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Political Correctness
JOSEPH H. FRIEDMAN, MD
[email protected]
P
o litical correctness
Mongolian idiot was the
fashion for the non-ill. They have been,
(PC) exists for a reason but
technical term for what
for the most part, discarded, although
can be taken to extremes.
we now call Down syn-
retardation and spastic are technical
Political correctness
drome, or trisomy 21.
terms that, like idiot, describe syn-
affects all spheres of
These people were some-
dromes. For example, spasticity is
human interaction. Let
times called “Mongol-
the term to describe an abnormality
us consider PC in the
oids” or “Mongols,” as if
of muscle tone in which the tone is
medical sphere. It was
physiognomy signaled an
increased in a way that depends on the
not long ago that we used
ancestry, which, in turn,
rate at which the limb is moved, and is
terms that even those
was linked to a denigrat-
associated with increased deep tendon
who now mock PC might
ing term both for the pa-
reflexes and possibly positive Babinski
tient and for people from
reflexes. Describing a “spastic parapa-
possibly find repellent,
or not, unless the terms were used to
Asian countries.
resis” is a useful distillation of clinical
describe their family members. The
In my own subspecialty of neurology,
findings. Calling someone “spastic”
word “idiot” is a good place to start. In
movement disorders, terms like “reptil-
or “a spaz” is a denigrating term that
Fyodor Dostoyevsky’s novel The Idiot,
ian stare” and “simian posture” were
presumably means clumsy, and is
the protagonist suffered from epilepsy,
also used in a “technical” way. People
used only as an insult. We describe
just like Dostoyevsky himself, a syn-
with Parkinson’s disease, who had a
degrees of retardation, mild, moderate
drome which earned the sufferers the
fixed, staring expression, a hallmark of
or severe, depending on one’s score on
label “idiots.” Perhaps it was a kind,
the disorder, were described as having
tests of intelligence, including ability to
euphemistic term back then, but I doubt
a reptilian stare. The posture in PD is
understand, recall and solve problems.
it. It was a term used in Western med-
stooped, hence, “simian,” or “ape-like.”
Not long ago it was common to use
icine that had more than one meaning.
There didn’t used to be a lot of PD
the word “senile,” which should sim-
For example, there were syndromes, like
patients because they died early, and
ply mean elderly, as synonymous with
Amaurotic Idiocy, now called Tay-Sachs
people didn’t live as long as they do now.
dementia. This is presumably because
disease, among others, that incorporated
And doctors held a more prestigious
it is tied to the term, “senile dementia,”
the term in the official labels given to
and august status than they do now so
which had meant Alzheimer’s disease.
certain diseases. In a sense, then, the
that patients and families were proba-
The word has continued to be used in
term was technical, rather than jargon. It
bly less likely to complain. How many
isolation to mean demented, conflat-
is easy to see how the “technical” term
middle-aged people would like to hear
ing dementia and old, implying that
idiot was picked up by the lay public
that their parent, or they, themselves,
dementia is part of the aging process.
to mean what it does today. One might
were diagnosed with PD because of their
contrast the idiot concept of epilepsy
reptilian stare and simian posture?
Dumb is an interesting word. Its
real meaning is mute, but has been
with that of Pharaonic Egypt, where epi-
Hysterical, of course, referred to his-
extended, probably because not talking
lepsy was considered a “royal disease,”
trionic and flighty behavior ascribed to
is sometimes interpreted to mean stu-
because it occurred in the royal fami-
movement of the uterus.
pid, to mean just that, stupid. “Struck
lies due to a genetic disorder, resulting
from inbreeding.
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Midget, retarded, and spastic are terms
dumb” means “struck speechless,” but
that are widely used in denigrating
“dumb bunny,” “dumb fool,” etc. means
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lacking in intelligence or thoughtfulness.
“Oriental” was often interpreted as
mean.” This is not correct. Words can
I agree there is sometimes an over-
denigrating. While I had no idea at that
hurt. We should use the terms based
emphasis on political correctness. For
time that this was the case, it seemed
on how they are perceived, not how we
example, I am not in favor of describing
quite clear to me that there would be
think they should be perceived. Using
short people as “height handicapped.”
no reason to use the term, “Oriental”
denigrating labels, even if they seem
And, perhaps because I’m a neurologist,
anymore, except for describing certain
not insulting to the user, is a way of
I do not object to the term mental retar-
forms of art, despite the fact that I had
distancing ourselves but also reduces
dation, with the modifiers mild, mod-
never heard the term used in a dispar-
how patients think they are valued. v
erate or severe, although just as much
aging sense.
Author
information would be present with the
In the early days of clinical genet-
terms of mild, moderate or profound
ics, scientists used to coin terms they
Joseph H. Friedman, MD, is Editor-in-chief
“learning impairment” or “intellectual
thought “cute” for a gene they isolated,
of the Rhode Island Medical Journal,
limitation.”
for example “sonic hedgehog.” However
Professor and the Chief of the Division
The real issue is what the affected
this caused problems when a family
of Movement Disorders, Department of
population experiences when we use the
would be told that their child has a
Neurology at the Alpert Medical School of
term. I recall giving a talk to medical
disorder, holoprosencephaly, caused
Brown University, chief of Butler Hospital’s
students and, in talking about the epi-
by this gene, and the terminology was
Movement Disorders Program and first
demiology of a disorder, mentioned its
quickly reined in.
recipient of the Stanley Aronson Chair
prevalence in Asian countries. A student
Being PC simply means being sen-
of Asian descent thanked me after the
sitive to the meaning of the words we
talk for using the term Asian instead
use. In Alice in Wonderland, Humpty
of “Oriental.” I had purposely used the
Dumpty states that “when I use a word,
term because someone had told me that
it means exactly what I choose it to
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in Neurodegenerative Disorders.
Disclosures on website
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Grateful Patient Philanthropy (GPP) raises ethical concerns among doctors
HERBERT RAKATANSKY, MD
R
ecently two doctors ,
insurance status. This
techniques either by email (14) or lec-
separately, expressed their
information permits the
ture (18) or personal coaching (19.) The
concerns to me about
development office to accu-
doctors in the coaching arm generated
being asked to participate
rately evaluate patients as
$219,550 during the study. No gifts were
in soliciting patients for
prospective donors.
received in the email or lecture arms.
donations to a hospital.
A disclosure of this
The primary ethics issue is whether
Medicine has evolved
policy must be included
solicitation by doctors violates the fidu-
into a “big business” mod-
in the “notice of privacy
ciary relationship between a doctor and
el in which doctors are
practices.” And to quote
a patient. The fiduciary nature of this
regarded by management
from the regulations:
relationship has been well established in
as “revenue centers.” The
“Each fundraising com-
US case law. The introduction of a third
revenue comes mostly
munication made to an
from patient care but asking doctors
individual under this paragraph, a
Changes in HIPAA regulations
to solicit grateful patients to donate
covered entity must provide the indi-
(in 2013) allow institutional fund-
is becoming widespread. In fact, this
vidual with a clear and conspicuous
endeavor now has a name: Grateful
opportunity to elect not to receive any
Patient Philanthropy (GPP). These
further fundraising (solicitations).”
programs are based in the institutional
Thus, patients cannot prevent the devel-
of health care service, treating
development office.
opment office from accessing the above
doctor, outcome information and
information and may opt out only after
health insurance status.
GPP is big business. In 2012, $28.12
billion was donated to health organiza-
raisers to learn the name, address,
age, gender, date of birth, dates
the first contact has been made
tions, 75% from individuals (not all of
A recent survey indicates that 95%
party may “destroy the trust that the
them patients). The median cost to raise
of institutions without a GPP were
patient has that the doctor’s only goal is
a dollar is $0.31. Gifts vary in size from
planning to start one and 88% of
the health of the patient.” The fiduciary
$400 million given by Denny Sanford to
institutions with a GPP were planning
duty of a doctor to his patient is a legal
a health system in South Dakota to gifts
changes and/or additions. By far the
obligation as well as a moral commit-
of a few dollars. Funding for hospitals is
most popular change was “increasing
ment and violations may trigger legal
perilous at best and likely to get worse in
focus on physician/clinical staff engage-
consequences. The doctor’s moral and
the next few years. In the current politi-
ment in patient referrals.” No GPP pro-
fiduciary obligations are in peril if solic-
cal climate philanthropy is an essential
grams considered downsizing! A 2016
itation alters clinical decision-making.
component of our health care system.
report on GPP noted that the two top
We know that gifts from drug com-
You might ask how administrative staff
“insights” about GPP were 1.) Grateful
panies to doctors be they small, such as
even knows about who has been treated.
patient programs are in growth mode
items with a nominal value, e.g.: pens,
Changes in HIPAA regulations (in 2013)
and 2.) Today’s top investment: engaging
etc. or of moderate value such as meals,
allow institutional fundraisers to learn
physicians in referral.
influence doctor’s clinical decisions.
the name, address, age, gender, date of
Are doctors good at fundraising? The
And, despite the evidence, doctors
birth, dates of health care service, treating
answer is “it depends.” In a randomized
generally believe that others might be
doctor, outcome information and health
trial, 51 doctors were taught soliciting
influenced, but not themselves.
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So what is a doctor to do?
Doctors who engage in fundraising by
Another ethics issue is Justice. Might
It seems obvious that a doctor should
giving talks about research or clinical
scarce resources be more available to
not be reimbursed a percentage of dona-
programs to groups of patients at special
donors?
tions for soliciting patients. Indeed only
events are in little danger of damaging
Thus, I would advise the two doctors
3% of 405 doctors surveyed in 2015
their relationship with a specific patient.
whose concerns spurred this response
reported such payments. However,
The closer one gets to an individual doc-
that policies concerning physician par-
financial reimbursement is not the only
tor soliciting an individual patient, the
ticipation in GPP should be determined
reward doctors may receive for success-
more danger there is of compromising
not by “management” alone. To protect
ful fundraising. Public recognition, titles
trust. In a study of 20 Johns Hopkins’
us all from ethical lapses and thus
such as “champion fund raiser,” etc.
doctors, 18 identified misuse of the
protect our patients, a comprehensive
and other non-monetary rewards may
doctor patient relationship as the “most
discussion of GPP policies should be
be very powerful. Napoleon opined: “A
significant ethical concern” in GPP.
initiated by the hospital ethics com-
soldier will fight long and hard for a bit
of colored ribbon.”
The AMA Code of Ethics states that
doctors should:
Best practice GPP guidelines issued
mittee and then be considered by the
by management consultants state
entire medical staff of the hospital. Joint
that a doctor, the more prominent and
ownership (management and doctors) of
respected the better, be identified as a
GPP policies might accomplish a dual
“Refrain from directly soliciting
“physician champion” and be recog-
purpose. Patients would be protected
contributions from their own patients,
nized by other doctors as the leader of
by an ethically appropriate GPP and
especially during clinical encounters.”
the GPP effort.
involvement of all medical staff mem-
It is important to note that although
Management consultants have sug-
bers might increase enthusiasm for
non-caregivers in the hospital may have
gested that department chairs might
GPP and produce increased funding by
access to some data, they cannot access
lead GPP in their discipline and receive
grateful patients. v
diagnoses or treatment details. This infor-
a bonus if defined fundraising goals are
mation is protected and may be divulged
met. Might fundraising then unwit-
Author
to the development office only with
tingly influence the clinical or academic
Herbert Rakatansky, MD, FACP, FACG,
specific permission from the patient.
status of department members or reward
is Clinical Professor of Medicine Emeri-
It is critical to assure patients that
“special treatment” of VIP patients by
tus,The Warren Alpert Medical School
department members?
of Brown University.
the quality of their treatment is in no
way related to their willingness to make
Other management best practice
donations. But the erosion of trust may
suggestions include visits to patients
be subtle and doctors must be sensitive
(while in the hospital) by administrative
to this issue.
or development personnel.
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