(Continued from An Ethics Odyssey I)
Other State Associations, District Branches
By the middle of April I reasoned that the only way to solve the problem of potential disagreements among the various state associations and district branches might be to refer the same question to each of those where I found more apparent APA members listed on the company Web site as providing the protocol. On April 17, 2007 I sent letters to state associations and district branches in Texas, Hawaii, Georgia, Florida, New Jersey, and Queens County in New York. In each letter I provided the name or names listed on the company Web and described the financial arrangement.
By May 1, 2007 there was still no determination. I asked Dr. Williams about the letter I had written him to formalize my request, including the names of four psychiatrists listed on the company Web site as providing the protocol in the state of Washington. He responded two days later that the WSPA office had forwarded the letter directly to Dr. Adler and, “The Ethics Committee is meeting tonight and this is the main item on the agenda.”
Months passed with no response from WSPA, but other district branches and state associations began to respond.
Queens County, NY
Stanley Brodsky, MD, Chairperson of the Queens County Psychiatric Society, was the first to respond. In a letter dated May 12, 2007 he asked if I could provide more information. I wrote him a letter and put him in touch with Dr. Adler. He also provided his direct phone number. In our last conversation he told me the Society’s attorney had attempted to review the matter with the APA ethics committee but with no response. In a telephone conversation with Dr. Brodsky on September 10, 2008 he told me, “They dropped it.” When I asked about a written response, he told me the district branch would get back to me.
The New Jersey Psychiatric Association completed the investigation first with a letter dated June 18 indicating that the named member was indeed licensed with the company “through affiliation with the [a clinic in] NJ” but that he “is no longer affiliated with them and in fact did not accept any fees for any treatments using the… protocol.” The physician later called me to inquire about my letter and explained that he had severed his relationship with the company.
Peter Ash, MD, chair of the Georgia Psychiatric Physicians Association Ethics Committee responded with a letter dated September 17, 2007 indicating the committee determined the member there “administered the … protocol [as a] full-time salaried employee of a clinic” and had “no contract” or “other financial arrangement” with the company.
In a letter dated November 14, 2007 Milton Altschuler, MD, Chairman of the ethics committee of the Texas Society of Psychiatric Physicians wrote that the committee had found no ethical violation. When I telephoned Dr. Altschuler he explained that the committee believed “informed consent” to the financial arrangement obviated any ethics concerns. It was not clear whether anyone on the committee had actually looked at the agreement or whether the committee even determined that either of the psychiatrists named had been involved in the arrangement described above.
I questioned whether otherwise unethical conduct could be made ethical simply by informed consent, so I appealed the decision to the APA ethics committee. The Texas decision was upheld with little further explanation. This determination raised more questions than it answered. First, the committee offered no evidence that they had determined the nature of the financial arrangement between the company and the named members. Second, the committee offered no evidence to support the assertion that informed consent was obtained. Finally, the notion that an action that would otherwise be considered unethical might be rendered ethical simply by obtaining informed consent seems unprecedented. This might mean, for example, that pursuing a sexual relationship with a patient might be ethical provided there is informed consent.
Karen Teston, MD, Chair of the Florida Psychiatric Society Ethics Committee, wrote in a letter dated December 3, 2007 that she had identified two of the three psychiatrists I had listed as members. She then described a Florida statute (Section 456.054 of Chapter 456) prohibiting “kickbacks.” She suggested I refer the matter to the Florida Attorney General and indicated that only if a member were convicted of violation of such a law the committee would proceed with an investigation.
It had never occurred to me that this arrangement might constitute a kickback, but the label sounded as fitting as fee-splitting. I contacted both the Attorney General and the Florida medical licensing board. Each agency declined to pursue the matter but referred me to the other. I hoped that since there appeared to be little likelihood of a criminal or licensure investigation the ethics committee might look into the matter from a purely ethics perspective, but there was no further response.
If not the most prompt, Hawaii was perhaps the most courteous and diligent. Soon after receiving my letter the Hawaii Psychiatric Medical Association informed me theirs is a small association and that their President who also acted as chair of their ethics committee had died. When they finally regrouped and considered the matter they quickly found that the member I had named had no relationship whatsoever with the company. It was a simple case of mistaken identity, a doctor with a similar, but not identical, name.
Continued: An Ethics Odyssey III