, and in pursuing that aim, individuals will inevitably be injured.

Societies need ferocious warriors for justice like Assange, but his stance of constant vigilance and deep suspiciousness come at a high cost - isolation, fear, and vulnerability to despair. Societies also need gentler leaders who expect imperfection, meet individuals and organizations where they are, and ask them to become better, more in tune with their ideals.

That's the Yin and Yang of organizational ethics!