Examining the duty of physician officials in the government [PODCAST]

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“The duty of physician officials in the government exceeds that of other officials. As physicians, they have a unique moral obligation to do more than protect the constitution from enemies, foreign and domestic. They have a duty to be unambiguously truthful, to use their power to do good, and to avoid harm. If they fail in any of those regards, they must be held accountable by their peers, and by society. This is especially urgent when those who appointed them to these positions of authority fail to manifest in their actions the moral necessity of telling the truth, doing good, and avoiding harm. In that case, peer and public accountability are all that is left to uphold these essential ethical standards.

If this level of peer accountability seems extreme, imagine the consequences if the most powerful and public-facing physicians in the country continue to erode public trust in their own profession. Physicians have always held one another accountable to the highest ethical standards of medicine. The need is more urgent than ever. The potential for great human suffering demands that the unified voice of medicine muster its moral courage and act as though its life depends on it.”

Charles E. Binkley is a bioethicist and general surgeon.

He shares his story and discusses his KevinMD article, “The failure of the U.S. government’s physicians to do good, avoid harm, and tell the truth.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we welcome back Dr. Charles Binkley. He is a bioethicist and a general surgeon, and he recently wrote the KevinMD article “The failure of the U.S. government’s physicians to do good, avoid harm, and tell the truth.” Charles, welcome back to the show.

Charles E. Binkley: Kevin, thank you. It’s good to be with you this morning. It’s morning here in San Francisco; it’s probably afternoon on the East Coast, where you are in New Hampshire. But it’s very good to be back.

Kevin Pho: Now, for those who didn’t listen to your first podcast, can you briefly share your story to where you are today?

Charles E. Binkley: Oh, absolutely. So I trained as a surgeon. I went to medical school at Georgetown and did my surgery training at the University of Michigan, and then practiced hepatobiliary surgery here in San Francisco for about 15 years. I was also involved in bioethics from the time I was in medical school, through residency, and then on into clinical practice, and I was also involved in health care quality. I left practice a little over a year ago, and I’m now directing the bioethics program at the Markkula Center for Applied Ethics of Santa Clara University.

Kevin Pho: Now, the pandemic has brought on so many bioethical issues, and you talk about those in your recent article, “The failure of the U.S. government’s physicians to do good, avoid harm, and tell the truth.” Now, for those who haven’t read the article, can you walk my audience through it and share the story of why you decided to write it?

Charles E. Binkley: Well, absolutely. So what I was seeing in the public were physicians like Stephen Hahn and Robert Redfield really not necessarily holding up these virtues and these values that medicine has, things to which they vowed, to which they took an oath: do good, avoid harm, and tell the truth. Those are sort of the very basic things. These men are both physicians, and I argue in the article that their responsibility toward these ethical principles, their responsibility toward the profession, doesn’t end just because they took these public offices and they may not be actively practicing. Their oath transcends that, based on the fact that they’re physicians. And I also call on our peers, other physicians, to hold them responsible to those principles: do good, avoid harm, and tell the truth.

There’s a long history of physicians holding each other accountable when there are these lapses. The most extreme example would be physicians who performed experiments on human subjects in Nazi Germany. They were physicians, it was recognized that they had a higher level of responsibility than just an average person, and they were held accountable based on the fact that they were physicians. And I think this transcends just public officials or people in clinical positions; it also goes into the boardroom. Physicians who are leading companies, physicians who are leading health plans, biotech, whatever it may be. The fact that you’re a physician, I think there’s a greater level of accountability and responsibility regardless of the position that you’re in.

Kevin Pho: Now, there’s a lot to unpack there. So can you provide some specific examples from both the FDA and the CDC where you felt that the leaders there may have violated their oaths as physicians?

Charles E. Binkley: Yeah, so it really is about doing good, avoiding harm, and telling the truth. And so there are these hedgings about things like the convalescent plasma and its potential benefit. There are even really kind of ambiguous statements about hydroxychloroquine that I wrote about. So it’s the ambiguities, the lack of transparency, the lack of truth-telling. And it seems to be serving dual purposes. So there’s this political drive, and then there’s also this really very basic ethical demand, command, duty that physicians have. And so it may be a political post, but the primary duty of those individuals, I argue, is again to tell the truth, to do good, and to avoid harm.

The same thing came out with some of the CDC guidelines about mask-wearing and social distancing and even aerosol transmission of the virus. It’s the editing. Truth-telling is not only what you do tell but what you don’t tell, what you withhold. And as public officials, they have a duty there, but also public officials who are physicians.

Kevin Pho: One of the things is that they’re under a tremendous amount of pressure, because their duty to do what is right as physicians is sometimes in conflict with the Trump administration. What ought to be done? What should they be doing, right?

Charles E. Binkley: Well, Kevin, there’s no physician in the world who doesn’t experience pressure, right? So I took out people’s livers or pancreases for 15 years, and so I’m very familiar with pressure and the need to always do good for the patient. And so I think that you just have to have some moral responsibility. I think you have to be able to step up and say, “This is wrong, and I won’t do it. And so what? You fire me.” You have to have moral courage. The heroes of our world always stood up and had moral courage. We don’t applaud, we don’t build statues to those who cower to authority. I’m not saying that everybody has to die on every hill, but at some point you have to say, “This is not right. This is not beneficial to humanity to do this, and as a matter of fact, it’s harmful, and I won’t do it.”

Kevin Pho: Now, let’s talk about the president’s recent hospitalization and his personal physician, Sean Conley. Did you see any of those same ethical quandaries during his press conferences, during the president’s hospitalization?

Charles E. Binkley: I think that’s actually a little bit different. A personal physician’s primary responsibility is actually to the patient, and so Dr. Conley doesn’t hold a post in the same way that Dr. Redfield and Dr. Hahn hold posts. His post, his role, is really his duty to the president, and so it really is taking the president as a patient. It isn’t the president’s purview to be able to say, “This is what I want you to tell people.” In the same way, if you were seeing a patient in the clinic and the husband said to you, “I don’t want you to tell my wife these things,” unless there’s some sort of clear and immediate danger to another person, we respect that contract, that relationship with patients.

And so it gets a little bit tricky. I mean, if the president and the president’s people say to him, “You can’t say these things,” I think you have to kind of negotiate so that you maintain your own kind of moral compass. But at the same time, your primary relationship as a personal physician really is with that patient. I don’t think Dr. Conley owes the American people anything. Just for the very basic virtues and morality, you shouldn’t lie to people; he shouldn’t lie to people. But he can withhold things based on the request of his patient, the president.

Kevin Pho: So let’s go back to the FDA and the CDC. Now, what’s the solution here? Is it as simple as a change in administration, where the potential political pressure may be reduced and you feel things can go back to the way they were in the next few months? What do you think is going to happen?

Charles E. Binkley: Yes, I think that’s a good question. It’s hard for me to look into the crystal ball. I don’t think that all of a sudden, I think a change of administration may have an effect, but more basically, I think we really do have to hold, again, I think it gets down to physicians holding physicians accountable. There are really three levels of accountability for a physician. The first is self-accountability: Should I be doing this? Is this the right thing to do for this patient? The second is peer accountability. We hold each other accountable; we have M&M conferences, we have peer reviews. And then the third is public accountability. So we’re licensed, for instance, and so if there are errors or if there are problems, we have a responsibility to the public. We’re accountable to them.

And so I think the next level of responsibility, if we find that the individuals aren’t holding up these virtues, these values, is that we hold them accountable as physician groups. And I think that would be a role for an entity like the AMA, to be able to say, “This is not right. You are not doing the right thing.” And again, that would take moral courage. But I think there are three levels we have to get back to as physicians: It’s self, and then peers, and then public.

Kevin Pho: Now, are you seeing any accountability being taken against the leaders of the FDA and CDC?

Charles E. Binkley: You know, I’m not. There have been physician groups that have come out and have said there needs to be greater transparency, there needs to be greater truth-telling, but they haven’t really called them as physicians. They haven’t really held them accountable as physicians; they’ve sort of been stepping around it. But there hasn’t been that sort of direct kind of confrontation, and I actually don’t know that it’s risen to that level yet. But I do think that if it rises to that level, the appropriate next step is for us to hold each other accountable.

Kevin Pho: The CDC has come under a lot of criticism, both in the Washington Post and New York Times, in terms of bowing to political pressure. Now, if you were Dr. Redfield, what would you do?

Charles E. Binkley: Gosh, that’s a difficult question. I want to believe that I wouldn’t have been appointed to that position unless my values, my respect for doing good, avoiding harm, and telling the truth, were congruent with whoever’s appointing me. So that’s the first thing. You don’t want to put yourself in a losing situation; you want to make sure that everyone is aligned. And these positions are very powerful; there’s lots of prestige associated with them. But I really hope that I wouldn’t take something to set myself up for failure and, more than that, to erode my own sense of morality.

Kevin Pho: We’re talking to Charles Binkley. He’s a bioethicist and a general surgeon. He wrote the KevinMD article “The failure of the U.S. government’s physicians to do good, avoid harm, and tell the truth.” Charles, it’s been a few months since we last talked. Tell me something that you’ve been passionate about recently.

Charles E. Binkley: Well, Kevin, really what I’ve entered into with my group and my colleagues at the Markkula Center is how we can take these same ethical principles and not only apply them to individuals, but also apply them to systems. And so we’re very engaged in looking at ethical dilemmas that are arising in digital health platforms: digital health as it interfaces directly with patients, as it supports clinical decisions, and then also on the payer side, this potential to mine such large amounts of data that can affect public policy and health policy. And so that’s really what I’ve been engaged in a lot recently with my colleagues at the Markkula Center.

Kevin Pho: What are some of the major ethical quandaries that are associated with digital health platforms currently?

Charles E. Binkley: Yeah, so just at the most basic level, there’s the idea of privacy, particularly if you have, for instance, an app that’s collecting information about you that you’re not necessarily clear that it’s collecting. You think about these contact-tracing apps that have come up in the midst of COVID. Those can be used in so many different ways. Employers can insist that you use them and examine your contacts to see if you’ve had any potential contacts, to see your risk of infection. So there are so many ways in which data can be collected without us realizing it, and so there’s the privacy issue.

There’s also the data that’s used to drive decisions, and how accurate that data is. So just at a very basic level, the dermatology literature has reported how there are not enough pictures, there are not enough photographs of lesions in dark-skinned patients to make some of the AI applications accurate. And so that’s a biased system; that’s a discriminating system, because you don’t have a representative representation of the population, and also because dark-skinned patients present with dermatologic disorders, or dermatologic manifestations, differently than do light-skinned patients. And so that’s one example.

And then the other piece of it is how that information from digital health is then used, what’s actionable, and what are the actions that are taken based on it, and whether that’s ethical. And then the third is really how you hold a system accountable. Do you hold the data input accountable? Do you hold the algorithm accountable? Do you hold the programmers accountable? Do you hold those who make decisions and execute the actions accountable? So that’s the other issue within digital health: the traceability of accountability.

Kevin Pho: So I want to follow up on what you said about contact tracing. At what point does the public good of those contact-tracing apps outweigh the privacy concerns that are associated with them?

Charles E. Binkley: Yeah, so I think that there has to be consent, first of all. You have to know what’s being collected about you, and then it’s also really how it’s used. So, for instance, in Scotland they found that, in sort of a reverse way, older patients didn’t have the latest software on their phones, and so the contact-tracing app that was used in Scotland was actually disenfranchising older patients, because they didn’t have the most up-to-date technology. And so they weren’t able to identify their contacts, and they weren’t able to determine who they had had contact with and their potential susceptibility to infection. So that’s a reverse way in which you can discriminate, based on not having the technology.

But in particular, having employers require you to be actively tracing your contacts, and then to have that as a requirement for employment, that would be one instance in which it would be somewhat problematic in terms of your privacy, you giving up your privacy in order to maintain employment.

Kevin Pho: And my final question, Charles, what is your take-home message that you want to leave with the KevinMD audience?

Charles E. Binkley: You know, it really is just this very basic idea of what it means to be in health care, and what it means to be a physician, a nurse, wherever you are in health care: that there’s something very special about that, and that we have a special moral responsibility based on that. And I think that’s best cultivated through virtue rather than through some duty or some set of rules. You cultivate this idea of what the virtues are and what’s the right thing to do.

Kevin Pho: Charles, always wonderful to have you back on the show. Thank you again for sharing your insight and stories, and thanks again for being on the show.

Charles E. Binkley: Great, my pleasure. Good to see you.

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