Legacy

The fundamental essence of medicine is trust. Without trust, there can be no meaningful doctor-patient relationship. The sine qua non of the professional person is that they are honest. “Trust me, I’m a doctor” is a sad myth that has always been based more on hope and need than reality. Yes, the reality that (some) doctors lie is not a novel conclusion. This was put into a very tangible perspective by BM Hegde, retired Vice Chancellor from Mangalore in India in a rapid response to the BMJ.^[1] He referred to the Nuciform Sac in George Bernard Shaw’s wonderful satire, “The Doctor’s Dilemma.” (Look it up!) Vested interests in the profession will lead to doctors who lie for profit or financial gain. Doctors will lie to avoid accountability when confronted by exposure from a whistleblower. Unethical medical experts will lie in court for personal and professional advancement. A sad thing is that few will live out their professional career without some personal knowledge of, or impact from, matters arising from professional dishonesty.

Take the case of Peter Brookes,^[2] a burn surgeon from Nottingham in the UK. Peter had raised concerns about patient safety, in particular the safety of children with burns. The issues related to clinical cover and the commitment of those supposedly in charge. Peter was branded a whistleblower. He was hounded and harassed, and his life turned into a nightmare. In the early hours of January 14, 2021, in what can only be regarded as a moment of insanity, Peter got on his bicycle, donned a ski mask, and set out into the freezing night armed with a knife, a crowbar and a bottle of flammable fluid. His destination was the house of his arch nemesis, Graeme Perks. Graeme was the head of the plastic surgery unit and had been instrumental in pursuing disciplinary action against Peter. A fight ensued leaving Graeme critically injured, while Peter fled the scene and was found sleeping outside in the freezing January morning. Peter is currently on trial for attempted murder. I met Graeme many years ago when we were trainees in Manchester and more recently, after retiring from the Chinese University in Hong Kong, I did 1 year as a locum for Peter in the burns unit in Nottingham.

Dr. Chris Day^[3] was a young and enthusiastic junior doctor with his life and dreams ahead of him. In 2013/2014, Chris raised some very legitimate concerns about patient safety in the intensive care unit of a South London hospital. Instead of dealing with the concerns, senior NHS managers and officials began a campaign of lies and misinformation branding Chris a whistleblower. The NHS has used almost 1 million pounds of taxpayer’s money paying lying barristers to defend the indefensible. Chris has endured a relentless attack on his integrity and reputation by institutions responsible for the training of doctors and the care of patients. In a recent bizarre twist in this tale, a hospital official went into his workplace and deleted thousands of emails on the day he was supposed to attend court for cross examination. Where is the accountability? I know Chris and am one of many who had the privilege to help with funding his legal defense.

Dr. Vanessa Kwan^[4] is a cosmetic surgeon in Hong Kong. Her case is particularly troubling as she was on trial charged with causing the death of a patient following a liposuction operation. There is no doubt that some of the aspects of the case reveal Vanessa engaging in clinical practice that was less than desirable but certainly not illegal. Further, causation and correlation are very different and need to be clearly defined. Of note, the cause of death has never been established. What is not in dispute is that the prosecution called on medical experts who had no problem with lying under oath. That is a crime. It is called perjury. Vanessa is now in prison, incarcerated for 6 years while the “real” criminals carry on fabricating truth and justice. I know Vanessa and was involved in reviewing the clinical details of her case.

I have described just three recent cases where I have some personal insights which allow me to differentiate between the real and the false “news.” There is absolutely no doubt that in each case, great harm has been caused by doctors who lie. When doctors lie in the course of their professional duties, they no longer deserve to be called professionals. Indeed, I think that being a professional is a matter of character, not occupation. For a doctor, the fundamental basis of the relationship with the patient is one of trust. No honesty. No integrity. No trust. Why do we allow these people to continue calling themselves professionals?

The world is going through unprecedented times. Major changes are occurring in the moral value of the virtue of honesty. Honesty is being devalued and we see little accountability associated with dishonesty at the highest levels of government in some of the world’s most powerful economies. Propaganda remains strong and insidious leading to confusion and instability in society. Fake news is rife. Across the globe, we have seen a lack of coordination to fight a single disease, COVID-19, resulting in very different responses in terms of cases and deaths. We have seen public health driven to the forefront of policy and we have seen the complete fracturing of the relationship between science and medicine. Conspiracy theories have flourished and we have seen doctors shout down other doctors when talking about treatments, the use of masks, lockdowns, vaccines, and other drugs.^[5-7] Meanwhile, set against this backdrop, there are continuing cases where “Whistleblowers” are fighting for survival.

The treatment of whistleblowers is a matter of increasing concern as more cases come to light illustrating how establishments respond to justifiable criticism. The “establishment” may be any organization with money, power, and resources to deliver care or services to others. The whistleblower is too often an individual who has to wrestle with their conscience to decide whether to keep quiet or to speak out. The cost of speaking out can be devastating in terms of career advancement as well as being detrimental to mental, physical, and financial health. Is it worth it? What is the cost of keeping silent? It may be a patient safety issue. It may be a culture of discrimination or abuse. Keeping silent has a cost too. Surely, it should not be left to individuals to make such a choice? Indeed, the power differential between an individual and an organization is just too great, and I would strongly counsel individuals not to make complaints to anyone within the organization which employs them. That is not to say, do not complain. While cultures are changing and more protections are being created for formal “whistleblowing,” it is still best to adopt a cautious approach. This involves finding the support of like-minded people and/ or finding organizations that represent the interests of the individual in the context of the organization. This is where unions or professional associations can be very helpful.

We generally think of a legacy as something that an individual leaves behind for the benefit of others. Something that they will be remembered for. This is not something that many doctors consider although there is increasing commercial pressure to be proactive in creating a legacy. It is possible to find professional “Legacy planners” or “Legacy gurus.” I have no problem with individuals who are concerned with creating their own legacy, but I think we also should look at legacy in generational terms. A collective legacy that we, as professionals, want to leave for future generations. No matter where we are trained or where we currently practice, we will have taken pledges usually based on the Hippocratic Oath to adhere to the fundamental ethical basis of being a true professional, a doctor. We work in the context of a regulated framework with codes of conduct. In Hong Kong, there is a medical council and it issues to all registered practitioners the professional code of conduct. The introduction to the code begins thus:

“Medicine as a profession is distinguished from other professions by a special moral duty of care to save lives and to relieve suffering. Medical ethics emphasizes the priority of this moral ideal over and above considerations of personal interests and private gains.”

It then continues with a statement that focuses on the key moral virtue of honesty:

“Trust is essential to the practice of medicine. There can be no medicine in the absence of trust. The patient’s trust imposes on the doctor a corresponding duty to be trustworthy and accountable.”

As mentioned above: No honesty. No integrity. No trust. If we cannot be trusted, then we cannot call ourselves doctors. However, if we do want to be doctors, then we must have zero tolerance for dishonesty in our own professional lives. That is the beginning of a legacy that we can share. What makes such a legacy more powerful is when we extend zero tolerance to others. How that “zero tolerance” is actually affected is a great challenge and ultimately a matter of wisdom. Right from the days of being a student, it must be stressed over and over that lying will not, cannot, be tolerated. A junior doctor who makes up laboratory test results is dangerous but the senior doctor that creates an atmosphere of fear so that junior doctors lie is also dangerous. We absolutely need the truth even if the truth is that we have overlooked or forgotten something. Hence, zero tolerance must be nuanced. We all make mistakes as human beings. Honest mistakes require forgiveness. Where dishonesty can be so destructive is when it is used deliberately to cause professional harm to another doctor. This behavior cannot be forgiven or overlooked. Sadly, the scope and extent of such dishonesty in the medical profession appear to be increasing year on year. This is not good. And standing by and doing nothing is not an option. So, our legacy? We have to push back.

There is a saying that a journey of a thousand miles begins with one step. As we have seen from history and our current observations, medicine has always had an ambivalent relationship with honesty. Accepting that and ignoring it is not an option. To acknowledge the problem and to seek solutions is the only virtuous option. We begin with ourselves and reach out to others of similar moral value. Real doctors and professional doctors are honest, have integrity, and earn the trust of patients and colleagues. There can be no medicine without trust. Let that message be our legacy and let us act accordingly.