Waste, Fraud, and Fish...

 

The high point of summers when I was a kid was fishing with my grandfather.  It was only about 4 or 5 hours but it was an adventure.  He had a 1933 Diamond-T flatbed truck that he used for his business that I have highlighted in a couple of places on this blog.  He also had a 14 ft. wooden boat built by the Peshtigo Boat Factory that he kept in immaculate condition.  He shellacked the interior and repainted the exterior every three years.  It always looked new.  He powered it with a 15 hp Johnson outboard motor.

Every fishing trip started the same way.  We put the boat and motor into the back of the Diamond-T, headed to the local bakery and picked up a dozen plain donuts or “fry cakes” as he would call them, and then drove out to Bad River where we put the boat in.  He knew several people with boat landings and occasionally we would just drop it in down a steep river bank from a dirt road.  We were always within a few miles on the upstream or downstream side of the U.S. Hwy 2 bridge.

Our fish of choice was walleye (Sander vitreus).  My grandfather’s preferred bait was June Bug spinners with nightcrawlers.  He and I usually used those with bait casting setups and 40 lb test nylon line.  The third person in the boat was a guest who in some cases would use exotic spin casting or spinning setups with many different artificial lures.  Bad River has a lot of snags and brush on the banks and that caused trouble for exotic lures cast great distances with monofilament line. 

We did not catch a lot of our preferred fish but there were plenty of other species to keep things interesting.   We typically caught and released them all except for the occasional walleye.  Between the fish biting we ate donuts and drank coffee.  There was always some kind of explanation for why we did not catch fish.  The water was too muddy or warm.  The river had been fished out with commercial gill nets. At one point there was talk of electrified nets and poison applied to catch or kill the sea lamprey (Petromyzon marinus). Sea lamprey are cartilaginous ancient parasitic fish that have been around for 340M years and survived all of the extinction events.  Before the advent of shipping canals in the mid-19^th century, Niagara Falls was a natural barrier to sea lamprey migration into the Great Lakes.  The first sea lamprey was discovered in Lake Superior in 1938 and in other Great Lakes earlier.  Sea lamprey have a devastating effect on the commercial and game fishery of the Great Lakes because of their reproductive success and success as a parasite.  Each lamprey can kill up to 40 lbs of game fish per year and reduce the fishing harvest to a fraction of what it should be.  The program to control sea lamprey is highly successful largely by controlling the larval forms that develop and migrate in various tributaries off the Great Lakes like Bad River.

What got me thinking about the sea lamprey again?  Over the past two days I was staying at a hotel on Lake Superior and noticed the parking lot had a small fleet of trucks from the US Fish and Wildlife Service (USFWS). Each pickup truck had SeaLampreyControl.org painted on the rear quarter panel.  When I saw all of these trucks, I was actively looking for the personnel driving them.  I was interested in how this program was able to survive the cuts of the Trump administration.   It seemed like an easy target.  Most people don’t know anything about the Great Lakes ecosystem or how it is scientifically monitored and managed.  Most people have no clue that as they are driving across Michigan’s upper peninsula and across northern Wisconsin into Minnesota that there are fishery biologists all along the way focused on that habitat and trying to keep it healthy.  The Trump administration has made it very clear that they don’t care about the environment or any of the associated science and in fact have open contempt for it.  But I was not able to find any of the staff driving those trucks so I decided to do my own research.  I have done limnology and freshwater biology and chemistry courses and research as an undergraduate – but this research was more straightforward.  I wanted to know if this program was a target of the Trump administration’s cuts.

The Department of Government Efficiency (DOGE) did target the U.S. Fish and Wildlife Service’s (USFWS) Sea Lamprey Control Program. In early 2025, 14 critical personnel (12 from USFWS and two from the U.S. Geological Survey(USGS)) were terminated right before the spring treatment cycle.  The Resolution highlights the fact that terminations and hiring freezes would reduce the lamprey control program by 1/3, leaving insufficient staff to implement the program and putting the Great Lakes fishery at great risk.  At least one reference states that the Trump administration was “ordered” to reinstate the fired workers (2).  Other sources suggest the cuts were potentially much larger and that Trump reversed them in January of 2026 by a bill. There is also supposed to be a paper trail of what happened in Congressional Committees and within the Department of the Interior / USFWS Memos.  But I can’t find any details about this.  I was eventually able to locate a press release about the firings and how they were reversed by court order.  The specific USFWS employees were mentioned (4).

My overall analysis based on limited information highlights the obvious lack of rational thinking. Before I had located any of the references, it seemed like the usual bad administrative exercise of just cutting an arbitrary number of people for the sake of making numbers. We know from DOGE headlines that this effort saved nowhere near the amount that they claimed and fired critical workers who had to be immediately rehired because the firings created a safety threat to the American people.  At first glance it seems like that is what happened to sea lamprey control. After the initial workforce reduction, the economic details presented in reference 1 were considered and the staff were rehired in order to prevent massive losses to the Great Lakes Fishery.  

But that is not what appears to have happened.  There was no rational thinking by the administration, only a legal technicality noted by a judge who said the administration does not have the power to fire staff from agencies outside the Executive Branch.  A Supreme Court decision eventually blocked reinstatement of probationary employees on a technicality.  So, no rational reversal of an irrational decision. To be clear, I am not sure that anyone knows the status of the fired employees from the USFWS and USGS.  I have sent an email to the USFWS to clarify what happened and I asked them specifically about whether sea lamprey control was at full strength.

My intent in writing this post is to focus squarely on the shortcomings of ideological decision making.  First, it short circuits rational decision making. Just looking at the economics – it makes no sense to stop a cost-effective government initiative that benefits a multibillion-dollar fishing and tourist industry.  That alone has value even without comparisons to how the current administration has squandered billions in tax dollars and continues to do so.  Second, the ethical dimension exists in the form of: “Is it ethical to stand by and watch the Great Lakes ecosystem destroyed and overrun by millions of parasitic fish?”  According to the numbers the sea lamprey is capable of this level of destruction.  The sea lamprey would not even be in the Great Lakes if it were not for government canal building initiatives bypassing Niagara Falls allowing the initial migrations.  At that level sea lamprey and other invasive species are a manmade problem and it seems like a serious ethical lapse to not want to prevent that catastrophic outcome.

This is one small example of what happens when you have ideological myopia. Allowing the destruction of the Great Lakes ecosystem would be consistent with this administration's approach to climate science, medical care, scientific and medical research, and international aid all based on an alleged financial gain. It is essentially running a government that should have benefits for the people - like running a business to produce benefits for only the favored few.  

It is hard to imagine a Great Lakes without Grandfathers and Grandchildren fishing.... 

 

George Dawson, MD, DFAPA

 

References:

1:  United States Committee of Advisors to the Great Lakes Fishery Commission. Resolution 25-01: A Resolution Calling for Full Support of the Great Lakes Sea Lamprey Control Program Including Full Restoration of Staff and an Exception to the Hiring Freeze in the United States to Implement the Critical Bi-National Control Program.  https://www.glfc.org/pubs/pdfs/resol2025_1.pdf

2:  Greco F.  U.S. firings reversed, yet Great Lakes Sea lamprey fight faces uphill battle.  CBC Lite April 4, 2025.  https://www.cbc.ca/lite/story/1.7501665

3:  Krumme M.  The invasive sea lamprey is poised for comeback in the Great Lakes.  Wisconsin Public Radio.  December 8, 2025. https://www.wpr.org/news/invasive-sea-lamprey-comeback-great-lakes-federal-funding

4:  Jenkins D.  Judge adds U.S. Fish and Wildlife to order curbing DOGE firings.  Capital Press.  March 3, 2025.  https://capitalpress.com/2025/03/03/judge-adds-u-s-fish-and-wildlife-to-order-curbing-doge-firings/

5:  Totenberg N, Gatti C.  Supreme Court lets Trump move forward with firing thousands of federal workers.  NPR News April 8, 2025.  https://www.npr.org/2025/04/08/nx-s1-5351799/scotus-probationary-workers

6:  Fritze J, Cole D Sneed T.  Supreme Court backs Trump for now on fired probationary federal employees.  CNN.  April 8, 2025.  https://www.cnn.com/2025/04/08/politics/probationary-fired-employees-supreme-court-trump

7:  Bijman V. The Sea Lamprey (Petromyzon marinus) Invasion: The Construction of an Invasive Animal Threatening a "Healthy" Great Lakes Ecosystem. J Hist Med Allied Sci. 2025 Oct 8;80(4):363-383. doi: 10.1093/jhmas/jrae046. PMID: 39889225; PMCID: PMC12504013.

“Although sea lamprey research, localized control practices, and environmental discourses considerably changed, the sea lamprey continued to be regarded as an invasive fish that was not allowed to exist in the Great Lakes.”

8:  Siefkes MJ. Use of physiological knowledge to control the invasive sea lamprey (Petromyzon marinus) in the Laurentian Great Lakes. Conserv Physiol. 2017 May 30;5(1):cox031. doi: 10.1093/conphys/cox031. PMID: 28580146; PMCID: PMC5448140.

9:  Dale P. Burkett, Jessica M. Barber, Todd B. Steeves, Michael J. Siefkes, Sea lamprey control 2020 – 2040: Charting a course through dynamic waters, Journal of Great Lakes Research, Volume 47, Supplement 1, 2021, Pages S809-S814,

“Delivery of a successful Sea Lamprey Control Program depends upon bi-national, government-funded operations and research and is contingent upon public understanding of the need for the Program and its ecosystem and economic benefits. Changing social, political, regulatory, and climatological environments present a host of strengths, weaknesses, opportunities, and threats requiring an array of responses.”

10:  F.B. Neave, R.M.W. Booth, R.R. Philipps, D.A. Keffer, G.A. Bravener, N. Coombs,  Changes in native lamprey populations in the Great Lakes since the onset of sea lamprey (Petromyzon marinus) control, Journal of Great Lakes Research, Volume 47, Supplement 1, 2021, Pages S378-S387,

The control of invasive sea lamprey in the Great Lakes basin has been highly successful, but has deleteriously affected native lamprey species. American brook, northern brook, silver and chestnut lampreys are all susceptible to lampricide treatments.

 

Supplementary 1:  It is widely known that Freud studied eels as a young biologist and in that process also studied the nervous system of the sea lamprey.  Here are some of Freud's original drawings:  https://chsi.harvard.edu/freud-riddle-eel

Supplementary 2:  The sea lamprey pesticides:  Are they toxic to dopaminergic neurons? 

TFM and Bayluscide, are specialized pesticides called lampricides. These are applied by agencies like the Great Lakes Fishery Commission to targeted streams and tributaries where young lamprey larvae hatch and develop.

 

• TFM (3-trifluoromethyl-4'-nitrophenol): This is the most widely used lampricide. It is a selective poison that disrupts the energy metabolism (mitochondrial decoupling) of sea lampreys at concentrations that leave most other native fish and organisms unharmed. Lampreys have a reduced capacity to detoxify the chemical.

 

• Bayluscide (niclosamide): Highly toxic lampricide that is often used in combination with TFM. By adding a small amount of Bayluscide to TFM, agencies can reduce the overall amount of chemical needed, keeping treatment methods highly effective and lowering costs. A granular time-release form is also used to treat deep, slow-moving waters or estuaries where TFM is less effective.

 

Both chemicals are regulated restricted-use pesticides that break down naturally in the environment and do not bioaccumulate.  Niclosamide has been suggested as a treatment for neurodegenerative disorders including Parkinsons and it a potential neuroprotectant:

 

Apolloni S, D'Ambrosi N. Repurposing niclosamide for the treatment of neurological disorders. Neural Regen Res. 2023 Dec;18(12):2705-2706. doi: 10.4103/1673-5374.373705. PMID: 37449632; PMCID: PMC10358648.

 

Does the Insurrection End the Debate on the Goldwater Rule?

 

I think it does and both sides lose.

As a refresher take a look at my earlier comments on the Goldwater Rule at this link.  More briefly, the Goldwater Rule was implemented by the American Psychiatric Association (APA) as ethical guidance to its members following an incident where a 1964 magazine survey of psychiatrists concluded that the Republican candidate Barry Goldwater was “psychologically unfit” to be President of the United States.  As you can see from the ad in this previous post, there was a strong implication by the Lyndon Johnson campaign that a Goldwater presidency would put the country on a path to nuclear war.  Goldwater subsequently sued the magazine and was awarded damages – three years after he lost the election.

In the meantime, the APA included the following section in the Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry.

Section 7.3

On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.

Since I wrote the original post, I have queried many colleagues who are also APA members and as far as I know no member has ever been sanctioned by the APA or any of its district branches for violating the Goldwater Rule.  There has been a lot of intense debate about it and that debate has never been as intense as during the recent Trump administration.  Beyond the debate there are unequivocal examples of psychiatrists ignoring the Goldwater Rule and, in some cases, criticizing the APA about it. The rhetoric extends to the point that the APA invented the rule because it was embarrassed about the original Goldwater incident and it was suppressing the free speech rights of its members who felt an ethical duty to use their skills to either warn or protect the United States from President Trump.  While some have found that rhetoric to be admirable, I do not. First, APA membership is completely voluntary and the obvious way to escape its long reach into First Amendment rights is to not be a member.  The predictable response to that suggestion is that all of the benefits of membership will be not be available and that might put non-members at a disadvantage.  Having been an APA member for over 30 years, I can attest to the fact that there are minimal advantages to being a member primarily as discounts to publications by the organization.  Even then, the American Medical Association (AMA) membership fee is much lower and includes free access to many more publications.

A second consideration is the context of what is happening.  In my previous post, I pointed out that psychiatrists are trained to assess problems in a particular context.  During years of training that comes down to a face-to-face discussion with the patient about problems that were either identified by the patient or someone else.  Collateral information is considered and that can be exhaustive. A diagnosis and problem formulation follows. Until the profiling of political leaders, criminals, and historical figures came into the scene in the past few decades there was no suggestion that psychiatrists could assess people at distance with any degree of accuracy. In fact, criminal profiling is generally done these days by trained law enforcement personnel suggesting that no psychiatric qualifications are necessary at all.  It all seems predicated on a folk psychology model that personality features and patterns of behavior are constant over time and dependent on past behavior. Some of the commentators on this issue have identified themselves as forensic psychiatrists. Forensic psychiatrists are paid to do even more exhaustive interviews and review of collateral information than clinical psychiatrists. They may take 15-20 hours to do an assessment compared with a clinical psychiatrist who probably has 60-90 minutes at the most. The idea that forensic psychiatrists endorse assessments at a distance seems even more incongruous to me.

Focusing only on the conclusory article (1) post insurrection it is clear why psychiatric opinion adds nothing to the political mix.  In the first paragraph, the authors conclude that Trump is “clearly mentally unbalanced and unable to grapple with a reality that threatens his inflated and fragile ego.”  They suggest that only reason that people would not believe their statement is that they ascribe his behavior to “puckish idiosyncrasy or creative disruption”.  That gives their statement way too much explanatory power. How about the obvious political considerations and Trump’s previous behavior as a businessman?  He is clearly a guy who is used to steamrolling over people and often uses the legal system to do it.  He demonstrated that in the primary and the debates.  He demonstrates it on a weekly basis toward anyone who he thinks is being disloyal – irrespective of their track record. He threw his Vice President under the bus for adhering to the Constitution that he was sworn to uphold. Who would describe that behavior as puckish?  Any objective observer would see that President Trump is a negative force and somebody that you do not want to deal with and hopefully would never be employed by. In political terms, he is an autocrat that deals in propaganda and he knows the power of propaganda. By definition, that is dangerous to any democratic republic but once again – it has nothing to do with psychiatry or the special training of psychiatrists.

The preamble in that conclusion: “clearly mentally unbalanced” is also rhetorical.  He has tens of millions of followers who all believe the propaganda. The authors themselves acknowledge that if Trump was a private citizen they would not be concerned and that their concern is only based on the fact that he was the President. This would be the first case of mental illness based on the condition of Presidency. The additional evidence in this article that Trump was “delusional”, “impulsive”, vengeance seeking, or “deranged” is non-existent and it can easily be argued that deficiency occurs as a direct result of not having personally examined him to ask him for direct explanations.   All of the examples cited are consistent with the behavior of a highly self-interested politician or businessman who will do anything to win. In the event that the authors have not noticed there are tens of thousands of these people walking around in American society. Possibly hundreds of thousands and none of them are being treated by psychiatrists.

The authors previous argument that they have an ethical responsibility to warn the public about Trump’s dangerousness based on a presumptive personality disorder falls apart under that scrutiny.  If there is no clear evidence of a diagnosis there seems to be no basis for the authors to base their actions on. Further Trump’s recent statement on the day of the insurrection and even since are no more radical than many of his colleagues or followers. Why are psychiatrists needed when there is nothing to base a professional opinion upon?

Early in the course of the Trump presidency, the issues arising with the Goldwater Rule were analyzed by Kroll and Pouncey (2).  After considering all of the variations their conclusion was that the Goldwater Rule was based on the need of the APA to prevent embarrassment to the profession by making statements similar to the statements made by psychiatrists during the original Goldwater controversy. That assumes that the APA as a guild is successful in preserving and promoting the interests of psychiatrists in the USA.  The track record there is very sketchy.  The APA and medicine in general has been completely unsuccessful in preserving a practice environment conducive to quality care.  At many levels it has facilitated that transition most notably by a near complete lack of opposition to managed care tactics and legislation and more recently collaborative care initiatives.  The APA has not been successful in advocating for patients with the most severe forms of mental illness. There has also not been any success in advocating for reasonable infrastructure to help the severely mentally ill avoid homelessness and incarceration. That string of failures is potentially more embarrassing than whether or not a few psychiatrists look foolish on the evening news.  I think there is an ethical basis for the Goldwater Rule that extends far beyond embarrassing the many by the few.

One of the key dimensions that I have not seen anyone comment one is that most psychiatrists are liberal Democrats. Psychiatry is the only medical specialty where that is true.  That is a clear bias when assessing a President from the opposite political party.

The insurrection itself clearly illustrates that psychiatric intervention in a Constitutional crisis is not possible or advisable.  I am basing that on the fact that for 25 years I participated in thousands of civil commitments, guardianships, and conservatorships.  I know all the legal requirements for these proceedings in both Minnesota and Wisconsin.  There is no court in any county in either state that would accept a legal proceeding against the President based on his current public behavior.  A typical argument against my position would say it is a utilitarian argument and therefore limited on those philosophical grounds. I don’t think it is at all.  If you are arguing that psychiatrists need to be involved, the question needs to be asked: “What for?”  The psychiatrists who have been the most vocal that President Trump is dangerous or irrational and, in some cases, claim that they are being stifled by the APA and the Goldwater Rule need to have an endpoint.  Every day psychiatric practice dictates that if you are seeing a dangerous individual you have to enact a plan to protect the patient and others. I don’t think that level of evidence exists – it certainly does not rise to the level of court intervention. The next step would be approaching members of Congress and asking for Impeachment or invoking the 25^th Amendment. They don’t need psychiatrists for that.  So what mysterious psychiatric intervention do the Goldwater Rule deniers want to see happen?  Should psychiatrists sitting in arm chairs call someone in the White House and tell them to remove the President based on his most recent outrageous statements?  That clearly would not work.  The concern that he has access to the nuclear briefcase also does not work. The evidence at this point is very clear, his cabinet had the opportunity to enact the 25^th Amendment and they declined.  Vice President Pence declined even after he was publicly berated by the President. Limits were set by the Department of Justice, the Joint Chiefs of Staff, social media companies, the National Guard and law enforcement on the ground.  President Trump had an unorthodox exit from the White House but he did leave.  Several days later the public was informed that he left a letter for President Biden.

The Republic survived without psychiatric intervention and none was indicated. The Goldwater Rule did not prevent some psychiatrists from making rhetorical statements from both the right and the left.  Nobody was sanctioned because from a practical standpoint it is ethical guidance – and I think it is good ethical guidance.

Is there a role for psychiatrists in these situations apart from making a speculative guess about the mental status of the Commander-in-Chief?  I think there is and that is in an advisory capacity about some of the group dynamics and containment of violence that occurred. It is absolutely critical to notice when propaganda is being used to incite violence or in this case an insurrection. Propaganda is not a “shared delusion” it is emotionally charged speech that can lead to fixed irrational positions.  It has to be recognized and countered in order to prevent the mass level of dysfunction associated with the denial of systemic racism, pandemic denial, mask denial, climate change denial, and the denial that the Presidential election was free and fair.  All of those levels of denial associated with the Trump administration occur in the context of longstanding denial that there is a serious problem with firearms in this country.  If psychiatrists want to be politically involved – those are the hard problems that need to be addressed.

There is much to be said for psychiatrists’ experience with containing violence and aggression.  When I witnessed what happened on January 6, I had many concerns about Inauguration Day.  My primary concerns were whether there would be adequate force to stop a similar attack and minimize the risk of injury to the police or demonstrators.  As I saw the barriers erected my concern was whether they was a plan in place to keep large groups away from the fences and avoid a violent confrontation.  Was there intelligence about the possibility of foreign actors taking advantage of the situation? And most of all – did the police and National Guard have clear rules of engagement to contain escalating violence and aggression and avoid serious injuries.  It turns out that everything except the rules of engagement were handled well. 

My advice about the Goldwater Rule either way is straightforward.  Forget about debating the President’s mental status in public.  The standard for Presidential capacity is a lay standard and not specified by any statute.  Psychiatric opinion is and will be remain unnecessary.  And if an APA member decides they want to bring an ethics complaint based on a violation of the Goldwater Rule – that is a waste of time as well. Stay focused on your own medical professionalism and remember that being a psychiatrist does not necessarily make you immune to emotional reasoning, political rhetoric, or propaganda. There are probably many more friends, neighbors, and relatives that need to get back on track to carry on the more mundane work of democracy.  

 

George Dawson, MD, DFAPA

 

References:

1:  Leonard L. Glass,  Edwin B. Fisher, Bandy X. Lee.  Trump’s Danger is now Undeniable.  He is clearly mentally unbalanced and unable to grapple with a reality that threatens his inflated and fragile ego.  Boston Globe January 7, 2021.

2:  Kroll J, Pouncey C. The Ethics of APA's Goldwater Rule. J Am Acad Psychiatry Law. 2016 Jun;44(2):226-35. PMID: 27236179.

Graphics Credit:

1:  Donald J Trump official portrait By Shealah Craighead - White House, Public Domain, https://commons.wikimedia.org/w/index.php?curid=63769676  Downloaded from Wikimedia Commons on 1/29/2021

2:  Barry Goldwater 1960 portrait By United States Senate - https://www.senate.gov/artandhistory/history/common/generic/Featured_Bio_GoldwaterBarry.htm  Public Domain, https://commons.wikimedia.org/w/index.php?curid=79152516

Downloaded from Wikimedia Commons on 1/29/2021

 

Disclosure 1:

Jerome Kroll, MD was one of my professors when I was a resident at the University of Minnesota.  He is a brilliant psychiatrist and wrote one of the best books ever The Challenge of the Borderline Patient.  He was also one of many professors who taught me that you can argue with colleagues and nobody has to take it personally - a good lesson in politics as well. 

Disclosure 2:

In my previous post I pointed out that for the past several decades I have been a small "i" independent.  That has changed with recent events.  I would find it very difficult to vote for a Republican based on their collective behavior and inability to respond to President Trump for the good of the American people.  But I still  do not think that psychiatrists have anything to offer in that area.

Supplementary:

I decided to attach the next several paragraphs based on what I have encountered over the Goldwater Rule into arguments I have heard from deniers and supporters of the rule. The last section are my personal observations (from above) - admittedly not independent of the others

Goldwater Rule Deniers:

1: Psychiatric or mental health experience is necessary in the case where a President may be incapacitated and unable to perform their duties.

2: Psychiatrists are ethically bound to publicly speak out if the President is incapacitated and a potential danger to the country.

3: The only reason the Goldwater Rule exists is to prevent embarrassment of the psychiatric profession.

4:  There may be an element of financial conflict of interest if the Goldwater Rule was recently modified over concerns that the APA may receive less money/tax benefit because of criticism of the President.

4: The APA suppresses the free speech rights of psychiatrists who speak out on the basis of their public assessment of the President.

5.  At least some deniers of the Rule believe that there should be a lower standard for capacity or mental illness if it is applied to the President. In other words, psychiatric opinion is conditional on whether or not the person being observed is the elected President at the time.

6.  The personal interview is not reliable and all of the information necessary to make a diagnosis is already out there in the public domain.

7.  The President's personality or alleged mental illness is the primary problem in what appear to be poorly thought out decisions.

 

Goldwater Rule Supporters:

1:  The Rule is the rule and direct examination of the patient is required to get the assessment out of a purely speculative mode where observations potentially have multiple possible meanings.

2:  The politicization of psychiatry is inevitable with experts for either party.

3:  The politicization of psychiatry potentially impacts patients’ willingness to see psychiatrists for help.

4:  Competency versus capacity – competency requires legal definition, capacity may be informal but that is unlikely in a contested procedure.

5:  Scientific accuracy of predictions of dangerous behavior are not good (Estelle v. Barefoot and APA amicus brief)

6:  Psychiatrists are not immune to rhetoric, propaganda or emotionally charged speech. The original treatment of Goldwater is a good example.

7:  If the issue is dangerousness and we are talking about President Trump there were many more dangerous presidents based on total war casualties that occurred during their terms – including Lyndon Johnson who was elected in part on the alleged dangerousness of his opponent Barry Goldwater.

8:  The President's personality or alleged mental illness is difficult to separate from purely political tactics like intentional misinformation or propaganda that are designed to disrupt and manipulate the electorate. 

 

GD:

1:  The Rule is ethical guidance that has never been enforced.

2:   The Rule is obviously ignored – nobody has ever been sanctioned by the APA or a District Branch in the 50 years it has been in effect

3:   The Rule only applies to APA members so people outside of the APA should not be concerned about it.  If you are really concerned about it don’t be an APA member and comment as much as you like.

4:   Presidential capacity is a lay standard that is not specified in any legal statute. In other words, there are no judicial descriptions of a standard for Presidential incapacity, no standard of proof.

5:  There is no mechanism to remove the President from office based on psychiatric opinion.  There are however political and legal mechanisms (25^th Amendment, Impeachment) to remove the President based on the opinion of his cabinet and in the case of repeated impeachments disqualify from further election eligibility.  A non-psychiatric standard is defined in the 25^th Amendment.

6:  In retrospect, some of the original campaign against Goldwater was propaganda (see ad on nuclear war) and that was reflected in some of the psychiatric opinion at the time.

7:  Psychiatrists potentially have a more significant role at the level of the group dynamics of violence, aggression, misinformation, propaganda, and the containment of violence and aggression.

8:  Several polls have characterized psychiatry as the most liberal medical specialty and the only one where a majority of members are Democrats.  That conflict of interest should be disclosed when commenting on opposition party politicians.

 

Admit What You Don't Know - An Unmentioned Organizing Principle

Everybody has ideas about medical ethics.  Often that is their own version.  There are medical ethicists who routinely comment on it in the media. There is endless speculation about what is ethical and what is not.  That speculation frequently focuses on financial compensation and reimbursement for physicians from outside services like pharmaceutical companies. Every physician in the United States is monitored by their state medical practice board who have varying ideas about what is ethical and what is not. Those ideas can even change over time. When I started out, it was common for physicians to prescribe various medications for friends and family members. At some point that was determined to not be a good practice for several reasons and it became a general rule adopted by most medical practice boards.

Ethics debates frequently are political debates and other common areas have to do with abortion, resuscitation, and unnecessary prolongation of life. Many of these debates played out in public arenas and resulted in legislation, court rulings, and practical applications like living wills and advanced directives in the event that the decision-maker is compromised and decision-making is limited.

I am constantly thinking about my training and how it relates to what I do every day. That means that from time to time I revisit what happened to me during that time frame and what it means today. I always seem to come up with something new even though I have thought about it many times before. Just yesterday I was contemplating the scenario where President Trump talked about disinfectants and ultraviolet light being used to kill coronavirus in humans. There are many places where you can view that videotape as well as the responses to it. In a politically charged partisan atmosphere many of those responses are predictable. The President and his allies are certainly in a spin control mode since this happened. They are contemplating having less frequent news conferences which I would agree with. Political opponents have seized the opportunity to characterize this as a lack of leadership and irresponsible statements. One of the physicians working with the president has suggested that he was simply “problem-solving” and “thinking out loud”with physicians in the Department of Human Services.

I think there is a more parsimonious explanation that will take me back to the third year in medical school. It should be fairly apparent to any trained physician that the President does not really know much about medicine. The clearest example would be his quote that we don’t really know much about nature of the coronavirus pathogen, when of course we do. There has never been a better time to study viruses and their molecular biology than right now. The President has made many other errors when talking about the pandemic and the associated medical problems. He approaches it like he does political rhetoric. He makes contradictory statements to gain some time and then sweeps in at the end with the correct position even though it is often in opposition to what he said in the first place. In medical school that would not get you past the third year.

Third-year medical school is an exciting time. Everyone is starting intense clinical rotations. You are scaling up in your ability to see more patients per day. You are getting more efficient in conducting the elements of the patient evaluation, differential diagnosis, and treatment planning. You are learning more about relevant laboratory and imaging testing. But there is also important ethical element that you need to discover right away or you rapidly get into very deep trouble. Simply stated that element is - know what you know and what you don’t know and clearly state whether you know something or not. The corollary is that time is of the essence and there is no time for equivocating. If you are asked directly by an attending physician or a senior member of the team and you draw blank - the correct answer is “I don’t know”. There is no room for guesswork or rhetoric.

During my training I saw some relatively brutal enforcement of that rule. One conversation went like this:

Attending: “Do you know this patient’s calcium level?”

Intern: “I think it was 10.8…”

Attending: “Do you know or not? Are you just guessing?”

Intern: “No I am pretty sure it was 10.8.”

In this brief scenario, the correct answer was “I don’t know”. It turns out the calcium level was not 10.8. That led to a fairly intense private conversation between the attending and the intern about his expectations of patient care and how they were not being met. The intern was subsequently asked to leave the program.

I witnessed several scenarios like this and they are tense situations. The expectation of course is that individual team members will know everything about the patient particularly all the relevant evaluation and testing that occurs in the hospital and that they will be able to synthesize that for the attending during rounds. It is a high-pressure situation because all eyes are on the person being questioned. I can still recall being in ICU with a fairly intense pulmonary medicine staff person who decided he wanted to question my favorite Internal Medicine intern on pulmonary function testing in various lung disorders. For anyone not familiar with this testing there are a set of esoteric terms and concepts that vary across lung diseases and the attending in this case wanted an extemporaneous summation. He provided no structure whatsoever for the intern. The other four members the team took a deep breath and focused on the intern. In his southern drawl he provided a perfect description of pulmonary function testing and how it varied in the pulmonary conditions of interest. It was pretty amazing.

Similar high-pressure situations don’t go that well. I had just started out on a cardiology team in the same hospital and rounded on a patient and went to present to one of the cardiologists. It seemed to be going pretty well until he asked me to show him the chest x-ray. In those days, we had to go to Radiology and collect all of the films we needed, check them out, carry them around all day and then return them. I did not have a chest x-ray and for the next several minutes fielded a few sarcastic comments like “You didn’t think a chest x-ray was important in a cardiology patient?” In similar situations it was always better to say “I don’t know” rather than trying to bluff your way through a barrage of questions from an attending physician. Not having a chest x-ray is relatively easy one.  It is harder if it is a question about specific history or data or information that you are expected to know.

An important part of the lesson is that even though it may be emotionally painful to say “I don’t know.” it must be said if you really don’t know. There is no spin after the fact in medicine. The patient and everyone else on your team depends on you being able to make that statement. When you complete your training - it is equally important to make that statement to your coworkers and the patients you treat.  I have never really heard much comment about it in the media or by the ethicists but for me it is a central organizing value. There is a ripple effect. If you don't want to end up with that statement - you do everything possible to prevent it.  But most importantly you recognize the vast information base of medicine and you recognize the uncertainty of the day to day decisions.

This post is not supposed to be a lesson for politicians. It is not a suggestion that politicians should adopt ethics that are useful to physicians. It is a simple observation that being able to admit that you don’t know something even when it seems like you should is transformative. It is better to be brutally honest with yourself upfront than having to do it later to deal with the complications. All medical decision-making and professionalism hinges on this ethic. 

When it comes to medicine - you can't just make something up or think you know something - when you don't.

George Dawson, MD, DFAPA





Full Disclosure:

I am a small "i" independent.  Yes - I am one of those guys who does not hesitate to "waste" his vote on a non-major party candidate, but at times have voted for those candidates.

The Charlie Gard Case - Why Political Rhetoric Can Never Be Ignored...

  Charlie Gard died three days ago after his life support was withdrawn.  He was a British infant born less than a year ago with infantile onset encephalomyopathic mitochondrial DNA depletion syndrome.  There are three genetic subtypes listed on OMIM and I those linked in the Supplementary material below.  Note that the capital letters in the titles is a convention of OMIM and not my addition.  The medical details as well as the basis for the legal decision is available online.  In this case the court sides with the Great Ormond Street Hospital in deciding to withdraw life support because of Charlie Gard's terminal medical condition.  In the summary an American physician is mentioned who apparently suggested that nucleoside therapy might be tried even though it has never been tested for this condition in humans and it has never been tested in a mouse model of the human disease.  The judge refers to the culture around these issues in the USA as being "slightly different" in that anything might be tried.  This court document was apparently written before Charlie Gard was examined by the American physician Michio Hirano, MD who offered Nucleoside Bypass Therapy an experimental treatment for mitochondrial diseases.  The parents of Charlie Gard ended their legal case to bring him to the United States for experimental treatment on July 24, 2017 - four days before he died.  In the language of contested court cases - their attorney said that new tests confirmed that the experimental treatment would not help.  In fact, there was no real evidence that the experimental treatment would have ever helped.

The conflict between Charlie Gard's parents and the Hospital began after they successfully raised enough money to take him to the USA for treatment in January.  The Hospital's argument at the time was that it was not in the best interests of their patient and subsequently that the treatment being offered was unlikely to be of benefit.  The court documents describe their opinions included the opinion of an expert in mitochondrial diseases who had authored 140 scientific papers and book chapters. He is described as a person with grave neurological disease who is maintained by life support and the in the opinion of the Hospital staff the life support should be removed and he should be allowed to die.

From a political standpoint, the right wing in the United States picked up on the case as a case of a socialist health service against the rights of the parents or as Brook Gladstone (On The Media) said: "a martyr to statist tyranny."  On that same show, Melanie Phillips a conservative blogger and writer for the Times of London described the conservative commentators position in the US as "ignorant and ideological".  She describes their writing about the case as something that could be used in the fight to repeal of Obamacare.  She points out that conservative commentators in the UK are not invested in portraying the National Health Service as a killer.  She points out that right to life activists and that agenda only exist in the US.  It is part of a long succession of political rhetoric that suggests that the risk of a more openly government run system is that it puts the government between the patient and the doctor and the decisions are more likely to be consistent with what the state wants.

I decided to read and footnote one of the articles from the right (5) on this dilemma. In her article on Fox News Health, Penny Young Nance makes the case that the problem is really big government and socialized medicine and that no government can take away God given rights.  The counterpoint to this opening premise is that the political right generally does not view health care as a human right.  They view it a a business and something that must be earned based on merit.  Her second premise is that American healthcare is cutting edge and driven by cure as opposed to National Institute for Health and Care Excellence in the UK that is driven by profit.  Both elements of that second premise are erroneous.  I don't think that there is any evidence that the UK uses less technology and irrespective of how they use it their outcomes are better at a fraction of the cost than the most expensive medical system in the world in the USA.  I also don't know how socialized medicine is making profits (and for who) by denying unnecessary care.  The third premise is that technological advances like the eradication of smallpox requires a free market approach to innovation so that mistakes can be made.  In actual fact, smallpox eradication was a long effort of physicians, academics, public health departments, some private industry, and the World Health Organization.  That is hardly a free market effort. It could easily be argued that it would not be profitable enough for American companies to enter.  She goes on to critique the Independent Payment Advisory Board (IPAB) under ObamaCare as being similar to NICE as a health care rationing body.  NICE is not a rationing body and this opinion leads me to question if she ever viewed their extensive web site of some of the best medical evidence collected in the world.  She conflates IPABs ability to control prices as "shoving us in the direction of single payer health insurance." Every more successful and far less expensive health care system in the world has cost control mechanisms.  Her summary statement connects the Charlie Gard case and IPAB:

"We should heed Charlie’s case as an example of gross government overreach and repeal IPAB immediately."

Only the political right wing in America can draw such a connection.

The rhetoric of the political right, is basically rhetoric that is thinly disguised as concern about individual rights.  It requires a complete suspension of the current reality in health care. Those realities include the following.

1.  Medicine is best practiced by physicians especially the ones taking care of you: 

In Charlie Gard's case he was assessed and treated by experts from multiple specialities in the UK.  No reasonable American physician would doubt that he received expert care and care that is probably available in a small minority of medical centers in the United States.

2.  Medical ethics can easily be politicized but their foundation is more sound than politics: 

There are two relevant concepts here - futile care and experimental treatment.  In this case the best summary appears to be that there was really no evidence that the experimental care would do anything to alter the course of Charlie Gard's terminal neurological illness.

3.  Political opinions on ethics don't have to be consistent:

There are striking inconsistencies in the positions offered by the political right.  At the level of personal choice they make it seem like there is a panel that will be taking healthcare choices away from Americans.  In fact, the panel will be addressing prices and cost containment.  The political right also seems to have completely ignored how health care is rationed by health care companies and subject to racial and socioeconomic disparities. We are currently in the midst of a very inadequate system of mental health and addiction care based on 30 years of rationing by private American companies.  If you are elderly and have a significant illness in an American hospital managed by an American company, you or your family is likely to be approached about the idea of palliative care or hospice care.  It might be recommended that you forgo certain diagnostic tests or procedures because of your illness and transfer to a hospice setting. Nobody discusses the fact that these recommendations are aligned with the financial interest of the hospital.  If you stay there too long or use too many resources - they lose money.  This is the current system of care in the United States. As most people know - you don't have to worry about the government.

You do have to worry about the the corporations making profits by charging you plenty of premiums and copays and deciding how they will not have to pay that out in services.  That is the rationing that occurs millions of times a day in the US.  

4.  How is a market system that appoints private businesses as proxies for rationing services and  that ignores the health of tens of millions of people ethical?

As noted above - as millions of people are uncovered, tens of thousands die and more suffer.  If your ethical priority is choice - these people do not have a choice.  If your ethical priority is the sacred nature of life - these people have immediately been devalued.  Unless I missed it - these seem to be the main ethical arguments of the political right.

On the whole idea of the government getting between you and your doctor - there are currently two people standing between you and your doctor in the United States.  The first is your health care company.  The second is the company that manages your pharmacy benefits.  If either of these companies does not want to act on your preferences or your doctors orders - they can make life miserable for both of you.  The level of misery can extend from a flat denial of service or medication to saying that you don't meet their medical necessity criteria for a service.

The only logical conclusion here is that American healthcare is highly flawed from an ethical perspective and right wing opinion clearly wants their constituents to believe that it is something that it is not.  We are certainly technically competent to provide care.

The political right has elaborate rhetoric to cover the flawed ethics and the balance tipped in favor of corporations rather than people.  That keeps Americans from getting to the same level of performance as the other, less expensive systems in the world.  That includes the National Health Service in the UK as evidenced by the life expectancy graph at the top of this post.


George Dawson, MD, DFAPA




References:

1:  Melanie Phillips.  Why America Got the Charlie Gard Tragedy So Wrong, July 29, 2017.  http://www.melaniephillips.com

2:  On The Media. July 27, 2017. WNYC studios - The Charlie Gard story is near the end of this podcast.  

3:  Lori Robertson.  Dying from a lack of insurance. The Wire. September 24, 2009.

4:  Truog RD. The United Kingdom Sets Limits on Experimental Treatments: The Case of Charlie Gard. JAMA. 2017 Jul 20. doi: 10.1001/jama.2017.10410. PMID: 28727879

5:   Penny Young Nance.  Charlie Gard: Why his struggle may soon be ours.  Fox News Health. July 10, 2017

Supplementary:

MITOCHONDRIAL DNA DEPLETION SYNDROME 9 (ENCEPHALOMYOPATHIC TYPE WITH METHYLMALONIC ACIDURIA); MTDPS9

MITOCHONDRIAL DNA DEPLETION SYNDROME 5 (ENCEPHALOMYOPATHIC WITH OR WITHOUT METHYLMALONIC ACIDURIA); MTDPS5

MITOCHONDRIAL DNA DEPLETION SYNDROME 13 (ENCEPHALOMYOPATHIC TYPE); MTDPS13

RIBONUCLEOTIDE REDUCTASE, M2 B; RRM2B

A Circular Ethics Argument About Psychiatric Services

I attended the Minnesota Psychiatric Society MPS spring meeting yesterday.  The current American Psychiatric Association (APA) President  Anita Everett, MD was there and gave a presentation on ethics.  The title of her presentation was Ethical Issue Management in Team Care.  The conference was focused on collaborative care and innovative ways to extend psychiatric practice out into areas where there is little to no coverage.  The afternoon was dedicated to an APA sanctioned presentation called Applying the Integrated Care Approach: Practical Skills for the Consulting Psychiatrist.

The central theme in Dr. Everett's presentation involved streamlining the 9 dimensions of the AMA code of ethics annotated for psychiatry to 4 dimensions from Principle of Biomedical Ethics.  Those dimensions include beneficence, non-maleficence ("do no harm"), autonomy and justice.  There was not a good 1:1 translation largely because in her formulation autonomy seemed to apply to patients but there was a question mark regarding physician autonomy.  Some of the AMA/APA dimensions applied to two of the 4.  For example, commitment to medical education was seen as applying to both beneficence and non-maleficence.

Dr. Everett is a community psychiatrist and has studied various community mental health centers.  She makes the distinction between simple and complex systems and how applying ethical principles to complex system. She gave some examples of how this might apply like integrated care in a medical shared ACO and meeting a patient in a coffee shop as part of an ACT team intervention.  She  poses the the ethical analysis as a series of questions pertaining to the 4 dimensions.

The open discussion was instructive.  There was a psychiatric administrator present who talked about the ethical issue of emergency department congestion.  In his hospital there are 80 ED beds.  There has a chronic problem with psychiatric patients stranded in the ED sometimes for days.  The problem is basically a systems problem because most Minnesota acute care hospitals do not have psychiatric units, and very few (2 or 3) in the Metro area are equipped to treat patients with aggressive behavior.  As a result practically all of the police and paramedic related acute admissions in a 5-county area are brought to this hospital.  At the same time acute care beds in Minnesota are rationed to the point that there are fewer beds available than in practically all OECD countries including Mexico.  One of the other attendees at the conference also made a statement consistent with what I have put on this blog many times: the state of Minnesota has systematically dismantled the state hospital system and came up with an inadequate secondary system that they no longer use.  That participant was an expert in the state hospital system.  In the meantime, individual counties have essentially eliminated supervised housing for people with severe mental illnesses.  I really don't know what people expect when all of the resources to treat severe mental illnesses are rationed away and emergencies continue to happen.  What occurs is a large steady state population of mentally ill people who are rooted partially on the street or in very suboptimal housing, inpatient units, the ED, or (worse case scenario) jail.  In what was probably the most illogical approach to a solution, the ED reported the Psychiatry Department to the ethics committee for not solving the problem of ED congestion with psychiatric patients!

The ethical conflict in this situation was discussed from the perspective of turf (ED physicians versus psychiatrists) and patient autonomy.  Physician autonomy was touched on only so far as the question of whether physicians need to sacrifice autonomy for the greater good. Does the sacrifice of autonomy lead to resources to treat more people in the long run?  That argument was advanced by a managed care physician-administrator.

Any reader of this blog knows that I view ethics as basically political arguments.  Most ethics seem relative to the political arguments that carry the day.  For example if you think doctors aren't paying enough attention to costs and you are a health care administrator - make cost effective care the new definition of professionalism.  In this case, it comes down to blaming psychiatrists for severely rationed services.  The technical argument basically transfers blame directly away from the rationers to psychiatrists who are left with a huge problem.  That ethical argument carries the compounding problem negatively impacting all of the ethical elements as outlined by Dr. Everett and leaving the psychiatrists in a totally untenable situation.  It also illustrates how a dissection of a complex system - in this case the entire universe of mental health care in Minnesota - results in a ethical argument that only applies to one environment - in this case the emergency department.  Even there it should be painfully obvious that these problems selectively apply to psychiatric patients.  There is no backlog of patients with chest pain waiting for 2 or 3 days in the ED or being transferred to a remote hospital 200 miles away.  All of the illogical approaches to psychiatric care that apply in the ED can be traced back to decisions by politicians - not the least of which is to hire managed care proxies to ration access to care.  It is obvious that sacrifices in physician autonomy to managed care administrators has only made the problem far worse and not better.

In the state of Minnesota. there is no justice for psychiatric patients.


George Dawson, MD, DFAPA


References:

Anita Everett, MD, DFAPA.  Ethics in complex systems of care.  Minnesota Psychiatric Society Spring Scientific Meeting.  June 16. 2017.      





               

Ethics, Law, and Politics In Psychiatry

I just spent yesterday at the 2016 Minnesota Psychiatric Society Ethical Issues In Mental Health for 2016.  It was a long day, especially for a guy who wants lectures and information.  About 1 1/2 hours was dedicated to a group discussion of cases.  I am always more interested in what the experts have to say - that is my comfort zone at CME courses and meetings.  The first lecturer was Rebecca Weintraub Brendel, MD, JD from the Harvard Medical School Center for Bioethics.  She was also the Chairperson for the Ad Hoc Work Group for the American Psychiatric Association on Revising the Ethics Annotations.  That resulted in the document APA Commentary on Ethics In Practice from December 2015.  A complete listing of the members of that working group is available in the document.  She started out by talking about the Trolley problem and reviewing the various approaches to this issue.  The ethical theories that applied were briefly reviewed including deontology, consequentialism (utilitarianism), virtue ethics, and principalism.  She said that the field has evolved to the point where principalism is the dominant paradigm.  Principalism includes the broad areas of autonomy, beneficence, non-maleficence, and justice.  At this time any search on bookselling websites will pull up a number of references on principalism, including critiques of the concept.  I will probably pick up a copy of one of these books to see just how heavily  the justice component in medicine includes social justice and concepts like global warming.  I have always been amazed at why physicians would expend valuable energy on these issues when they have been unable to protect the integrity of their profession.

A lot of time was spent discussing professional boundaries with some focus on electronic media and communicating with patients.  The afternoon cases discussion focused on two psychiatrists with multiple ethical problems some of which included clear ethical issues involving both social media and electronic communication.  In Minnesota, the consensus is that e-mail communication with patients using typical insecure e-mail is not a good idea, but many psychiatrists are employed by organizations that use secure e-mail through a health system portal.  One of the hypothetical case examples given was membership on Facebook of group therapy members and all of the problems that involves.  One of the key aspects of treating patients like psychiatrists involves not just interpersonal boundaries but also boundaries around the therapy like contact and phone calls outside of the sessions.  Online contact with either frequent e-mail or social media creates the illusion that the psychiatrist is always online and available.  That every comment will be noted, analyzed and responded to.  This is not only unrealistic availability, but also unrealistic analysis.  Psychiatrists more than any other physician should know that typed statements online are very poor substitutes for analyzing the emotional content of communication especially where aggression, suicide, and other critical aspects of judgment are the focus.

The second lecture was given by Colleen M. Coyle, JD General Counsel for the APA and it was titled When Law And Ethics Collide....   Privacy rules, informed consent and substituted consent were the early issues.  A suggested authorization form that covers all of the contingencies was suggested.  I can recall signing several including the standard recredentialing forms that authorizes multiple unknown parties complete access to any and all information about me.  The coercive nature of these forms was not discussed.  I see even the most standard consent to treatment form as fairly coercive these days, especially the sections that cover requirements for disclosure by state laws.  A comparison of attorney-client privilege vs. physician-patient privilege would have been instructive.  I think it would point out the obvious - once again that physicians have done a poor job of protecting their profession and that lawyers have succeeded in making legal decisions (Tarasoff) part of the psychiatric code of ethics.  Some of the vague situations of disclosure under the more liberal HIPAA versus the more restrictive CFR42 were discussed.

The discussion ended on prescription drug monitoring programs, the ethics and the current legal landscape.  The legal landscape was most interesting in terms of who inputs the data and whether mandatory accessing of the database exists.  Thirty one states require that prescribers access the database and 11 of those also require a query.  Nineteen states do not require mandatory access.  There are criminal and civil penalties for not reporting controlled substance prescriptions in the database.  Twenty six states and D.C. provide some immunity from civil liability for not accessing and using the database.  Minnesota has a very reasonable approach.  Pharmacy data populates the database and accessing the database is not mandatory.  As a physician I can't imagine having to treat patients, do all of the necessary documentation and orders/prescriptions and then access a separate database and re-enter the prescriptions.  If that is happening to any extent in other states that is another serious abuse of physician time.  It is also part of the general trend of dictating how physicians practice medicine.  Learning what rules apply to you in your particular state is critical irrespective of how rational the process may or may not be.

Ruth Martinez, MA Executive Director of the Minnesota Board of Medical Practice was the third presenter.  Her emphasis was on documentation, boundary issues, informed consent, and response or lack of response to the treatment plan.  An important concept that I have always used is documentation of the informed consent process.  A written and signed document is not needed (with the exception of ECT and antipsychotic medications in the state of Minnesota), but documentation of the discussion is useful.  In situations where the discussion covers a lot of contingencies, it is useful to come back to that part of the document in terms of treatment planning and what the next step might be.  The only potential problem is that when everyone has access to your thinking, suddenly everyone is an expert as in: "I noticed in your note that if this antidepressant was not effective your plan was to change to antidepressant B.  I discussed this with the patient and he wants to try B now."

The part of the presentation that I was in disagreement with was the discussion of the power differential in the physician-patient relationship.  The rhetoric of power is an interesting one that I hear discussed much more frequently outside of medicine than inside.  In my experience social workers tend to discuss power in relationships.  To me,  power is a nonspecific word.  When I am obsessing about making the right decisions in very uncertain situations - being some sort of omnipotent authority figure is the farthest thing from my mind.  All of the psychiatrists I know operate from a therapeutic alliance model and that can be captured by two sentences:  "The therapeutic alliance means that you and I are working to solve your problems.  In that context it is my job to give you the best possible medical advice on how to do that and your job to decide about whether you want to use that advice or not."  Even in the cases where substitute consent is required like civil commitments or guardianships, the physician involved basically brings the problem to the attention of a judge who makes the determination.  Physicians do not want to run patients' lives.

Steve Miles, MD from the University of Minnesota Center for Bioethics gave the scientific part of the program on the epidemiology of gun violence.  It had striking similarities to some of the positions I have posted here on how to approach this problem that I plan to discuss that as a separate post.  He also reviewed the political timeline on how research into gun violence was eventually defunded courtesy of heavy lobbying by the pro-gun forces in Washington.  

I thought that politics was the important word that was left out of the ethics discussions.  As an example, the issue of torture was discussed and how the American Psychiatric Association came to the position that psychiatrists should not participate in torture.  That was a lengthy discussion that eventually came down to a line in the sand - psychiatrists should never participate in torture.  That is not true for two other ethical dilemmas discussed in this conference - managed care utilization review and collaborative care.  Instead hypotheticals were discussed.  If you were this managed care reviewer and your company wanted you to deny specific care that you knew was indicated - what would you do?  Similarly - if you were in this collaborative care arrangement and your salary and bonuses depended on what you were using to fund the "at risk" population that you were seeing - what would you do?   So basically being a military psychiatrist asked to perform torture there is a clear ethical guideline and in the managed care and collaborative care situations you are on your own.  You can call me concrete, but if I was king, the latter two situations would also be forbidden by the ethical code of psychiatrists.  In the case of collaborative care the APA recently announced (1) it received a federal grant to "train 3,500 psychiatrists in the clinical and leadership skills needed to support primary care practices that are implementing integrated behavioral health programs."  Instead of questioning the ethics of a practice that limits the direct assessment of patients by psychiatrists and potentially creates financial conflicts of interest - at the organizational level the APA celebrates this grant and making the practice it more broadly available to all psychiatrists!

Calling the APA Ethics Committee with your ethical dilemmas was encouraged and they clearly take it seriously, but I think these inconsistencies do not make the organization popular among clinicians who deal with these problems on a day by day basis.  They are as easily solved as the questions about physician participation in torture and executions.


George Dawson, MD, DFAPA


References:

1:  Mark Moran.  APA Receives Federal Grant to Train Psychiatrists In Integrated Care.  Psychiatric News - November 6, 2015.  v50(21): p.1.

The grant to train 3,500 psychiatrists was $2.9 million over 4 years or about $828 per psychiatrist.  Each psychiatrist is expected to support up to 50 primary care providers and consult on the care of 400 patients per year.  The ultimate goal is to support 150,000 primary care providers and consult on the care of a million patients a year.  Does anyone see the problems here?