Wednesday, March 11, 2009

Medicine, Harm, and the Human Response

M. Scott Peck lead a three psychiatrist team appointed by the Army in 1972 to examine the "group evil" called the My Lai Massacre. His experience in this investigation lead him to develop a theory of "human evil" that appeared in his second book, "People of the Lie." After offering a psychology of love in, "The Road Less Traveled," he explored the psychology of evil in his second book. It is one of my favorite books--not because I agree with all of Peck's theories, but because he asks a simple question that troubles us all at some time in our lives, "How is it that normal people, individuals who may be upstanding citizens in many situations, end up doing unspeakably evil things to others--and even seem to have no recognition of the harm that they cause?"

It is a challenging and frightening question for us all. It is a question that points to the dark side of life and wonders. Can we understand more about good by understanding more about evil? It is a question that has been asked by many generations, in many ways. Lao-tzu framed it this way, "When the people of the world know beauty as beauty, there arises the recognition of ugliness. When they all know the good as good, there arises the recognition of evil."

In medicine, as a whole, we try ardently to do good. Although I have read about medical providers who try to hurt patients, in 29 years of practice I have never met such a person. However, medicine does cause great harm to patients (often without knowing it)--what used to be called iatrogenic harm. Iatro- meaning physician, -genic referring to causation, unintentional harm caused by the medical system--by the act of doctoring.

The wrong medicine is given and the patient has a side effect. The wrong diagnosis is made, and the correct one is missed. Care is delayed, and the disease gets worse. All of these, and other situations occur on a regular basis. So much so that the IOM estimated in 1999 that the US health system kills between 48,000 and 98,000 patients unnecessarily every year.

I wonder if it would be useful for us in the field of medicine to explore Peck's experiences and concepts? Could it help us to understand the harm that we cause and find ways to avoid it? Not because we as individuals intend any harm to our patients, not because medicine is evil, not because what we do is similar to My Lai; but because we, as a system, do cause harm to our patients--harm that happens despite our best intentions.

Some background is needed for me to ask the right questions.

On March 16, 1968, Charlie Company murdered between 300 and 500 unarmed civilians in the town of My Lai, South Viet Nam. The civilians included many women and children. The murders were horrific--individuals were tortured, mutilated, raped, signatures of the killers carved in the flesh of some of the deceased. Hundreds of soldiers witnessed the event, scores participated in the murders. Only one officer, Hugh Thompson, Jr., tried to stop the killing, and after he subsequently filed a formal complaint the facts of the event were covered up by scores of upper echelon officers in the Army.

How could that possibly happen? There is no evidence that these soldiers were inherently "bad" people. It is statistically impossible that all of the hundreds of soldiers involved both directly and indirectly could possibly be a random conglomeration of evil, peculiar, or sociopathic individuals. There is no evidence that the soldiers planned this attack days in advance. Yet, they all participated in a serious wrong doing. A wrong doing that is not unique. In every war throughout history, similar episodes have occurred. Indeed, episodes similar to My Lai occur today in parts of the world that practice genocide. In many ways, it would seem that this behavior is "hard wired" into the human behavior system--triggered in certain extreme ways.

How is it that one individual, apparently no different than the rest, was able and willing to stand up to his colleagues and attempt to stop them in My Lai? What is different about Hugh Thompson that made him approach the massacre differently than all of the others? And, more relevant to us who have made a career from the study and treatment of the human situation, "What does this sad episode say about the human process of 'group think' and 'group morality?'

Peck developed a psychological theory of "human evil" in order to explain the sad facts before him. He noted that when individuals see themselves as part of a group under stress, they tend to abdicate their ethical decision making to the "others" in the group. "Others" can mean one person in the group or many people; but often means the "lowest level of common assessment" in the group. That is, when all members of a group take action based upon an assessment that the group is "responsible" for the actions--then no one is really responsible and the only limitation of group behavior comes from the most "base" levels of our humanity. Furthermore, Peck observed in this case, and in others, that denial of reality is a prevalent coping "skill" that humans use to deal with stress and uncertainty--a "skill" that he calls "evil" when it is used constantly by individuals.

This is not the typical form of denial (i.e., the initial response to loss, or the childlike response to making a mistake). The type of denial that Peck talks about is a pervasive personality structure that constantly and persistently causes the individual to frame all experiences so narcissistically that the reality of the outside world becomes secondary to the internal fantasy world of the individual. DSM might call this a form of narcissistic personality disorder or some form of sociopathy when it is happens to one individual, but Peck wasn't trying to talk about diagnoses of one individual. Rather, he was concerned about how humans do "evil" as a group.

He observed in his discussions with involved soldiers that each one individually believed that the massacre had been sanctioned by "someone higher in the chain of command." The individuals claimed that they felt justified by that belief. In addition, they did not see the dead as innocent victims. They felt like they were "the enemies" even though they were mostly women, children and elders. The episode seemed "unreal" to the individuals involved. And, since they had been trying to kill as part of the war, the killing did not seem "real."

In the end of his analysis--he reasoned that, when "group dynamics" are active, the simultaneous (1) abdication of responsibility and (2) individual "denial of reality" enables the group to cause harm without limitations--almost without recognition of the harm.

"What does this have to do with medicine," you ask. "Has Jeff 'gone off the deep end?" Does he believe that medical mishaps are like mass murder. NO! But I do wonder if the extreme case of My Lai gives us an insight into human behavior that can help us in our own "group function." Let me ask the questions that challenge me when I think of all of this. Your answers will determine whether it is relevant to medicine or not. I do not have any answers, just questions.

Do doctor's constitute a group that functions based upon "group dynamics?" What about the entire therapeutic team? Is the practice of medicine akin to "group think?" Do we take for granted that the system of care, as it currently exists, is necessary to the health and well being of our patients? Do we, as a whole, take individual responsibility for the actions of the group? Do I think of myself as responsible for the medical errors made at CCRMC? Do you think of yourself as being individually responsible for those episodes of harm? Are we individually responsible for the harm caused when mistakes are made at some hospital in Florida (or anywhere else)? Does medicine freely admit its mistakes? Do we see bad outcomes as "necessary evils" of the process? Do we challenge bad or useless research? Do we accept clinical practices merely because "experts" tell us it is the "standard?' Does US medicine accept that the public thinks that we provide a mediocre product that costs double what other health systems cost? Do we acknowledge that the standard measures of health care quality in the US are far below where they should be? Is it all the insurance company's fault? or the lawyers'? or the administrators'? or the drug companies'? Do we accept the reality that we are fallible? Do we tell patients that we have harmed them? When we do make a mistake, do we blame someone else--a colleague or a nurse or the patient? Do we acknowledge that it is impossible to practice medicine, as it is currently practiced, without mistakes? Does that mean we try to change the current style of practice, or that we are satisfied with the incidence of harm? Do we acknowledge the fact that many of our "interventions" are not proven to be effective (we do not have an evidence basis for many treatments)? Do we truly weigh the risks and benefits of intervention in each case? Do we challenge the "system" when "new technologies" cost more and bring no really significant benefit to the health of the patient? Do we challenge the medical schools who produce many more specialists than primary care physicians?

In essence, do we in health care have a risk buried deep in our profession...the risk that we may function as a group that abdicates individual responsibility for the harm that we do and relies upon a false sense of beneficence that we have as a group to comfort us when mistakes do occur? If so, is it possible to change this structure? How can we be more like Hugh Thompson--unwilling to buy into the (1) abdication of responsibly and (2) the individual denial of reality? What characteristics make us different from the military men who acted at My Lai? How are we similar? Do we need to create systems that will modify "hard wired" behavior that is problematic? Do we need to change the entire belief system of health care?

Do we face the risk of being good people who cause bad things to happen without really being aware of the extent of injury? And, most importantly, can we, as a group, change our system of care so that harm does not occur?

My final question, "Can we learn from Peck about the human condition, and take steps to improve our systems of health care?

Lots of answers from me. The answers are yours.

1 comment:

  1. Absolutely fascinating post. I was very struck by Scott Peck's chapter on the My Lai massacre when I read his book a couple of years ago and have often seen (thankfully much less atrocious) parallels in society since. All who work for big institutions need to think these things through.