Diagnostic abuse of veterans and the dilemmas of health professional ethics
Michael de Yoanna and Mark Benjamin in Salon have just published the first of a three-part series on pressure from the military to not diagnose soldiers with PTSD. They obtained a secret recording of a Denver neuropsychologist confessing to his patient, a sergeant wounded in Iraq, that he is under tremendous pressure to not assign PTSD diagnoses. [Thanks to Salon, you can listen to a portion of this recording here.]
“OK,” McNinch told Sgt. X. “I will tell you something confidentially that I would have to deny if it were ever public. Not only myself, but all the clinicians up here are being pressured to not diagnose PTSD and diagnose anxiety disorder NOS [instead].” McNinch told him that Army medical boards were “kick[ing] back” his diagnoses of PTSD, saying soldiers had not seen enough trauma to have “serious PTSD issues.”
“Unfortunately,” McNinch told Sgt. X, “yours has not been the only case … I and other [doctors] are under a lot of pressure to not diagnose PTSD. It’s not fair. I think it’s a horrible way to treat soldiers, but unfortunately, you know, now the V.A. is jumping on board, saying, ‘Well, these people don’t have PTSD,’ and stuff like that.”
Salon reporters talked with Dr. McNinch, and secretly recorded that conversation, obtaining confirmation of Sgt. X’s experience:
Contacted recently by Salon, McNinch seemed surprised that reporters had obtained the tape, but answered questions about the statements captured by the recording. McNinch told Salon that the pressure to misdiagnose came from the former head of Fort Carson’s Department of Behavioral Health. That colonel, an Army psychiatrist, is now at Fort Lewis in Washington state. “This was pressure that the commander of my Department of Behavioral Health put on me at that time,” he said. Since McNinch is a civilian employed by the Army, the colonel could not order him to give a specific, lesser diagnosis to soldiers. Instead, McNinch said, the colonel would “refuse to concur with me, or argue with me, or berate me” when McNinch diagnosed soldiers with PTSD. “It is just very difficult being a civilian in a military setting.”
McNinch added that he also received pressure not to properly diagnose traumatic brain injury, Sgt. X’s other medical problem. “When I got there I was told I was overdiagnosing brain injuries and now everybody is finding out that, yes, there are brain injuries,” he recalled. McNinch said he argued, “‘What are we going to do about treatment?’ And they said, ‘Oh, we are just counting people. We don’t plan on treating them.’” McNinch replied, “‘You are bringing a generation of brain-damaged individuals back here. You have got to get a game plan together for this public health crisis.’”
When McNinch learned he would be quoted in a Salon article, he cut off further questions. He also said he would deny the interview took place. Salon, however, had recorded the conversation.
Salon got the tape from another medical worker and a Congressional aid, not from the soldier, whom they dub Sgt. X, to protect his identity. The soldier, surprised that the media got his recording, is afraid that retribution against him will negatively impact his disability claim.
The Army conducted one of those “investigations” so well-known to those familiar with the military and promptly cleared itself. Unfortunately, the Senate Armed Services Committee declined to investigate, though, one might suspect, it was an aid on that committee who gave Salon the tape. Perhaps there is an attempt to create enough public outrage to push the Committee to do the right thing.
This article provides new confirmation of previous reports, several of which are by Mark Benjamin, that the military is seeking to reduce the number of PTSD diagnoses assigned to soldiers. In some cases they have been accused of assigning personality disorder diagnoses, presumed to have existed prior to enlistment, to soldiers more likely suffering from the traumatic effects of war. A personality diagnoses makes the soldier ineligible for veterans benefits, thus avoiding the government assuming the potential high costs of treatment.
The question of what to do with mental health clinicians, like psychologist Dr. Douglas McNinch is complicated. If he, or other clinicians, modified diagnoses to please the powers that be, this is unethical. Dr. McNinch apparently knows full well that his actions are wrong, yet lacks the moral courage to refuse to play along, or to speak out. His actions arouse little sympathy.
On the other hand, our healthcare system is based upon diagnostic deception. Clinicians often give less or more severe diagnoses in order to get coverage for their patients’ conditions. In many cases this deception is in the patient’s interests, but, other times it is not. Sometimes, rather, the deception is more in furtherance of the clinician’s financial interests. It seems problematic to punish a clinician for giving in to pressure from a dishonorable system. Yet, it also seems problematic that a clinician should get away unscathed for these transgressions.
At present health professional ethics, including that of psychologists, are based upon a model of the individual moral actor doing the right thing. These ethical principles essentially requires every professional to be willing to become a whistleblower. Yet, there is little tradition in the health professions of whistleblowing. We have no whistleblower heroes about whose actions we are taught in our training programs. We participate in no discussion of the extreme stresses that most whistleblowers experience. And our professional associations have not developed any support mechanism beyond “ethical consultation” for those contemplating risking professional suicide through refusing to play their role in an unethical system.
We know that the health professions failed miserably to respond to a state-sponsored system of torture, a system that was designed by psychologists and required extensive involvement from health professionals, including monitoring of the extent of damage being caused as detainees were tortured, and brutal forced feeding of hunger strikers. As we know, the professional associations failed miserably to respond to this challenge. The American Medical and Psychiatric Associations banned their members participating in interrogations, but remained silent about the monitoring of torture conducted by physicians and the participation of physicians in force feedings that violate professional ethics. The American Psychological Association closed its eyes to the abusive roles that psychologists played in the Bush administration’s torture program, thus providing cover for that program until almost the end of that administration. Professions that failed to adequately confront the moral challenges posed by state-sponsored torture unfortunately cannot be counted upon to deal adequately with other potential state-sanctioned abuses. These professions, and their organized expressions in professional associations, need major reforms to confront the moral challenges of our times.
In any case, the most important result of the current revelations of diagnostic abuse would be to fix an unjust system that is apparently deliberately assigning the wrong diagnoses to returning soldiers, most likely in order to save money. Unjust and unethical systems generate unjust and unethical behavior in those who practice in them. While ethics codes are important, no amount of ethics teaching alone will prevent ethical lapses in powerful unethical systems. At a minimum, health professional associations should be pressured to provide support and training on the responsibilities and the challenges of becoming a whistleblower.
Soldiers who return from war shouldn’t have to face a system out to screw them. Nor should they have to fear retribution for exposing these abuses. It is now up to the administration, the Congress, the health professions, and the public to take action to see that our returning soldiers stop needing lawyers to get the appropriate treatment for the wounds they suffer in our name.
April 9th, 2009