What Ethics

Medical students and young doctors have a major blind spot. They know doctors can have awful personalities. They know it from movies, TV shows, and real life. They’ve enjoyed watching it at play as long as it wasn’t directed at them.

But what makes these doctors particularly appealing in pop culture is not their callousness, but the impeccable medical skills that go hand in hand with it. This ability to be mean without being purely malicious makes competent assholes incredibly entertaining characters.

It’s true across the board. Doctors, lawyers, serial killers, mob bosses. Terrible people with spectacular redeeming qualities or good people with spectacularly dark shadows.

We want to be these people because we want our bad traits to seamlessly blend into a more interesting self. It’s a lazy attempt at repurposing our weaknesses. Instead of working through our bad traits, we do some clever mental maneuvering and look for the shortcut. We fail, of course, because this complex character we imagine is only entertaining for a third, uninvolved observer. In real life, people are invested. And in real life, people loathe assholes, no matter how competent.

As young doctors, we know this, so this is not our blind spot. We are not ignorant of the fact that one is entertainment and the other is real life. Sidestepping and acting like the misunderstood genius will usually earn you contemptive looks. It’s an instant dislike and one that is not too subtle. The few who have this proclivity have it quickly beaten out of them in the social arena.

Instead, most of us start with good intentions and believe that we will never change for the worse. We think of our great personalities as fortresses, never to be breached. We almost always change for the worse. Some of it is just growing up and becoming more cynical about life itself, but most of it is the accelerated growth of adaptive mechanisms.

This is not what we expect when we go to medical school, and that creates immense friction. We might have imagined it being hard, but “hard” was insufficiently specific. Drudging through tens of thousands of pages of dense material is hard, but seeing ourselves mutate into people we don’t recognize (or like) is harder. No book, YouTube video, or blog post warns us about that, so we need to figure it out ourselves. That’s hard work, and most doctors don’t want more work. So, they just let it happen.

The change is slow. Years of living amid sickness, death, arrogance, apathy, and chaos slowly erode who we are. It’s so slow, in fact, that we don’t even notice it until the day we find ourselves to be completely different people. We can’t pinpoint when it happened because of a lack of constant and careful readjustments.

And that’s when the blind spot rears its ugly head. All the mean, antisocial doctors we see on TV or down the hospital hall subtly normalize unhealthy behaviors. It sticks to us like the smell of food on clothes. Too tired for introspection and deep thought, we somersault morality and go straight to the easy answers.

As time goes by, we become more and more entrenched in the system. We learn what the rules are and how to break them. We can justify everything once we convince ourselves we’re doing it for the right reasons. This is the real danger of competency, ambition, and good intentions without a steadfast moral compass.

Enter Dr. Perry Hudson.

In 1951, Dr. Hudson was on top of the world. At just 33, the John Hopkins-trained, Columbia University urologist had just been appointed head of Urology at the Francis Delafield Hospital, a cancer-focused hospital in New York.

As a very competent and ambitious young man now in charge of 45 beds and a fully-fledged research facility, his intentions were noble. He wanted to challenge his field’s pessimism surrounding prostate cancer at a time when mortality rates were extremely high. One way to do this was through early detection and immediate and radical action.

One of the main issues in the early ‘50s was the delay in diagnosis. So Dr. Hudson set out to research this. While discovering patients with early symptoms and treating them through radical interventions was becoming the standard, he aimed to take this one step further.

He recalls thinking about people “wandering about the street who don’t have a benign enlargement. What about them? How do you screen for it?”

In essence, how do you discover prostate cancer before any real symptoms appear?

This required some experimentation. His plan was to biopsy as many prostates as possible and find a link. This required open surgery in which a piece of the prostate measuring 1/0.4/0.2 inch would be resected and analyzed.

As one can imagine, recruiting people to poke around with invasive procedures, under local or general anesthesia, in a sensitive area, was not going to be easy. Initial enrollment stalled, but Dr. Hudson was determined to do it.

While caring for a former Princeton University history professor who had become a homeless alcoholic and was living in a flophouse, he got an idea. What if he used down on their luck destitute vagrants for his studies? Surely, they would be more perceptive.

He set his sights on the Bowery flophouses—cheap, run-down lodging houses in Lower Manhattan where people—often homeless or very poor—could rent a bed or a space to sleep for a low price. These places typically offered very minimal accommodations, like shared rooms with cots or bunks, and little to no privacy. In the mid-20^th century, transient workers, alcoholics, and the destitute would stay overnight in these often overcrowded and unsanitary shelters of last resort.

Even so, his initial attempts to convince people to participate were met with severe resistance.

“I had a lot of old vegetables thrown at me,” he said. “I was talking about making a small incision in a very interesting part of their anatomy.”

Yet he persisted.

He befriended two welfare department workers at the municipal shelter, a city-run facility for homeless men. This was a turning point for his study. He convinced the workers that his research was of utmost importance, and so, with their help, most shelter residents were convinced to take part.

“Just about everybody volunteered.”

And it’s no surprise.

Vulnerable people with little comprehension of what would happen to them were enticed by people with direct authority over them with a story of total care. They were promised “four or five days in a hospital [with] clean sheets, and three meals a day.”

When people agreed and made an appointment, out went the carrot, and in came the stick. According to an account of Bowery life, “the authorities lifted the man’s meal ticket and returned it only when he had kept his appointment.”

It turns out that getting volunteers for invasive procedures is easier when it’s not really volunteering.

This whole endeavor led Hudson and his residents to perform more perineal biopsies and prostatectomies than anywhere else in the world.

Initially intended to target people with signs of urinary obstruction, the scope of the study quickly extended to healthy men. The absence of proper cognizance among the study participants was clear. Many were convinced to join with words like “Oops, you have a prostate; let’s go up to the hospital.”

Many of these discussions were carried out as the men came out of the shower.

Also lacking was informed consent for possibly serious complications, including rectal perforations, impotence, and cardiac events. These were not explained, nor were they adequately documented in written forms.

Between 1951 and 1966, more than 1200 people were subjected to invasive surgical procedures by Dr. Hudson. In the published data, only around 10% had cancer. Of those who didn’t have cancer, one in five died over the next four years. Of those who did have cancer, one in three died over the same period.

The Bowery series was published in leading medical journals, cited frequently in the medical literature, and was the subject of popular and positive news coverage.

He only stopped publishing his results when an editor of the journal Cancer wrote him “a very careful letter and asked me what protection I had from the university’s legal department. And what measures I had taken to guard against lawsuits. And I had to tell him, “Nothing, I had done nothing.” That sort of scared me. So when I did the last of the studies, I never published them. The editor who warned me was a friend of mine. He didn’t send that out as anything but a friendly warning. That meant that he had heard things. Other people did, too. I was aware of that.”

And while publishing had stopped, recruiting and studying didn’t.

No disciplinary or legal proceedings were ever levied against Dr. Hudson.

When asked fifty years later if he thought that the Bowery series was ethical, he replied, “Oh yeah. You know these people, the ones who are persistent street people in New York, are not simple-minded. They are alcoholics. They have mental diseases very often. But (it) doesn’t appear when they are listening to a conversation or answering a question straightforwardly and honestly. No. They understood everything that was going on.”

Dr. Perry Hudson died at 99.

His practices were ultimately forgotten, and their direct impact on subsequent clinical developments was minimal.

Hudson was known to refer to his research facility as “that empire I put together,” and those words embody the problem. This is how most medical leaders feel. The overall demeanor reflects a deep comfort in the space that surrounds them. Not only because they are likely well-equipped to do their job but also because they’re hardly ever challenged.

Dr. Hudson’s example is extreme, but only because the guardrails are higher today. An underlying disregard for ethics can creep up on all of us.

Don’t let it.