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World's First Treatise on Physician Abuse

Research:  Dr. Richard Kluft

Dr. Richard Kluft Treatise:  Précis

Dr. Richard P. Kluft, graduate of Harvard University, wrote the world's first treatise on abuse by physicians:

The Physician as Perpetrator of Abuse [PDF]

Exploiting patients is forbidden by every code of medical ethics from the Oath of Hippocrates to sequential iterations of modern Medical Bylaws. Reality, though, falls far short.

MDs are in a power position vis-a-vis their patients. This power can be misused. Kluft defines 7 ways, citing 26 (disguised) cases from his clinical practice.

When MDs abuse individuals or society, it is a form of Affinity Fraud. Kluft concludes with guidelines for management.

Seven Varieties of Medical Transgressions

In 1993 Richard P. Kluft, MD wrote the western world's first treatise on physician abuse. He illustrated his points with 26 true examples gleaned from the charts of the high-toned American hospital where Kluft worked. (Identities were masked to preserve confidentiality). Said Kluft:

A general literature on abusive behavior of physicians other than therapists has been slow to develop. Abuse by MDs is an unpleasant but increasingly important topic. It has been studied and researched little, apart from a recent focus on sexual exploitation of patients by mental health professionals. This treatise draws attention to seven varieties of abusive behavior by doctors:

  1. MDs acting as agents of social control;
  2. MDs subverting medical rights and prerogatives for illicit purposes (this includes unnecessary medical procedures, a form of assault);
  3. MDs exploiting the power of their profession to gratify personal needs related to their own neurotic or character difficulties;
  4. MDs allowing the subversion of their medical judgement, co-opted by others whose intent is abuse;
  5. MDs causing suboptimal health care to be delivered;
  6. The MD's role in dehumanizing medical care; and
  7. MDs as perpetrators of sexual misconduct.

Kluft does not try to address the full range of human misbehavior by physicians: he does not cover fiscal fraud or malpractice unrelated to abusive activities. The scope of his treatise is physician abuse of patients. The version below was shortened slightly to place the focus on physical diseases and the general doctor-patient relationship. No other edit was contemplated: Kluft broke new ground, and his work remains fresh today.

FAMILY VIOLENCE AND ABUSIVE RELATIONSHIPS

THE PHYSICIAN AS
PERPETRATOR OF ABUSE

Richard P. Kluft, MD

From the Oath of Hippocrates to The Principles of Medical Ethics of the American Medical Association, the ethical codes of the medical profession have prohibited and proscribed the exploitation of the doctor-patient relationship. Hippocrates' Oath commands the physician to swear:

By Apollo the Physician, by Asclepius, by Health, by Panacea, and by all the gods and goddesses, making them my witness, that I will carry out, according to my ability and judgement, this oath and this indenture: … I will follow that method of treatment which, according to my ability and judgment, I consider for the benefit of the patient, and abstain from injury or wrongdoing. … With purity and holiness I will pass my life, and practice my art. … Into whatever houses I enter I will go into them for the benefit of the sick and will abstain from every voluntary act of corruption or intentional wrongdoing; and further from the seduction of females or males, bond or free. … Now if I carry out this oath, and break it not, may I gain forever reputation among all men for my life and my art; but if I transgress it and forswear myself, may the reverse be my lot. [24, 44]

Composed nearly 400 years before the common era, this oath speaks explicitly of the potential for abuse and exploitation inherent in the doctor-patient relationship. It emphatically commands the physician to respect and protect the vulnerabilities of those to whom he or she attends. It demonstrates a recognition, across times and culture, of the tremendous power accorded to the physician by the patient and the potential for that power to be misused.

A benign and caring relationship is assumed to exist between the medical professional and the patient, a relationship in which the one is designated to provide help for the other. The character and ethics of the physician and the prescribed roles and constraints that define professional behavior are held to be major safeguards for the patient, the weaker partner in a situation characterized by a profound imbalance of power.

Virtually all who have investigated the sexual exploitation of patients by health professionals have acknowledged the tilted nature of the doctor-patient interaction. Most have seen it as having much in common with the parent-child relationship, and have drawn analogies between such misconduct and incest. [4, 8, 10, 11, 12, 15, 16, 20, 22, 23, 25, 28, 29, 35, 39, 45]

The stature, power, and authority accorded to the physician stems from innumerable sources:

  • the influence of the physician's specialized knowledge (which may be inaccessible, incomprehensible, or both to the patient);
  • the privilege accorded to the physician to see and hear what is usually cloaked in privacy;
  • the importance of the physician's function to those who become patients;
  • the dependence of the sick on the physician for their recovery; and
  • the status of the physician as a valued member of the community.

The patient who comes to a physician, modern consumerism not withstanding, enters a relationship that has the potential to mobilize a regressive state of mind in the patient that bears striking analogies to the dependent mind set of the hurt child who comes to a parent, in pain, for relief of his or her distress. (But) the bond between doctor and patient (should be) a working alliance or therapeutic alliance. This alliance consists of the hopeful and more rational bond between doctor and patient to accomplish the work of the medical intervention and is most manifest in the patient's cooperation with a recommended regimen.

Its absence is all too apparent. It is crucial to be aware that the feelings patients have toward doctors may have relatively little to do with the here-and-now physician, and more to do with the there-and-then physician who treated/mistreated the patient in the past. But those past experiences amplify the current physician's power severalfold. When this power is exercised with benign compassion, it enhances the healing capacities of the physician. But if applied to inappropriate ends, it magnifies the likelihood that malign ends will be achieved.

In sum, the doctor-patient relationship is one in which profound psychological and sociologic pressures are placed on patients to abandon an adult role, suspend critical judgement, and to place themselves in a dependent position subject to the physician. Furthermore, in such a state, they may become relatively more suggestible than they would be in other situations. The patient who is in severe distress may, furthermore, enter a somewhat altered state of consciousness. Dissociation is a common response to severe stress or trauma. [30, 37, 38] It is worth noting that these characteristics are not unlike the relationship of the hypnotist and the hypnotist's subject. [5] Again, the nature of the situation holds the potential to accelerate either benign or exploitive interactions.

Ideally, patients enter the physician-patient relationship prepared to understand the nature of their circumstances, profit from the doctor's advice, and ready to ask important questions. Ideally, patients are able to ascertain whether they are comfortable with the doctor and the proposed course of action. Reality often falls short of these ideals. One example: a doctor may spend a generous amount of time talking to a patient and his or her family, but in the early stage of a dire illness, the patient or family may be too overwhelmed to absorb all the doctor said.

It is by no means universal or inevitable that the patient's ability to appreciate his or her circumstances is compromised, but it is not uncommon for the patient to be in an extremely vulnerable state of mind in his or her relationship toward the doctor. This vulnerable state, however benign or unintended its origin, allows the patient to be influenced more readily than would be the case in a less charged and complex relationship. It can be exploited by the unscrupulous.

To the extent that the patient is dependent on someone for his or her well-being who has superior knowledge and power and who is perceived as the embodiment of the parental omnipotence encountered and depended on by a young child, the doctor-patient relationship is a parent-child relationship in form and structure. The psychological experience of the weaker party is that of a child rather than that of a competent adult. The mistreatment of the person in the dependent position is analogous to child abuse in its dynamics and its impact.

Working from another perspective, Feldman-Summers has applied the legal term, fiduciary relationship, in her study of doctor-patient relationships. This term refers to a special relationship in which one person accepts the trust and confidence of another to act in the latter's best interests. [11] Black's Law Dictionary [2] states that a fiduciary relationship exists: where there is special confidence reposed in one who in equity and good conscience is bound to act in good faith and with due regard to interests of one reposing the confidence.

As Feldman-Summers [11] explains, there is no doubt that physicians, among other professions, are fiduciaries: People in these professions as a matter of course hold themselves out as worthy of the trust and confidence of their patients or clients, and routinely profess that they are bound to act in the best interest of those who seek their services. Part of the role of the doctor is to behave in a manner consistent with being the repository of the patient's trust; part of the role of the patient is to accord that trust to the doctor. The doctor who chooses to misuse that trust is in the position of the fox assigned to guard the hen house.

Temple University School of Medicine
Philadelphia, Pennsylvania
PRIMARY CARE Volume 20 No 2

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