COMMENTARY

How Long Should Physicians' Past Deeds Be Held Against Them?

Both Sides Now With Art Caplan

Arthur L. Caplan, PhD; Robert L. Klitzman, MD; Lloyd I. Sederer, MD

Disclosures

July 08, 2019

This transcript has been edited for clarity.

Arthur L. Caplan, PhD: Hi. I'm Art Caplan, head of medical ethics at New York University School of Medicine. Welcome to Medscape's ongoing series, Both Sides Now. We have a great topic today, one that has been in the news a lot: How long should your past actions and misdeeds haunt you? Is there a statute of limitations, so to speak, on how long something you said or did in the past should count against you? As many have found out, what happens in the past can come back in a big way to cause problems for them in the present. Take, for example, Virginia's governor, Ralph Northam, a physician who admitted to wearing blackface 35 years ago in some sort of skit. It was captured in his Virginia medical school yearbook. In today's digital age, a number of celebrities, athletes, and public figures have had to apologize for errors they engaged in years ago.

How long should your past stay with you if you did something terrible? Is that just something you have to bear? Should what physicians said and did as teenagers or while in residency be held against them today? Can individuals truly change their belief systems, personalities, and who they are as they age and gain experience?

To help me answer these questions, and other questions that I hope to torture them with, I am joined by Robert Klitzman, who is a professor of psychiatry at the Columbia University College of Physicians and Surgeons and also at Columbia's Mailman School of Public Health; and Dr Lloyd Sederer, a psychiatrist and adjunct professor also at Columbia University. These are two guys I've known for a long time. I picked them because they both have mental health, psychiatry, and psychology backgrounds, and they are wise in thinking about this difficult subject.

Do Past Norms Matter Today?

Caplan: I'll go to Lloyd first, partly due to the wisdom of age. We are talking perhaps about things like misbehavior, acting inappropriately toward the opposite sex, cheating on a test, or lying on your résumé—the kinds of things we hear physicians being accused of or proven to have done. Do you think standards about that or thinking about that has evolved? When you first got into medicine, what did people think if someone said, "I think he was a little too friendly with that female resident," or "I'm not sure this guy can be trusted because he once had an issue with abusing drugs."

Lloyd I. Sederer, MD: That was decades ago and things were different. There was much more of an envelope around people's lives. There were no social media and it was not the digital age. I don't recall this being that much of a topic then. Whereas today, it seems to be everywhere: our professions, church, other clergy, and politics. We have evolved because we've had to. We've had to confront these questions because there is no bright line between what happened in the past and how somebody is today.

Caplan: Bob, do you think attitudes have changed about accountability and holding people to account for past actions, or is it just more visible than it was?

Robert L. Klitzman, MD: On one hand, it is definitely more visible. You could have written or said something or been photographed doing something when you were 13 or 18, and now it can go viral and literally everyone in the world can see it. A photograph taken by your best friend showing you drunk or doing something inappropriate with someone of the opposite sex, or even the same sex, can be seen by employers. When people apply for a job, many employers regularly Google the person, so suddenly all of this information is available. At the same time, I think social attitudes have changed more broadly in the culture.

Caplan: We have the #MeToo Movement.

Klitzman: Exactly. On the other hand, it shifts both ways. Take marijuana use, for instance. Forty years ago it would have been a criminal offense, and now many states have legalized marijuana. Smoking some pot 30 years ago may raise questions now in many states, but I think culturally it has "become the norm." Things have shifted in a variety of ways, and many of us who have lived more than a few years have operated at a time where the mores were different. Of course, mores and morals have an interesting relationship.

Caplan: Let's say that 40 years ago it was accepted that people in positions of authority could have more leeway in indulging their approach to and touching of the opposite sex, whether they were heterosexual or gay. Let's say that people viewed it as a perk of the office. I know professors who told me that that was so 40 years ago. If it were so and we had different attitudes about the rights of women, the rights of people to consent, and the rights of people to not have their persons [bothered], does that matter to our assessment today?

[T]here is no bright line between what happened in the past and how somebody is today.

Klitzman: I think it does, because at all times it's important to think carefully about what we do from an ethical perspective. [It's important] to think about the rights of different people we interact with, the risks of behaviors I might do, the benefits [of my behaviors], and the socially just thing to do. I would argue that even though some—usually males in authority—thought that it was a perk of the office to have the "casting couch," a lot of people even then would have said that that was not quite right, that there was something wrong with that—it was unfair. Some people may have gotten away with abuses of the office, but I don't think it was quite the norm. Partly because of social changes like feminism and Black Lives Matter, there is more awareness of people's rights and that [those behaviors are], in fact, abuse.

In answer to some of these larger questions we'll be talking about, it depends on the offense. What was it? How bad was it? What was the intent? Of course, we don't always know these things. We don't know what someone was thinking. Sometimes there is a "he said/she said" with some of these things. That does not excuse it just because someone thought they could get away with it in the past.

Sederer: One point about the appreciation of the act at the time is that I doubt whether it was just the person who was acted upon who recognized that there was something exploitative going on. It points also in the direction of the power relationship as a driving force in terms of many of these behaviors or indiscretions, because it is with power that people act in ways that are unfair or exploit others.

Does the Crime Make a Difference?

Caplan: Does the crime or the misbehavior matter? Let's say I abused a child when I was a young man. There is a baseball player today who is trying to get into the Major Leagues who is accused of sexually assaulting a family member. The Major Leagues have not been willing to promote this guy but he says it was a long time ago, that he went to treatment, and is apologetic. Does the crime matter?

Sederer: Of course, the crime matters. Stealing money from a grocery store or cheating on a test is very different from violating the body of another person. I think the crime does make a difference. In terms of trying to put this more in context, though, one point is that age matters, particularly for the less egregious problems like cheating or drinking too much.

Caplan: Surviving puberty, those kinds of things.

Sederer: Exactly. Age matters, and we've learned that our brains don't mature until well into our 20s, or later for young men.

Caplan: Is this the frontal lobe control idea?

Sederer: The whole circuitry of the brain matures by the process of myelinization. That process enables the frontal lobes to show some reasoning and judgement. When someone is 13, that myelinization process is not that far advanced, whereas by the time they are 25, it is. That is an important factor in terms of what we can expect and it puts it more in context. Also, of course, is the culture that that person is living in. If they are living in the inner city in poverty, then stealing may be a way of surviving.

Do We Expunge History?

Caplan: A former dean of Harvard Medical School told me recently that one of their big lecture halls was decorated with photographs of all the great eminences of the past. But some of those great eminences had done some bad things. They pulled down everybody's picture, whether it was Harvey Cushing, who no one seems to think has done anything wrong, or others who were alleged to have perhaps abused minorities, been anti-Semitic or anti-Catholic, or whatever.

Bob, what do you think about the "whitewashing" of history? It's one thing to say, "How do we deal with behavior when you are accused?" It's another thing to say, "Do we take it away?"

Klitzman: That is a great question. Of course, there is also removal of statues of people, including J. Marion Sims, who was the "founder of modern obstetrics and gynecology" but then turned out to do a lot of experiments on slaves. He did not use anesthesia, etc. There are a few issues. At heart here is the question of how much we trust someone and we decide whether to trust someone and what that means. In the case of ongoing behavior, there is a question: Can we predict what they are going to do next? Again, this is based on trust. Can I trust you to now do this job?

Philosophers and psychologists say that trust is about a specific thing. I trust you to do something. I may trust you to watch my cellphone for a while or trust you to watch my bags in a public airport if I go to the bathroom. I am not going to say that I trust you to do surgery on me. With the removal of the portraits, it's a question of how do we look at these people and how should we look at these people? Given that some people have done some things that aren't right, that raises the question of what the threshold should be. The easy approach is to just take down everyone.

Caplan: Which seems to have been what happened in this auditorium.

Klitzman: That seems like an easy out and I think it's unnecessary. Freud and others told us that we have ego, id, and superego. We have desires to do all kinds of things. We may see someone and want to have sex with that person, or we may see a drug or drink and want to have it, or we may want to punch a person. Then our ego says that that is probably not a good idea because they will punch us back, or this is my professor, or this is my student, or whatever the case may be.

Caplan: It will go on my permanent record.

Do We Demand That Everyone Be a Saint?

Klitzman: Exactly. To say that everyone is perfect, that we should only have saints up on the walls, I think is misleading. In the ideal world it would be great to have a biography next to the person. "Here is this person. They invented X, Y, Z. They saved millions of lives. On the other hand, they did have..." and then you can fill in the blank, and the blank may change. Maybe they had an affair while they were married, and this may be something we may excuse now or not, depending. Maybe they owned slaves, or they had invested in South African stock under apartheid. Whatever the issue is, [the biography would] contextualize it. People are complicated. There can be people who save millions of lives who have done some things that are not so great. That is a harder moral position to take. We like to think that people are good or bad, but I think that is often not the reality.

To say that everyone is perfect, that we should only have saints up on the walls, I think is misleading.

Caplan: Agree?

Sederer: I do. There is a difference also between our own individual judgments and the standards by which we will allow people to take on certain responsibilities.

Caplan: Let's say I am applying to be dean of the medical school as opposed to applying to enter medical school. Does that make a difference to the accountability for my past and what people should expect?

Sederer: This gets to how much power and how enduring a position you are about to have. As a medical student, you have yet in many ways to prove your mettle. As a dean, you have a long history that should establish that you are trustworthy in countless ways because of the position that you have. It does make a difference in terms of how we decide about somebody being given a position of authority.

We're all imperfect, and we all have things that we regret to have done, myself included. It's important to think about personal judgment, particularly for doctors in roles they are going to have with patients, and for psychiatrists who have patients who bring to them these kinds of problems, for instance. It is a matter of holding a less judgmental position yourself and putting yourself into the circumstances of: What is this person going to do? What is ahead for them and how will they manage this?

Keeping It Private vs Being Found Out in Public

Caplan: From an ethics perspective, I always thought these could be good teaching moments. Whether it's historical figures who engaged in behavior we would find illegal or contemporaries who did things in their past that they are not proud of, wouldn't it be a teachable moment for them to explain to students why they did what they did? Like wear blackface in the school skit? I am not sure I have to make you a pariah forever.

Sederer: The more public you are about it, the more responses you are going to invite, so that is [something else]. Who do you share this with? Who are the necessary people to inform? For example, do you share this with your family or the head of the admissions committee at the medical school? I think these are different from a general public apology.

Caplan: I just want to underline this one duty: If you have that kind of past, make sure you disclose it to appropriate individuals.

Sederer: It is more than a duty. If you don't, you are going to get caught sooner or later for lying, and that is an even bigger crime in terms of how our profession judges people and responsibility.

Caplan: You get asked to write a letter of recommendation. Do you put things you know about somebody's past in there?

Klitzman: It's a great question, and it's something I wrestle with because I often am asked to write letters of recommendation. Do you just say the positive things? Of course, most students have not done egregious stuff, but they have done some stuff that they perhaps should not have, or they are just not the best or brightest student. What do you say? They have other good qualities. So there are different approaches. If I think I can't write a letter for someone in good conscience, I will say, "I think there may be people who can do a better job writing a really good letter for you."

I can think of one student, for instance, who cheated on an exam when he was under huge stress for a variety of personal reasons when he was a young undergraduate. It was written in his transcript and when he applied to our program, he wrote a long explanation. I felt that he was a really bright guy who was under the thumb of this thing. He clearly regretted [his action] and was very apologetic about it. I thought that to help that person would be good. I don't remember if I alluded to [his transgression], but I was careful to present all the positive things. I would never lie about that. I would never say he's a perfect person, but I would say here are some good things about him and why I think, on balance, that he would be a great doctor.

[I]f you have that kind of past, make sure you disclose it to appropriate individuals.

Can Individuals Truly Change Over Time?

Caplan: Let's assume that x is a not good, but not horrid, behavior committed 30 years ago. Here is something that many doctors say to me: "I did x. I'm not the same person. I've evolved. I've changed." Can they? Do they? Is it possible?

Sederer: Of course. For this, it's trust but verify. The longer it is from when that act happened to today, the more information there is about who that person has become. I do think there is such a thing as redemption. People discover that they want their lives to be different. They work at it. Faith becomes a factor for them. People can absolutely change, but you need to see proof of it and corroboration—not only their scores on the rotation in cardiology or the rotation in psychiatry, but also [proof from] other people who have worked with them. You develop a body of information that says, "I think this person can be trusted. They may have done something a long time ago, but they're different now."

Klitzman: There are a few ways in which it depends. How bad was the thing? What are we suggesting they do? Let's say it is someone being nominated for the Supreme Court. I would have a much higher threshold or want to make sure they are "squeaky clean" because they will have that job for life. They have enormous power. It's different if it's a position where there will be feedback, we can see what is going on, the thing they did was not so bad, they have really apologized, or we have talked to them. Communication about these issues is [important]. The person should explain what was going on.

Caplan: That might be with the hiring committee or an interviewer.

Klitzman: Exactly. What happened? Tell me about it. They may say they really screwed up and feel terrible, and as a result they have done this and that, like psychotherapy. Maybe their mother had just died, or they had just broken up with a spouse. We want to look at what the thing was, but we should try to forgive each other rather than say that because you said this back then, that's it and I'm never going to talk to you again, or I'm never going to hire you.

Caplan: Forgive each other if we see the signs of change.

Trust but verify.

Klitzman: That is absolutely right. We should be open—I agree. People can and do change. People do have youthful indiscretions. As Lloyd was saying, the brain matures, particularly in males, through adolescence.

We've all done things when we were young that we can't believe we did or said. We should be open to giving people a second chance, although as Lloyd said, "Trust but verify." Even after you give them the job, check in with them. Make sure you're not just giving them free rein to do whatever they want. Keep an eye on things and make sure things are going okay.

Sederer: A really good example is drug use among physicians and nurses. Many states, like New York, have set up an impaired physician or an impaired nurse committee. It's essentially a couple of professionals who meet with that person, try to understand, and set certain standards for their behavior. They are carefully monitored, and they are given a chance to reestablish a professional career at first under careful surveillance and monitoring.

A doctor may have had too much access to drugs and other kinds of circumstances that led to the use or selling of drugs, and that person has also, as you were describing, had a richer life than just that moment. Is this person capable of recovering their full professional standing? I think people should be given that chance.

Caplan: Let me give you a deep question. I can understand when somebody says they want to be a Supreme Court justice, and people say you have bad behavior toward women, and we're not sure that that is going to allow you to carry out that lifetime role. Why does it matter if physicians have indiscretions or behavior that they are ashamed of in their past, aside from personally wanting to come to terms with it? If I am a patient, why do I care?

In other words, if the anesthesiologist can do the anesthesiology, do I really care anything at all about whether he cheated or did something inappropriate back in medical school or undergraduate life or whatever? Why should it matter to me?

Klitzman: We are talking about trust. We want patients to trust their physicians, and that is important because we want patients to tell the physician personal things. Patients are literally putting their body in the hands of the doctor. "Inject me with whatever. Cut me however you think depending on what is needed. Put whatever in my mouth. Stick things in my body," etc.

You want to make sure that the trust is warranted to the degree that we can seek. If an internist has had sex with patients or has done inappropriate things with patients sexually, you would be concerned that that may affect what happens in the doctor-patient relationship and may impede the doctor-patient relationship. You don't want women to say, "I can't trust this guy because he may do something inappropriate."

The same is with drug use. I would say that we do not really care if people have some wine when they go home and relax at the end of the day, but if a doctor is drinking on the job, that may impair his or her judgment in what he or she does with the patient. We're really concerned about the doctor's performance. We're looking for evidence that the doctor may not be able to perform as he or she should.

[P]eople can find out things...Art Caplan may even Google me and expose me in some Medscape show.

Will Your Social Media Posts Come Back to Haunt You?

Caplan: I am going to wrap up with a slightly different question. Let's say that I'm a young doc. I come to you as more senior and experienced clinicians and say, "What advice would you give me about social media and Google? I'm not saying I've done anything, but people can find out things. My patients may Google me, the medical board may Google me. Art Caplan may even Google me and expose me in some Medscape show." How should a young doc comport themselves? What is their duty today in terms of both conduct and disclosure?

Sederer: This is another "depends." It depends on what that behavior was, how egregious it was, and how far along they are in terms of establishing that they are different. If someone has spent 20, 30 years practicing, establishing that he or she is trustworthy and effective, what good will come of it rather than simply some public apologia? I'm not sure that does a lot for anybody, and if we're talking about preserving somebody who is functioning, it's not such a good idea.

Klitzman: A key implication of all of this is that going forward, we should all be very careful about what we say or do in general but especially because of social media. Young people who are thinking of going into medicine, law, politics, or probably anything else should be very careful about what gets posted about them and what they post on social media.

Caplan: It's funny. We may be old fogies about all of this because younger people I know are a little more comfortable saying, "Everybody has their drunk picture or their summer break experience up there." Do you think that norm about what is expected is going to be changing too down the road?

Klitzman: Through all of this there are risk-benefit calculations. If I know that person x said or did something, what is the risk that that might affect now what they do with, say, a patient versus how they can help the patient, for instance? Similarly, should I post pictures of me on spring break getting drunk? I have the freedom to post whatever I want. But you should realize that there are potential risks. Maybe they won't come to pass. Maybe I won't be a doctor. Maybe I am just going to open my own company and be the boss, and no one is going to care. In general, people need to be careful, and they ought to be aware that there are potential risks to posting stuff that others may look at differently than you look at it at that time.

Caplan: I want to thank both of you. I think we got both the nuances and the complexity of trying to deal with our imperfect pasts. Everybody I know, including me, has an imperfect past, so trying to manage that is a tough moral challenge. We had some good insight into that and also some ways to try to respond when approached. Managing these challenges is just part of being a physician as well. We'll probably have an episode down the road on making moral judgments about our patients. But that is for another day.

I am Art Caplan. Thank you for watching Both Sides Now, and I hope you learned something about a very interesting and complicated subject.

Follow Medscape on Facebook, Twitter, Instagram, and YouTube

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....