[This post originally appeared at Lean Left, a general-issues blog KTK also contributes to. The founders of Lean Left graciously allowed me to re-post it here to bring all my health-related posts into one place. Original posting: 8/23/2004]

“Will you look at the man? He’s a Freudian delight; he crawls with clues!”

- Lieutenant Tom Keefer, The Caine Mutiny

“What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.”

- Hippocratic Oath

I’m getting tired of seeing medical blowhards aggrandizing themselves with their self-important opinions regarding public figures. In recent months we’ve seen someone who may or may not have been John Kerry’s treating physician for one of his Purple Heart wounds reveal his memories of the treatment and, further, offer his opinion that Kerry is lying about the incident; a psychiatrist who has never met or interviewed George Bush has published a book claiming to offer accurate, but very unflattering, medical diagnoses of Bush, and psychological explanations of his behavior and policy decisions, on the basis of speeches and incidents from his life – he claims endorsements from other prominent psychiatrists as well; that doctor also reportedly “confirmed” rumors that Bush is now taking psychoactive medications – again without ever having met him!; a psychologist previously published a separate article claiming similar insights based on similarly distant knowledge; now a doctor who claims he was one of Michael Jackson’s plastic surgeons has revealed details of Jackson’s medical history and surgical treatments, while offering some unsolicited medical advice to his patient through the medium of the New York Daily News!

This is a travesty – one with consequences for all patients of all healing professionals.

Medical confidentiality matters a great deal. It’s one of the overriding principles that – like freedom of the press, due process, the laws of war, and other fundamental protections of basic human interests – are expected to be observed almost without limit, and even when the immediate needs or temptations of the moment make a breach of that principle seem attractive. It is the feature of the healing professions that, along with their traditional altruism, not only earns those profession their esteem, but makes it possible, in a basic way, for those professions to command the trust and openness that patients must be able to grant for treatment to take place. To violate patient confidentiality – or, what is similar, to exercise (real or imagined) professional insight to violate privacy even where confidential knowledge is not possessed – is not merely to use professional trust or professional knowledge to harm one individual, it is to put the very institution of professional practice at the service of public ends that patients have not endorsed. That threatens every patient, who must now wonder what their treating professional may say about them in the newspapers or in a book. If confidentiality and professional discretion may be waived unilaterally – as long as the patient is famous, or is in politics, or is “an enemy”, or enough time has passed (in the professional’s opinion), or for whatever other reason – no one may count on their confidences being respected. This has obvious consequences – possibly disastrous ones – for patients considering what to tell their treatment providers, but aside from practical considerations it is disrespectful to the point of malevolence, and an act of grossest unprofessionalism.

It is possible to concoct rationalizations. Justin Frank (the analyst with the Bush-bash book) has claimed that “applied psychoanalysis” is a standard practice “now used by CIA psychiatrists hired by the US Government” and, famously, used in WWII to try to figure out Hitler. In the case of arm’s-length diagnoses of famous people, one can argue that they have made themselves public figures, and anyone is free to examine and evaluate their statements or behavior, so trained professionals should be under no special restriction not to do so using their technical knowledge. In the case of influential leaders such as Hitler, Saddam, or Bush, it might even be unpatriotic or anti-social not to provide such insights.

I’m not buying that, though. Professional knowledge, and admission as a qualified practitioner into a healing profession, come with unique limits. Central to the ethics of all the healing professions, in every ethicist’s opinion, is the requirement that the special knowledge, special privileges, and special trust that professionals are granted must always be used for the benefit of the particular patient, and never against a patient’s interests. (This is taken to preclude even public-health or “greater good” practices such as forced vaccination or the sacrifice of one patient to benefit many others.) I think the principle extends to the use of professional knowledge for the indirect violation of the privacy of individuals who are not directly patients of the practitioner. Anyone can read Bush’s statements and see immediately that he’s a jerk; only those entrusted with special knowledge – on their pledge to use it beneficently – can claim to “diagnose” him, and that is a breach of their role and a misuse of their knowledge. (Again, anyone can read technical books and gain at least some “professional” knowledge, then claim to acquire special insights into others’ conditions; this is offensive, but it at least is not a violation of a professional obligation, since merely reading medical books does not make one a doctor. The wrongness of doctors doing the same thing is that they violate the constraints of the role they, particularly, have taken on as doctors, while also creating uncertainty among all patients that other doctors will do the same.)

What of important public figures whose behavior affects millions? Do we not have a right to know as much as possible about them? Do we not have a right to gain whatever insights we can into the minds of enemy leaders? I would argue that those who aspire to public office have an obligation to tell the citizens the state of their health, and that they and their aides abuse the public trust when they hide the truth about leaders’ disabilities (as was done with Reagan’s incipient Alzheimer’s, and possibly Cheney’s heart condition). But that obligation falls on them, the leaders themselves. Even they must have the right of confidentiality from their treating professionals, who are not obligated to violate that confidentiality unilaterally “as a public service.” I would argue that even if such a professional knew of something seriously wrong with a leader, that they knew the leader was hiding or lying about, it would still not be their place to reveal that condition without authorization. In the case of foreign leaders, I am not convinced that the obligations of professionalism are vacated simply because two countries are at war. As for “applied psychoanalysis,” it’s largely regarded as a crock of shit by everyone but applied psychoanalysts. (Note finally: one can devise strategies for getting around this principle. Arguably, in war certain constraints of medical ethics are voided – soldiers’ physicals are not confidential, and they are subject to non-voluntary treatments such as vaccinations. The role of medical professionals in wartime is controversial, but if there is one you could argue for an exception to the confidentiality principle on those grounds. You could also ask political candidates to take a non-confidential physical examination as a kind of “pre-employment screening” – which they would have to agree to do if they wanted to run for office. But these are specifically exceptions to the general policy I have outlined, and they require special justification.)

What is certainly not justified is the self-serving, unilateral, attention-getting breach of the most basic professional obligation by healers who have been granted an intimate trust by their patients, nor ignorant grandstanding by third parties looking for book deals, whose “professional” techniques would be unquestionable malpractice if they were used on a real patient. These people have violated a central principle governing their professional roles, harming individuals (however weird or reprehensible) they are obligated to protect, and threatening the confidence and the confidentiality of every other patient who seeks aid from any other professional. They have embarrassed themselves, harmed patients, and damaged their professions. It needs to stop.