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Comment by dvt | Hacker News Reader

The fact that people are defending this guy, or treating it as "no big deal" blows my mind. Just off the top of my head, a few ethical issues:

    - Breach of patient-doctor trust -- a very asymmetric relationship
    - Breach of the Hippocratic Oath (you don't *burn* healthy tissue without good reason)
    - Permanent bodily modification without consent
    - *Multiple* offenses

Should he have been terminated? Does the punishment fit the crime? Considering he was a leading surgeon in his field, I honestly don't know. One would have to consider potential future lives saved compared to these ethical breaches.

It's a tough call, for sure, but to exonerate him or, worse, downplay these egregious violations as "victimless crimes" is, to me, unfathomable.

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I've been a physician for about 16 years. I won't defend the guy, it's just that I routinely see things that I would consider worse: doctors drunk at work, doctors who sleep with medical students in exchange for good evaluations, rampant cheating in medical school, rampant stimulant abuse, and the list goes on and on...

It's unethical for sure, but I guess my gut reaction is that it's not necessarily an offense that demands termination.

>it's not necessarily an offense that demands termination.

Someone murdered someone near my workplace. This surgeon branding his initials on someone's liver isn't so bad in comparison. Therefore, it isn't so bad in the absolute.

You set up the slope yourself and then proceeded to slip on it.

You don't think he should lose his license?

This seems way worse than those things. Relationship problems, nepotism, and drug and alcohol abuse are problems. But permanently vandalizing a living human body while the person is unconscious goes far beyond the pale. The person should do jail time in addition to being permanently barred from medicine. Defiling a patient's body for "fun" should be taken extremely seriously.

To me, a doctor drunk at work is far, far worse. I would much rather have a doctor initial my liver but still do a good job of fixing my problem, than have a drunk doctor operate on me (or treat me in any sense actually). I suspect a lot of the outrage is to do with the insult to human dignity that initialing someone's organs brings. But look at the outcomes.

Yeah, if someone's initialing my liver, that's probably a good indication the operation went well :P

That's the defence he used. Something like "this is a work of art, and I'm proud of the skill and care I took"

What if your liver developed a problem due to getting initialed? What if every doctor operating on you felt that carving their name in you was their right? How about the entire team? After all, the outcomes are what matters right... Really, this is improper, it's nothing to do with human dignity, it's got everything to do with trust and consent. And consent is - in case you didn't know it - a rather large plank in our doctor-patient relationships. Doctors are supposed to do what's necessary, frivolous actions are not supposed to be part of the package.

Yes, it is definitely improper to say the least. It also brings the profession into disrepute. I agree that it breaks trust as well as insulting dignity; and I should also clarify that my aim was not to defend the actions of the surgeon. I'm not a doctor but I don't find the complications argument convincing in this case though (unless it took a long time and resulted in prolonged anaesthesia; then I believe there are added risks). I still maintain that something like being drunk at work, especially as a doctor, is significantly more dangerous and reprehensible - lives are put at risk. By contrast, I think having initials on my liver, especially if I don't know about it, is less of a hardship.

Edit: I haven't been able to clearly determine if the actual initial burning was harmful (in a significant way) or not.

No, it wasn't. Surgeons have to mark livers to show areas they're going to work on. These are normally temporary markings and heal over time. When this surgeon made marks he also added his initials. He did this to one patient, and the marks did not heal, and another surgeon found the marks.

I'm not trying to defend him, but it wasn't intended to be a permanent marking.

> What if your liver developed a problem due to getting initialed?

He only initialed livers as part of a wider set of markings that surgeons normally make. If the initials are going to be a problem those other normal marks would also be a problem.

> What if your liver developed a problem due to getting initialed?

I mean.. at least you know who to sue.

The Joe-job potential is limitless.

It's not a permanent modification in most cases.

He pled guilty to a criminal offence, but that offence is at the lower range. (Assault covers a range, from assault at the low end (doesn't require physical contact), then assault by battery (requires physical contact) to ABH then GBH.

I think he's going to get a suspended sentence.

He's got a warning from an interim hearing from MPTS, and you can see the warning on the GMC lists.

Does this work?

http://webcache.gmc-uk.org/gmclrmp_enu/start.swe?SWECmd=Goto...

Here's the text of the warning:

> In August 2013 and on more than one other occasion Mr Bramhall initialled patients’ livers using an argon beam coagulator. This conduct does not meet with the standards required of a doctor. It risks bringing the profession into disrepute and it must not be repeated. The required standards are set out in Good Medical Practice and associated guidance. In this case, paragraph 47 and 65 of Good Medical Practice are particularly relevant. 47. You must treat patients as individuals and respect their dignity and privacy. 65. You must make sure that your conduct justifies your patients’ trust in you and the public’s trust in the profession. Whilst this failing in itself is not so serious as to require any restriction on Mr Bramhall's registration, it is necessary in response to issue this formal warning.

Doctors are people too, so whatever ails the general population should not be a surprise to be found among doctors. Drug abuse was pretty common (after all, easy access to drugs) as was sexual abuse of doctors with patients. Even so, to treat your patients as a tree to carve your name in when they're powerless to do anything about it has a deliberate component that is inexcusable way beyond doctors simply being human.

Also, it would help if you did not include the word 'fantast' in a novelty account while making claims of being a physician for 16 years and then making light of this. Either you really are a fantast or you are not exactly a credit to your profession if you really believe that this does not warrant termination. As a patient I'm pretty cool with it, if I go under to trust a doctor with my life I'd rather not they use me as a calligraphy scratchpad and if it takes one doctor out of all those out there to be made an example of then it's a loss but not a large enough loss to offset the breach of trust between doctors and patients the world over by this guy.

That opinion stems from a place of privilege and over-entitlement. UPS drivers would get fired for ALL of that behavior, to not hold yourself to that standard at a minimum is shameful.

If it is a question of 'not having enough doctors' so we need to keep bad physicians around, then that's another reason that we need to drastically increase our enrollments for medical school. We certainly have enough willing and able Americans that would be ecstatic for the opportunity.

I assume physicians have something like law-enforcement's 'blue line', but it's pretty imperative that professionals like you hold each other accountable.

To me this is really no big deal. Honestly I think people are overreacting because they have absolutely no idea of anything about everything that's inside bodies. Having used coagulators and seen hundreds of livers (pathologist) and the eventual macroscopical but benign scars they get because of ("naturally occurring") small infarctii or such, this has really no consequences whatsoever. I don't know how it worked in this case, but there's a reason doctors are disciplinally judged by their peers in some countries.

But it's really dumb, and should lead to disciplinary consequences (although his reputation is already badly damaged) because of the paranoia it triggers in people about doctors.

What I wonder is why the surgeons who discovered it got the problem out in the public. What was possibly their goal ?

>Honestly I think people are overreacting because they have absolutely no idea of anything about everything that's inside bodies. Having used coagulators and seen hundreds of livers (pathologist) and the eventual macroscopical but benign scars they get because of ("naturally occurring") small infarctii or such, this has really no consequences whatsoever. I don't know how it worked in this case, but there's a reason doctors are disciplinally judged by their peers in some countries.

You must be Dr. Manhattan. It's a big deal to us uneducated ants but you're enlightened so you can see it for what it is, is that right?

Actually, you are simply too arrogant to see it.

It's important, just not for the reason most commonly accepted ie risk for the patient yada yada.

Easy question : do you know what it looks like ? I think no picture has been published, I infer what it probably looks like out of what I've seen and my experience which is relevant in this case, but most people are probably not able to do so (this is arrogant I guess ?).

BUT it is indeed bad and damaging for the doctor/patient relationship, which is today even more prevalent than the care one.

>Easy question : do you know what it looks like ? I think no picture has been published, I infer what it probably looks like out of what I've seen and my experience which is relevant in this case, but most people are probably not able to do so (this is arrogant I guess ?).

I have not seen a photo of it, but it's frankly irrelevant. You're shoehorning in your experience of having seen exposed organs as giving you some kind of expertise; but it does not, this is an issue of ethics about a breach of body autonomy and consent.

>BUT it is indeed bad and damaging for the doctor/patient relationship, which is today even more prevalent than the care one.

This is a very mechanistic interpretation which does not regard justice or principles as being a thing and only considers results.

This is why there's so many ethical issues coming to the forefront these days ... people grade things into "acceptable" levels of bad behaviour.

I don't see anyone in this thread claiming this is acceptable. What some people are doing/saying is putting it in proportion: compared to things like cutting someone an arm loose (either intentionally, or unintentionally), murder, assault, and robbery this is far less bad. Because there's no permanent damage, and nothing was taken away. The initials even get removed over time. Is it bad? Oh yeah, it is, because the relationship between these 2 is professional and top down (doctor being authority on the matter, patient being sedated). I haven't seen anyone arguing this person shouldn't be punished.

> people grade things into "acceptable" levels of bad behaviour.

So I don't see anyone grading anything into acceptable levels of (bad) behaviour. Putting behaviour in proportion to find adequate punishment is part of the judiciary system which you can find back as working decently since trias politica invention.

A minor nit, but it's not a permanent body modification. The marking is supposed to heal. He was caught because he marked a liver and it didn't heal because that patient was ill and another surgeon found the mark.

He was prosecuted and convicted for a minor offence ("assault by battery" is almost the lowest level of this offence) and because he pled guilty the more serious charge ("assault causing actual bodily harm" (ABH)) was dropped.

Some doctors in UK have been convicted of manslaughter by gross negligence (a far more serious criminal charge) and were able to return to practice after a time of suspension, so he might be able to return to work.

He's been through a hearing at MPTS (the independent medical tribunal service) after a complaint to the GMC (the regulatory body for doctors in UK). I think it was an interim hearing, and they're waiting for the criminal trial to finish.

But here's the warning he got:

They had several options: they could have prevented him from working; they could have required him to take action to prevent re-occurance.

If he'd done it to me, I'd have carved my name on his forehead. Completely unacceptable.

//edit// I'm not sure why this evokes such a strong reaction in me. I think it's because it's like a claim of "ownership".

I would not have retaliated in kind but most likely would have retaliated in court, and I would have pulled out all the stops to inflict maximum damage. So I'm sympathetic to your response but to react to the point where the damage you do is worse than the damage that was done to you - in spite of the breach of trust - is probably not the best course of action. Also, I've seen that movie.

I'm exaggerating, but I do think sometimes when a physical wrong is done to your person it requires a physical response.

> I'm not sure why this evokes such a strong reaction in me. I think it's because it's like a claim of "ownership".

That's because of the use of the word "branding", which is what cattle farmers do to their animals to indicate ownership. Had they used something more value-neutral like "initialed", our reactions wouldn't be nearly as strong.

(I'm not saying that "branding" is the wrong word to use, nor that "initialed" would have been better, just that the specific words we hear matter, even when their meaning is mostly the same)

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