Medicine is full of ethical dilemmas that we often have to face alone. Here’s one I’ll never forget.
As a med student at University of Texas Medical Branch at Galveston, I had to provide health care for Texas prison system inmates, many on death row.
They say everything is bigger in Texas, and they’re not just talking about hair, land mass, and guns. Turns out Texas leads the nation in executions performed per year (1/3 of all US executions)!
In fact, the prison hospital is conveniently attached to the main university hospital like right next to my apartment.
Anytime, day or night, with a flash of my school ID, the guards press a button and I’m in.
I remember the massive door opening ahead of me. Then a series of steel gates unlocking one by one as I made my way past rows of caged men.
Death-row health care is an oxymoron.
How do I reconcile “first do no harm” with the death penalty?
How do I care for someone soon to be killed?
I’m only twenty-three years old and med school hasn’t prepared me for this. Imagine little me as a young naive med student just standing alone and totally baffled by the ethical dilemma ahead of me. (of course, I couldn’t act like I was uneasy)
I believe all patients deserve the same kindness and respect. I’m basically an idealistic humanitarian who believes everyone is good at heart and those who aren’t have been wounded and are terribly afraid of something.
But all the rules of life and medicine are not the same on death row.
I’m in a place where “How are you?” is a loaded question, a place where men find Jesus and prepare their last statements before lethal injections.
I enter a cell. Sitting in front of me is a white man in his fifties recovering from a hernia repair. As I take his blood pressure and listen to his heart, I wonder how many people he may have shot or stabbed or killed.
“Blood pressure is normal. Your heart’s good.”
He disrobes and I examine his groin incision, testicles, and penis. And I wonder how many women he may have raped or dismembered.
“You’re healing just fine. No signs of infection.”
I flip through his chart to see how I may best serve him. I notice his cholesterol is high.
“When was your last complete physical exam?”
“They check me pretty regular,” he says.
Here’s where it gets really confusing for me. He’s due for a colonoscopy, but do we do colonoscopies before executions?
And I want to discuss his cholesterol, but first I need to know one thing: can death-row inmates get heart-healthy meals?
This is completely nuts.
I haven’t treated anyone on death row since med school (not exactly my ideal patient in my solo practice), but I’ve had some patients just out of prison—mostly for non-violent crimes like marijuana possession. And I’ve had other patients involved in unusual possibly illegal activities.
Hey, as long as you’re not hurting anyone your secrets are safe with me . . .
By the way, if you’re thinking of jumping off the grid from big-box medicine, I’ll walk you through how to liberate yourself from assembly-line medicine. Contact me for an invite to our free webinar.
Ethical dilemmas in medicine are numerous. Is it safe to practice assembly-line medicine in seven-minute visits? Should folks on death row receive free preventive care that isn’t even available for law-abiding citizens?
Opening the conversation on the hidden doctor suicide crisis has been an ethical dilemma of huge proportions for our profession. I certainly never predicted that I’d be inserted into the aftermath of doctor suicide scenes leading eulogies for my lost brothers and sisters in medicine.
I guess jumping into the unknown has it’s benefits. I’m totally fearless now in a way I never was walking among my patients on death row.
What’s the weirdest ethical dilemma you’ve faced as a physician?
I’d truly love to know. Please post (even anonymously) here.
(Warning: I have a lifelong problem of “freaking people out” by sharing too much detail. Hang with me . . .)
When I was a little kid, I had this ritual with my dad. I’m pretty sure we were the only two people in the world that ever did this. It’s kinda weird and I’ve actually never told anyone the full version of what we did together cause I didn’t want to freak anyone out.
Man, now I’m crying just remembering this ritual. . .
Dad’s been gone nearly 4 years. Maybe I can’t stop thinking of him because Father’s Day was last Sunday, but whatever the reason, every time he crosses my mind, this is the memory I come back to time and time again. I’m certain it changed the entire destiny of my life.
So here goes. . .
Both my parents are physicians. Mom’s a psychiatrist, Dad’s a pathologist, a medical examiner. They weren’t home much because they (like most docs) were total workaholics!
With no childcare (babysitters kept quitting and that’s another story), Dad would take me to work at the morgue. The morgue was my favorite spot. It was like our secret clubhouse. Nobody ever bothered us there. No interruptions. It’s not like anybody really wants to go to the morgue ya know . . . except me and my dad. So to me, it’s the most peaceful place ever.
Here’s the ritual. . .
Every morning when we entered the morgue, Dad would open up the stainless-steel doors to the big cooler and he’d say, “Good morning! Is anyone home?” Then he’d prop me up and introduce me to everyone one by one (by the toe tags!). He’d literally announce, “Look! It’s Sally!”
And he’d be SO happy to meet her. Kinda like introducing me to a long lost relative.
Okay, let me back up and explain I was one of those really talkative kids that would wear all the adults out because I couldn’t shut up for a minute. I was WAY too much for most people. Too intense. Too needy? I’m still not sure.
But Sally could handle me. So Dad would leave me there to talk to HER. (Plus he got the break from me I’m sure he needed).
“Sally, how are things going for you?” I pause.
So I answer for her.
In my eyes, Sally is a brave woman who has led a heroic life. And I make up a fantastically wild and amazing story about her life and all the beautiful things she got to see and do in the world and I’m VERY committed to my version of her life story.
[Granted this is a poor hospital in the inner city of Philadelphia—a city with the highest homicide rate in the USA at the time]
“She was probably a single mom who’s life was cut short by poverty, drugs, and violence,” Dad would try to explain.
But I’m relentless.
I keep telling him MY version of her life story (and I’m VERY persuasive).
Eventually, Dad would see there was no arguing with me, and would go along with my story.
What a great Dad. Right?
So that’s our special ritual.
That was it.
Just me, my dad, and one of his patients.
Every day when we went to the morgue. Different patient. Same kind of story.
Now as an adult and a doctor myself I realize I’ve spent my entire life seeing the heroic potential in all my patients, friends, and even my foster child. Not everyone lives up to their potential. I used to get sad about that. BUT that doesn’t mean I’m ever willing to let go of the beauty and courage—the heroic story I SEE in each person who crosses my path—even if they can’t see it in themselves.
My story of their heroic life—even if unlived—is still true to ME. I’m not willing to give it up.
I think this makes me a better doctor.
I’m exactly where I’m meant to be. I see it all so clearly now.
My dedication to celebrating the lives of doctors we’ve lost to suicide . . . how I refuse to let these beautiful souls just be covered with a tarp and thrown into a body bag without sending them off with a proper eulogy, flowers, and a celebration of their life and contributions to the world. Even if I have to write it myself. Even if I didn’t know them when they were alive. Someone has to write their heroic story. May as well be me. . . I’ve been preparing for this since I was a little girl.
As a child I enjoyed seeing the fantastically wild adventures in the lives of my dad’s patients in the morgue, but now, as an adult, I much prefer to help physicians LIVE out their wildest dreams while they are still breathing which is why I continue to lead “Live Your Dream” physician retreats . . .
So doctors can really be real healers—not just assembly-line factory workers. Everyone deserves to live their dreams.
The bottom line is I believe in your dreams even when you don’t believe in your own dreams.
I believe everyone’s a hero. (Some people just don’t know it yet).
Do you agree? I’d really love to know what you think.
Please leave your comment below.
Physicians experience the highest suicide rate of any profession. I’ve been investigating doctor suicides for more than 5 years. What began as a personal quest to discover why so many of my physician friends had died by suicide has now become an international inquiry and full-time job. Here’s what I’ve learned from my first 757 cases. I’ve now amassed 952 doctor suicides on my registry and anesthesiologists remain in the lead with the highest suicide rate among all doctors.
Thankfully two courageous anesthesiologists have stepped forward to address depression and suicide within their hospital. Both were forced out of their jobs. One has filed a lawsuit.
Dr. Michael Shaughnessy—an exemplary anesthesiologist much beloved by staff and students at Duke University—was wrongfully terminated in 2017 as retaliation for his objections to disability and sex discrimination in the Department of Anesthesia.
After the suicide of a second-year female anesthesiology resident (June 2016), Dr. Shaughnessy and others complained about the “insensitive response” and “stubborn refusal” to support those with mental health disabilities and the widespread discrimination against many female anesthesiologists in the department,” according to a federal lawsuit.
Yet the official stance of the Department Chair was that they held no liability in the Resident’s suicide. Many faculty, visibly upset, felt the focus should instead be helping staff experiencing depression and grief after the sudden death of their colleague.
Faculty member, Dr. Cheryl Jones met with surviving residents to offer her support—at which point faculty were warned they were “not permitted to gather with residents without the approval” of the Program Director. Furthermore, Dr. Jones was prohibited from organizing a candlelight vigil to mourn the Resident who had died.
“After being blocked from organizing a vigil, Dr. Jones attempted to distribute a book, Physician Suicide Letters Answered, to assist her grieving residents and was physically obstructed by her superiors. The books were stolen from the hospital where she placed them and banned from the department. In August 2016, I received the following email from Dr. Cheryl Jones:
I had previously written you about the death of one of our residents in the anesthesia department. I had mentioned another death [confirmed suicide] of a former internal medicine resident who had just started his fellowship.
I also want to let you know that our department is doing their best to continue the culture of shaming and secrecy around physician suicide. We are not allowed to talk about what happened. We have not had any sort of service to honor our own grief. We have been given various excuses for the lack thereof.
I had also purchased 6 copies of your book for my residents. I had not distributed them but had told a few about their presence. Please see the department-wide email that I sent last week. The departmental administration should be ashamed of themselves. Please share this information as you see fit.
Dr. Cheryl Jones
Subject: Book on Physician Suicide
I have purchased a few books about physician suicide by Pamela Wible, M.D. I have had them for the better part of a month and have not sent a notice that I had them available for anyone. I was refused reimbursement from the department as this was considered to be a personal expense (for 6 books). I had previously purchased books on wellness and had been able to cover them through the department.
On Monday I was summoned to the office of the division chief. I had assumed that I was to be informed as to why the books were not eligible for funds. Instead I was informed by the executive vice chair that “the department did not want me to distribute these books to the residents.” At that time I also discovered that the division chief had stolen these books from the anesthesia workroom where I had placed them on the shelf. Since I have now recovered them I am making them available for anyone that is interested.
Dr. Cheryl Jones
Dr. Shaughnessy was concerned about the mistreatment of Dr. Jones who resigned from Duke Anesthesia faculty it is believed as a result of harassment and retaliation.
During a subsequent meeting held by the Department Chair to prepare for resident application season, he expressed his “disdain for Dr. Jones and her disability and attributed her actions to mental illness” and told those in attendance to inform applicants that “the Resident had committed suicide because she had a drug problem.” They were not to mention her depression.
Dr. Shaughnessy objected to the mischaracterization of the Resident and mistreatment of Dr. Jones and then shared his own “struggle with depression.” Weeks later the Vice Chair warned him not to “rile up the troops” and told him he “could count on sabotaged letters of reference” and “blacklisting” from further employment upon nonrenewal of his contract. He was then terminated for “less than optimum professionalism” and “not being team-oriented.”
In United States District Court, Michael Shaughnessy vs. Duke now alleges discrimination (and retaliation) under the ADA, hostile work environment based on disability, retaliation in violation of Title VII of the Civil Rights Act of 1964 and wrongful termination in violation of North Carolina Public Policy—all actions taken with malice or reckless indifference to Dr. Shaughnessy’s rights. Read 24-page court document.
Yet harassment at Duke is not limited to the Department of Anesthesia as confirmed in a letter (published with permission) from a physician friend:
“A pediatrics resident at Duke took his life several months before graduating from residency. It was a horrible tragedy that had a profound impact on the psyche of all of us residents. Unfortunately, as residents we were completely silenced and the whole tragedy was swept under the rug. I was speaking with 2 other resident colleagues after the incident and said “something isn’t right here.” Within 30 minutes I was called into my program director’s office. There were 4 doctor administrators sitting behind a desk with legal pads and pens. They demanded that I sit down and share anything on my mind and furiously scribbled notes as I spoke. Tears streamed down my face and their cold stares persisted as they took notes. I can barely remember what happened because I was so scared and their intimidation and bullying tactics paralyzed me. The end result: I was immediately forced to go to psychiatric services to be “cleared” so I could report back to clinic that same day and finish seeing patients. I thought I moved on but these visions still haunt me, years later. Some memories can never be erased and linger on in your soul.”
Yet harassment is not limited to Duke; it is widespread throughout medical education in our nation’s most prestigious teaching hospitals as indicated by just a few of the letters in the book that the Department of Anesthesia didn’t want their residents to read:
Hello Dr. Wible, I’m a surgery resident in New York. I began my residency in California and during that time was very depressed due to abuse within my training program. My depression impacted my performance and I was eventually fired. I was lucky enough to find another position and continue my training. However, some days I feel my depression and despair returning—primarily when I feel my career has been irreparably damaged by my departure from my first residency program. Those feelings were initially tied to hazing and bullying that are an integral part of the educational program there. . . I am reaching out to you for two reasons: I’m interested in eradicating the abuse in medical education. I’d like to have a career in academics and to influence policy regarding the treatment of trainees. More importantly, can you help me make the flashbacks stop? Can you help me not worry so much about my future? Can you help me with my depression related to my change in career trajectory? Thank you for your work! ~ Lisa
Pamela, When I share what happens in our academic medical center with my non-medical friends, they are astonished and disbelieving. The level of bullying in my institution is amazing, including a faculty member seriously suggesting that a resident’s mistake was so heinous that he should “off ” himself. ~ Vicky
Dr. Wible, I was dismissed from medical school in the beginning of my fourth year because I had a medical condition that didn’t help the school’s “technical standards.” I suffered abuse my entire third year from residents and physicians telling me that I wasn’t fit to be in medicine, that if I knew what was good for me I would just drop out. My school told me that being sick was akin to being unprofessional, and that I should give up my dreams of wanting to become a physician. They pulled me into their administrative office several times to harass me, and eventually told me that I was dismissed. I couldn’t think, I couldn’t breathe. If I hadn’t called my parents immediately and spoken to them, I don’t know what I would have done because only the worst was running through my head at that time. Medical schools need to be more attuned to their students’ needs and psyches before treating them like slaves or robots with no regard for human emotion. ~ Sarah
Pamela, In anesthesiology, it seems we have a higher percentage of death by suicide than other medical specialties. My colleague took his own life over a year ago. I was basically okay until then, but it’s how everyone reacted that really got me. The show must go on. We diverted patients the first night, probably because the ER had to see Joe when he came in. The next day all of us were back at work in the operating room. There was no time to grieve and we in the department were so stunned we did not know what we needed and what to ask for. It felt like abuse to not honor him or his colleagues with some rescheduling of operations. I will never be the same. I no longer see medicine as a force for good. It seems like it is a way for other people to make money off our talent, intelligence, education, or determination. He was my friend! ~ Bruce
Pamela, I lost another colleague and friend to suicide two weeks ago. As he was an anesthesiologist and I am an obstetrician, I saw him every day and had no clue that he was in such a state of despair. How can we recognize others in trouble? ~ Elizabeth
Dear Pamela, I suspect that you would be hard-pressed to find one of us who isn’t at least sometimes suicidal. We’re just not allowed to admit it as it would end our careers. ~ James
Sometimes I’m accused of harping on the problem of physician suicide without offering real actionable solutions.
I’ve extensively outlined primary, secondary, and tertiary prevention strategies that could be implemented for no or low-cost way back in 2014. In fact, I presented these simple solutions in Washington DC at the American Academy of Family Physicians Convention and published my recommendations in an article that became the #1 most-read and commented piece in the history of Medscape—Physician Suicide 101: Secrets, Lies & Solutions.
Four years later, I’m not asking for any special rights. What I’m suggesting is that doctors are afforded the same protections by the ADA, OSHA, HIPPA, and labor laws that all other Americans enjoy—including their First Amendment constitutional rights to free speech and to peaceably assemble to mourn the death of a colleague with a candlelight vigil.
Just extend those basic laws to include doctors. Then punish institutions that violate the human rights of their physicians.
If you or your colleagues have been the victims of human rights abuses in medicine, now would be a great time to file a class action lawsuit. Contact me if you need a good attorney. I’ve already got one lined up for you.