The Doctor-Patient Relationship Can be Found in the Graveyard of Informed Consent

My master that was thrall to Love
Is become thrall to Death.

— “A Ballad of Death,” by Algernon Charles Swinburne, Poems and Ballads, First Series, 1866

The 21st century is only in its infancy, and the United States has revealed itself to be a truly remarkable country. We have imaginary jobs, an imaginary middle class, imaginary checks and balances, and an imaginary society. We even have imaginary bioethics. At the root of this new and exciting phenomenon is the dismantling of informed consent and the disintegration of the doctor-patient relationship that has followed in its wake.

The privatization of health care has contributed to the weakening of the physician-patient bond, as health care has largely been taken over by the gangster capitalists of the pharmaceutical industry, the health insurance companies, device manufacturers, and hospital administrators. In a KevinMD article titled “The Self-Inflicted Death of the Physician,” an anonymous doctor writes, “For certainly we, as a profession, have handed over our authority to others, not all at once, but slowly, inexorably, over decades. We are just a shadow of our former selves.” Mirroring these sentiments, Linda Girgis, MD, writes in Physician’s Weekly, “The doctor is no longer center stage, unless you are watching a puppet show.”

In what will inevitably foment more unscrupulous behavior, MD/MBA programs are teaching doctors to think like businessmen, an irreconcilable contradiction. Hospital administrators are pressuring doctors to see increasing numbers of patients each day, while the health insurance companies continue to play a major role in stripping doctors of their autonomy by regularly countermanding doctor’s orders. This corporate coup d’état, rooted in avarice, callousness, and sociopathy has caused many clinicians to become unmoored from their traditional moral compass.

Physicians are now compelled to use electronic medical records (EMRs), which force them to waste countless hours doing mind-numbing data entry. If an attending physician decides to employ a medical scribe, nurse, or medical student to assume responsibility for this onerous task, it means that a third party will be in the examination room during patients’ office visits, which if done without the patient’s permission, constitutes an egregious violation of informed consent. It is also common for businesses to change the health insurance plans of their employees each year, which invariably results in many patients having to leave doctors that they have established long-standing relationships with, and who may be critically important to their physical and emotional well-being.

In addition to seeking assistance with EMRs, many physicians opt to bring interlopers into patients’ office visits, either because they prioritize teaching trainees to establishing a sound physician-patient rapport, or because they have figured out that it is much harder to be sued if there is a chaperone present in the examination room. Unsurprisingly, the medical institutions that spend the most money on glossy advertisements boasting of their boundless magnanimity and benevolence are frequently the institutions that are the most eager to bully patients into accepting a culture anchored in authoritarianism and absolute contempt for the rights of the patient.

In a KevinMD article titled “Electronic Health Records Cannot Replace a Doctor Who Knows You,” the authors write: “Ensuring the best medical care is not primarily a technical challenge. It is a human challenge, which requires patients and doctors to be able to form deep and long-standing relationships.” And yet American teaching hospitals are churning out delusional and hubristic creatures who have not been inculcated with a respect for patient privacy and informed consent, and who are incognizant of the fact that once these principles have been jettisoned the majority of their patients will neither trust, nor respect, nor confide in them. The deterioration of this vitally important relationship has resulted in a situation where it is increasingly common for patients to fail to disclose pertinent medical information. The deplorable state of the humanities and the rise of subspecialization have undoubtedly  contributed to this scourge of blindness in American health care.

Commenting on the dangers posed by medical scribes, Ami Schattner, MD, of the Hadassah Medical Center in Jerusalem, said in an interview with The Medical Bag:

I have serious concerns about the impact of scribes on the tender dynamic and intimacy of the physician-patient encounter. Perhaps the word ‘sanctity’ is not too strong when talking about the physician-patient relationship.

In an article titled “Shining a Light on Shadowing,” by Elizabeth A. Kitsis, MD, the author warns of the ethical ramifications of imposing pre-med students on patients during their doctor visits:

Physician shadowing by college students…may involve subtle coercion of the patient. To maintain his or her rapport with the physician, a patient may feel compelled to allow students into the examination room if his or her physician makes the request. However, the patient may resent the intrusion, and feel uncomfortable during the interaction.

Indeed, Kitsis’ words are also applicable with regard to nurses, medical students, residents, and fellows observing office visits. In an article in Medscape titled “What is Medical Ethics, and Why is it Important?” the authors write: “Ethical decisions cannot be avoided. Whenever doctors make a clinical decision, they are almost always making an ethical decision, consciously or not.” It is not even unusual for attending physicians to inform patients of ominous test results with their entourage in tow. While this may be very exciting for medical students it can be perceived as callous, degrading, and inhuman from the standpoint of the patient.

In “Stop the Anti-Doctor Media Bias,” by Rebekah Bernard, MD, the author writes that “Most physicians are dedicated individuals who hold patient care as sacrosanct.” I saw more doctors from 2016 to 2018 than a person would typically work with if they lived to a hundred, and have yet to see a single doctor’s office present me with a choice regarding the presence of observers during my office visits. In what could form the basis of a Kafka story, I had to voice my objections to the same institution and the same departments over and over again ad infinitum. Is this indicative of holding patient care as sacrosanct?

Jeremy Brown, MD, has proposed that doctors be equipped with body cameras, and Myles Riner, MD, supports the recording of physician-patient encounters, arguing in “Should Physicians Record and Share Conversations with Patients?” that “One thing is certain, this approach is certainly indicative of patient-centered care, and I think many patients would greatly appreciate the effort.” Not to be outdone, The New York Times has waxed glowingly on the subject of group doctor visits. Virtual office visits and doctor visits at work also pose a serious threat to confidentiality. So little value is placed on patient privacy that hospitals have even allowed television crews into emergency rooms, resulting in one New York widow turning on the television one evening, only to watch her husband die before her very eyes. Even if medical students attend a few decent lectures on bioethics, this is frequently negated by what they see their attending doing on a daily basis.

When the time comes for doctors to be patients, they often take for granted having the finest insurance plans which permit them to see any doctor without restrictions. This is in contrast with the majority of patients, who are increasingly restricted to narrow networks.

In a KevinMD article titled “Please, be kind to your doctor. We need it.,” Sara R Ahronheim, MD, writes: “But when I go home, I am alone; no one knows your stories, no one sees the tears you cried when I told you the awful things I had to tell you.” No one, that is, except the nurse, medical student, and resident who also happened to be hanging out in the room at the time.

What will become of the younger generation, being mentored as they so often are, in an environment where degradation is professionalism, indifference is empathy, and the most sordid behavior is hailed as “patient-centered care.” Indeed, this practice embodies everything base, ignoble, and treacherous in contemporary American health care. So relentlessly are patients besieged by these indignities, that there are times when I cannot help but wonder if these are really accidents and misunderstandings or the result of knavery and villainy. Teaching hospitals have a sacred duty to inculcate their trainees with a comprehensive understanding of, and respect for, medical ethics. All too often they are derelict in this duty. That so many attendings and their charges are indifferent to the physical, psychological, and emotional vulnerability of their patients underscores the fact that doctors and patients often speak in completely different languages.

This imposition of interlopers during physician office visits — a depraved reality show euphemistically called “team-based care” — constitutes a violation of every foundational tenet of medical ethics: informed consent, confidentiality, patient privacy, patient dignity, patient trust, and the oath to do no harm. Moreover, once trainees have learned to disregard informed consent with regard to nonconsensual physician shadowing, it is highly probable that they will do so again when the opportunity presents itself.

For instance, it is common for medical students and residents to be instructed to do practice pelvic exams on anesthetized patients, and the practice is legal in 45 states. A 2007 study done in Canada — a country with a comprehensive single-payer system — revealed that over 70 percent of medical students had done practice pelvic exams on anesthetized patients, and women have reported pain and bruising from these unauthorized exams.

Teaching hospitals frequently regard their patients, especially those who lack the best commercial plans, as their property. In an online forum on The Student Doctor Network where the ethics of having trainees perform practice pelvic exams on anesthetized patients is debated, AmoryBlaine writes:

It’s surprising how worked up some people get over the issue. You will be naked on a brightly lit table for all to see. A medical student will put a tube into your bladder. We’re about to flay your belly open and remove your uterus and ovaries. But to do a pelvic exam! What a violation! If you get into this habit of being deathly afraid of the patient’s feelings about an internal exam you will never learn how.

Glorytaker writes:

When I was doing OB/GYN as a med student, the attending would have me do a pelvic right after the patient was under and before we started surgery. Of course, we were doing GYN-related surgery and he wanted me to note the difference before and after a cystocele or rectocele repair. We didn’t exactly get permission but it was for teaching purposes.

Any rational layperson would be able to tell you that this is unethical, and yet many medical students and residents would disagree. What does that say about our education system? Perhaps it is this sort of degenerate thinking that led The Stanford Encyclopedia of Philosophy to nonchalantly point out that “The turn of the 21st century has seen doubts surfacing about informed consent.” The fighter pilot that bombs wedding parties in Afghanistan and the impressionable trainee who is taught that it is acceptable to do practice pelvic exams on anesthetized patients have much in common. For they have both been inculcated with a profound sense of blind obedience.

It is common for doctors to do nonconsensual episiotomies and pelvic exams on women in labor, and women are frequently coerced into having pelvic exams in exchange for birth control prescriptions. This is an example of how, with a medical degree and some mental gymnastics, blackmail and rape can be transformed into cod liver oil and brussel sprouts. Writing about the lack of informed consent with regard to Pap smears and testing for cervical cancer, Joel Sherman, MD, has pointed out that cervical cancer is very rare in the United States. In Finland women are given the option of being tested for cervical cancer once every five years. And in an article that appeared in The Milbank Quarterly titled “Cervical Cancer Screening in the United States and the Netherlands: A Tale of Two Countries,” the authors write, “Even though three to four times more Pap smears per woman were conducted in the United States than in the Netherlands over a period of three decades, the two countries’ mortality trends were quite similar.” Perhaps this egregious lack of ethics in obstetrics and gynecology should come as no surprise, considering the fact that James Marion Sims, who invented the speculum and who is widely regarded as the founder of modern gynecology, performed experiments on black slave girls.

Will a 25-year-old woman continue to trust her oncologist should she go into permanent early menopause following chemotherapy, and her oncologist failed to disclose this as a common side effect associated with her chemotherapy regimen? What is the likelihood that a cancer patient will continue to trust their doctors should they experience long-term chemotherapy-induced cognitive dysfunction, they are unable to continue with their career, and this too was not disclosed? Indeed, failure to disclose common long-term chemotherapy side effects is standard practice in many American cancer centers. It is also common for school districts to force high school students to undergo genital exams as a requirement to play sports, despite the fact that the scientific rationale behind the practice remains murky at best. And there are medical institutions, such as Memorial Sloan Kettering Cancer Center in New York City, that do not allow patients to change from one doctor to another within any given department, which can leave a patient torn between seeking care at an inferior facility or being the slave of an overbearing scoundrel.

Informed consent is absent in routine mammography screening, as no evidence exists that mammograms provide any benefit, whereas evidence exists that they have caused considerable harm. Obstetrics and gynecology aside, in no other specialty is there greater contempt for informed consent than in psychiatry, where dangerous side effects from psychiatric drugs are regularly withheld from patients and these drugs are even being prescribed for children. Psychiatrist Lawrence Kelmenson writes in “The Three Types of Psychiatric Drugs – A Doctor’s Guide for Consumers:”

Psychiatrists are seen as hard-working, caring, understanding healers, but they’re really snake-oil salesmen, drug-dealers, and master-sedaters. What they do should be illegal. Someday everyone will realize that not only do psychiatrists not heal anything, they’re a major contributor to the recent rise in suicides and overdoses.

Dr. Peter Breggin has echoed these sentiments, and actually specializes in getting people off these drugs.

It is common for patients who are perceived as “anti-authoritarians” to be diagnosed as “mentally ill,” and a number of school shooters were found to be taking powerful psychiatric drugs at the time they unleashed a fusillade of bullets on their classmates and teachers. Informed consent is frequently absent in the treatment of prostate cancer, and tens of thousands of American men have their prostates removed unnecessarily each year, only to fully understand the dire consequences after the damage is irreversible. (Consider the words of Atul Gawande, MD, in “Overkill:” “The forces that have led to a global epidemic of overtesting, overdiagnosis, and overtreatment are easy to grasp. Doctors get paid for doing more, not less.”) These are all examples of how informed consent is routinely disregarded in an unconscionable manner. The Tuskegee Alabama syphilis experiments, as well as medical experiments conducted on the downtrodden of IndiaAmerican prisoners, and on prisoners in Guantanamo are emblematic of the barbarities that can be unleashed when the celestial temple of informed consent lies in ruins.

After undergoing a surgical procedure in the summer of 2016, I was given a prescription for oxycodone, a semisynthetic opioid. Never was the highly addictive nature of this drug disclosed to me. Thankfully, Dr. Google informed me that oxycodone posed a “high risk for addiction and dependence.” Perhaps this might explain why, according to the CDC, “On average, 130 Americans die every day from an opioid overdose.” Many medical blogs delight in reminding us of the fact that the doctor-patient relationship is foundational to sound health care, and yet narcissism, moral bankruptcy, and careerism are endemic to our health care system. The erosion of trust that has followed this satanic cult of medical coercion has led to a situation where it has become harder for physicians to get patients to follow through with their treatment protocols.

The hazing and bullying commonly experienced by many trainees can cause medical students and residents to become jaded, and to lose their sense of empathy. Residents are often so exploited that many suffer from depression and are chronically sleep-deprived, and the brutal military-style training they are forced to endure can lead to many trainees forgetting that “gall bladder in Room 213” is a human being with a name. It is incontrovertible that corporations have undermined the doctor-patient relationship and inflicted catastrophic damage to our health care system. And while doctors must support the fight for single-payer, they must also acknowledge the fact that the cavalier attitude towards informed consent on the part of many American physicians has played a critical role in the dissolution of the public’s trust. Inexperienced patients naively assume that every doctor will have their best interests at heart. All too often, this is sadly not the case. Moreover, once this trust has been violated, it can result in grievous and long-lasting emotional harm. A clinician that is indifferent to the doctor-patient relationship, and who is only interested in scans, pathology reports, and blood tests has been infected with the virus of technocracy and fallen into a morass of charlatanism.

In the Charmides Plato wrote that “The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated.” Medical students and residents may learn how to diagnose and treat different diseases, yet are seldom inculcated with an understanding of medical ethics and why it is so indispensable. In “Bringing Hospitality Back to the Hospital: Lessons From a Bartender,” by Cory Michael, MD, the author writes: “People remember how you make them feel. They don’t care how much you know unless they know how much you care.” Medical terrorism and corporatization are the Goneril and Regan of medical sacrilege. Perpetually locked in a deadly embrace, they fuel one another’s nefarious designs. The tragedy is that so many medical students and residents are being seduced, not by the voice of truth, but by the voice of damnation. Let us recall the chilling words of Iago: “When devils will the blackest sins put on / They do suggest at first with heavenly shows / As I do now.” (Othello II.iii.)

Informed consent is a river that separates the consecrated light of morality from the profane and blasphemous abyss of amorality. Once this Rubicon has been crossed, there is no turning back. Those who have strayed from their sacred oath will find absolution not in the ways of the wicked, but in a return to the path of compassion, integrity, and righteousness. Indeed, dignity for the patient and dignity for the physician are mutually interdependent.

The doctor-patient relationship now lies buried in the unhallowed primeval ground; a cemetery where broken tombstones litter the earth with thorns and broken bottles, the land is barren and no flowers grow, and a once-proud beating heart beats no more. Only with a return to this inviolable bedrock of medical ethics can we embrace its resurrection.

David Penner’s articles on politics and health care have appeared in Dissident Voice, CounterPunch, Global Research, The Saker blog, OffGuardian and KevinMD; while his poetry can be found at Dissident Voice, Mad in America, and Also a photographer, he is the author of three books of portraiture: Faces of The New Economy, Faces of Manhattan Island, and Manhattan Pairs. He can be reached at Read other articles by David.