Wednesday, December 08, 2010

IMPEACHMENT: IT’S ABOUT THE INSTITUTION, NOT THE PERSON

IMPEACHMENT: IT’S ABOUT THE INSTITUTION, NOT THE PERSON

The impeachment trial of Judge G. Thomas Porteous of Louisiana this week was a lesson in civic ethics. The lessons of the Porteous trial apply to academic medical centers, professional medical societies, medical journals, and granting agencies like NIH.

The Porteous trial is a straightforward case of bribes, kickbacks and corruption involving a Federal judge. The most enlightening arguments came from prosecutor Rep. Adam Schiff, D-California, laying out the case for impeachment in the Senate. He gave a lucid presentation of the logic and the historical origins of the impeachment process. The key points are these: impeachment serves to protect the dignity, honor, and credibility of the office more than to punish the wayward office holder; and impeachment is a constitutionally sanctioned way to clean the Augean stables without necessarily having to prove criminal liability. It is sufficient to demonstrate that the bad actors have brought disgrace on their offices.

What this means for us in medicine is that legalistic charges and defenses are not the right way to go in exposing and ejecting bad actors from our field. In the highly publicized cases of ethical compromise over the past few years, our group disapproval, when there was any at all, generally has run on two parallel tracks. The first is legalistic, and it favors the bad actors, who flaunt their constitutional protections with the taunt, prove it. The second ground of disapproval is esthetic, based on the tackiness of the bad actors’ behaviors – regardless of technical legalities, what they do is an affront and an insult to professional standards and mores. When we look at how recent incidents in medicine actually played out, however, we see a disconnect. The bad actors have narrowed the debate to the first ground of disapproval, while forcing the second off limits. In this strategy, they have received conscious or unconscious assistance from the professional establishment. The focus has been on legal technicalities involving the bad actors rather on preserving the dignity and credibility of high offices in academic medicine.

For instance, when Charles Nemeroff was exposed by Senator Grassley for conflict of interest in his NIH grants, he came up with the contrived legalistic defense that his unreported payments from GlaxoSmithKline were for ‘CME-like’ presentations, and thus somehow exempt from disclosure. Nemeroff’s obfuscations finally collapsed of their own weight and Emory University took decisive action against him, even though they had sufficient evidence dating back at least 4-5 years. In the end, Emory had to go through the wringer to discipline Nemeroff, and the institution suffered grave damage to its reputation for a number of years as the price of delay.

For instance, when Thomas Insel, the Director of NIMH, assured Pascal Goldschmidt, Dean of the School of Medicine at the University of Miami, that Nemeroff was absolutely in good standing for applying for new NIH grants if he left Emory for Miami, despite a 2-year ban at Emory, he hewed to the letter of the law while disregarding its spirit in order to help his friend. Moreover, when Insel appointed Nemeroff to two new NIH Research Review Committees, he established beyond any doubt that he was intent on trying to help Nemeroff get back into circulation, and that he failed to grasp the gravity of the dishonor that Nemeroff inflicted on the field. This obtuseness on Insel’s part damaged the credibility and reputation of NIMH. To his credit, NIH director Francis Collins finally ‘got it’ and forced a review of the NIH ethics rules that had been entrusted to Insel.

For instance, when Pascal Goldschmidt, Dean of the School of Medicine at the University of Miami, claimed he had done due diligence in his recruitment of Nemeroff as chair of his psychiatry department in 2009, he focused on the legalistic aspects of Emory’s review of Nemeroff, while failing to understand the degree of negative publicity associated with Nemeroff’s name. He ended up hiring someone who is an object of ridicule, and he in turn is ridiculed by association.

For instance, when Stanford University learned of Alan Schatzberg’s boundary violations vis a vis his NIH-funded projects and his personal corporation, they first pushed back on legalistic technical grounds. Only later did the Stanford administration get the message by removing Schatzberg from his Principal Investigator role with NIH grants, and eventually appointing a new chair of psychiatry. Meanwhile, the public image of Stanford suffered.

For instance, when the American Psychiatric Association was warned that Alan Schatzberg was a problematic candidate for election as President of the association on account of his history of ethical compromise, they went ahead anyway and they have since had opportunity to regret that decision. Here again, the professional society appears to have lost sight of the ethical forest for the legal trees. The credibility and reputation of the APA have suffered because of the taint associated with Schatzberg’s presidency.

For instance, when the New York Times recently exposed the ghostwriting associated with the 1999 textbook of Charles Nemeroff and Alan Schatzberg, the so-called authors responded with typical legalistic defenses. They and the University of Miami and the American Psychiatric Association Press (the publisher) again lost sight of the ethical forest for the legal trees. This stereotyped, public relations driven response ignores the visceral and esthetic distaste most observers felt on learning about the collusion between the ‘authors,’ the professional writing company and the sponsoring pharmaceutical corporation. Even the defense that it occurred a long time ago fails. In the Porteous trial, the prosecution established that dishonorable events in an officer’s past are grounds for impeachment, whether or not they also occurred during the person’s time in office.

For instance, when Harvard Medical School planned a new CME program on psychopharmacology in mid-2011, they engaged a number of compromised academic speakers, including Nemeroff and Schatzberg. What the hell was Harvard thinking? I told the Course Director, Carl Salzman, that this amounts to pandering. He replied defensively that Nemeroff and Schatzberg are well regarded speakers and that he would ensure that they gave unbiased presentations. That’s not the point. The point is that they have done serious damage to our field, and for Harvard Medical School to give them top billing amounts to denial of the elephant in the living room. It’s collusion in service of their public rehabilitation. I told Dr. Salzman that his logic amounts to compartmentalized thinking. I might have added that Adolf Hitler gave a lot of great speeches that received rave reviews and that compartmentalized thinking was widespread in the nation of Germany between 1928 and 1945. Meanwhile, Harvard Medical School gets a black eye through its association with these compromised individuals. So do the other speakers who will be on the panel. Who needs this kind of taint? Dr. Salzman can defend Nemeroff and Schatzberg all he wants on specious legalistic grounds, but who cares? Harvard Medical School could use some moral clarity.

So, we come back to the impeachment trial of Judge Porteous. Impeachment protects the institution. When sleazebags get into positions of authority and trust they need to be dumped, and our professional and academic institutions need to have enough spine to dump them. At the very least, we don’t need to tolerate institutions like Harvard Medical School pandering to compromised academic bad actors. For shame.

6 comments:

Scot M Silverstein MD said...

I told the Course Director, Carl Salzman, that this amounts to pandering. He replied defensively that Nemeroff and Schatzberg are well regarded speakers and that he would ensure that they gave unbiased presentations.

Perhaps Salzman will ghostwrite their presentations for them.

-- SS

John M. Nardo MD said...

Eloquently framed.

Salsman's comment that, "... he would ensure that they gave unbiased presentations" mirrors Dean Goldschmidt's reassurance when he hired Dr. Nemeroff in Miami, "Charlie committed to me that he would never make these mistakes again, and I am scrutinizing his activities to make sure that that remains the case." Emory Medical School took that same path for over a decade to no avail.

The repeated ethical [and worse] violations of Dr. Nemeroff and Schatzberg are now a matter of public legend. The fact that Tom Insel, Director of the NIMH, Pascal Goldsmith, Dean of the Miller School of Medicine in Miami, and Carl Salsman, Professor of Psychiatry at Harvard Medical School, are continuing to defend and actually promote these two men points to a profound systemic flaw in Academic Psychiatry - the stuff of tragedy.

In the past, impeachment in Academic Medicine was by expulsion. Failing that, it looks like boycott in the next available option.

Anonymous said...

What I find so disturbing is these are the very people who should be most sensitive to the underlying message promoting questionable speakers sends to the profession.

We seem to have moved from: How does that make you feel to I don’t care how you feel as long as I and my buddies make ours.

Steve Lucas

Roy M. Poses MD said...

Can anyone imagine a medical school hiring a junior faculty member whose presentations were likely to be so questionable that the Dean would have to monitor every single one of them? It would never happen.

This clearly shows the double-standard: one for the people who bring in a lot of money, no matter from where, and/or are the cronies of the leaders, versus everyone else.

No wonder, as I have posted before, the majority of faculty think they have been hired ONLY to bring in money:
http://hcrenewal.blogspot.com/2010/12/american-medical-schools-are-only-in-it.html

A long time ago, when the AMA code of ethics required that medicine not be commercialized, the AMA could also sanction members who broke the code. All that changed in this country with the US Supreme Court decision about the interpretation of anti-trust law (not the Constitution) that was seen as violating professional societies' regulation of their members ethics as being somehow monopolistic. This could have been reversed by a revision of US anti-trust law, but that never happened. See this post:
http://hcrenewal.blogspot.com/2009/06/why-did-us-physicians-give-up-their.html

Clearly, we need to resurrect meaningful ethical codes of conduct for physicians (and other health care professionals, and those who lead health care organizations) at a bare minimum.

Afraid said...

This is a post of importance Roy. It lays out the problem and points roughly to the solution.

So much of our American life is permeated by the "Hey, but its legal!" argument. Now its gone a step further to "Hey they didn't prosecute!"

We the people know pretty much what the situation is, and we don't like it but we feel powerless to change it. Money rules all.

Monopolies/dualopoloies of course have the best position, and an "800 pound gorilla" in a marketplace is not far behind.

I doubt we can expect our government to act, it is the biggest monopoly there is, and includes a faux-competition dualopoly as cover.

Are we on the verge of another 1960's type meltdown? Where protests get bigger and bigger, and voting changes occur and the 'silent majority' voted with their purchasing patterns?

Does the internet now facilitate mass action? Has that been successful yet? Could it be successful if it were used ONLY for bad acting companies/people/etc. and not as a political ploy? Will the forces of commercialism learn how to dominate the conversation on the internet too?

If the president's bully pulpit and enforcement responsibility could be used for greater good in the time he has left, maybe that would jump start the process.

They don't have to lose in court to be disgraced and paupered.

Anonymous said...

Thanka for the article. As a layperson, my view is that patients have only one recourse--lawsuits, if they can afford the costs. WE cannot change doctors' behavior--only their peers can do sthat. A meaningful effort to self-police (in my opinion) would reduce lawsuits, restrain burgeoning costs, and restore the trust that has slowly slipped away from this once-noble profession.

--Melody