A group of individuals were asked to participate in a study on learning and memory, to study the effect of punishment on memory. The secret motive however was to study ‘obedience’ in the execution of an inhumane act. The study was conducted in pairs of learners (who in fact were study personnel) and teachers who (unknown to them ) were the only ones being studied. The learners were asked to memorize word-pairs and tested on them. The teachers were asked to deliver shocks to the learners when they made mistakes in recalling the words. The pretend shocks increased in severity through the experiment and the subjects progressively winced, protested then yelled and screamed.
Most of us imagine that the study participants would refuse to shock the subjects when the agony of the latter was evident. Yet most participants continued the obviously immoral experiment to the end, delivering the highest level of shocks. Turns out these participants were’t some extraordinarily cruel subset of society; they were ordinary people like any of us. The question then is how did they deal with their conscience? Before I talk about that, let me describe the situation that had me put down my oncology reading and turn to psychology for a bit.
Since I’ve been back setting up practice back in India, I universally hear discussions that talk about how medicine here has become a shameful and unethical business. Doctors themselves talk about how ‘doctors’ are rampantly performing unnecessary tests, procedures and surgeries. The ‘whole system’ is described as corrupt. Fee-sharing and kickbacks are a norm rather than exception. Hospitals support doctors that bring in the money regardless of their means of doing it.. so on and so forth. The goal of this post however isn’t to rant, but to explore the psyche that sustains corruption and immorality in doctors. I had always imagined that this was a problem of an “older generation” or ” a mediocre group of doctors” or essentially some group that wasn’t like me. What I wasn’t expecting was that students I went to medical college with, professors that I respected through my training years.. had become part of the very system they described as a racket. Being face -to -face with their thoughts and practices, made me realize that the obedient participant of Stanley Milgram’s experiment could have very well been me.
The simple question is how does one cope with the guilty conscience when inflicting pain on another individual? How do doctors sleep at night after subjecting a person to a procedure they didn’t need… after stealing from patients that entrust them with their lives? Turns out, tricking your conscience is not that hard at all. Milgrams experiment sheds some light on that.
1) Transfer Moral Responsibility : Hitler was able to kill millions of people, only because thousands of other individuals obeyed and executed his orders. The participants in Milgram’s experiment were carrying out orders of those conducting it. Allegiance to authority, to the medical ‘system’ ; rather than a responsibility to the subject ( in case of the experiment )or the patient (in case of doctors) all represent a “shift of blame” from oneself. The same doctors that may be ” clean” elsewhere become obedient and adjusting to what the “system” here expects. A person accepting a “cut” may blame the one who gives it and vice versa. Individual doctors may blame hospitals and vice versa. Bottom-line is “Its not me”.
2) Getting absorbed in the technical side of process: The participants in the experiment were focused on ensuring the shocks were delivered precisely and as expected. A surgeon will focus on making sure there’s no injury to vessels and nerves, when trying to remove a difficult tumor. Engrossed in planning the challenging surgery, he or she can easily overlook the fact that the patient may not need the operation at all. Most of medicine involves making complex treatment decisions and your moral compass can easily be lost midst the gadgetry of diagnostic tools and sophisticated treatment equipment.
3) Devaluating the Subjects : The teachers in the experiment learnt to tell themselves that the subjects who were dumb enough to not remember the word pairs “deserved” the punishment. I’ve been startled by comments from doctors who tell me “The cheapest thing in India, is a human life” “Patients in India are stupid, non compliant” “Serves them right for shopping and going with a different doctor” “Why do you bother? if they don’t want to listen, let them suffer” I’ve often wanted to say “Are you listening to yourself?” Turns out they are..thats exactly what they’re telling themselves so they may sleep at night.
Well none of these reasons defend corrupt practices or make them right..they may partially explain thought processes that help sustain them, seducing the conscience. Some theorize that corruption in medicine, will only improve when corruption in other walks of life does. It may not happen until there is a condition of greater affluence and less disparity and who knows how long that might take. Meanwhile perhaps patients must seek out doctors that have the courage to disobey.