There was no danger of harm. In fact, though this was a stupid decision by the surgeon, I'm of the opinion that he should not be removed from his post.
He was proud of his handiwork and signed off on it. Have we enough skilled surgeons to remove them for a harmless boast? Reprimanded, sure, but removing him from his post is both an over reaction and unfair to society which is already lacking in skilled healthcare professionals.
He is not just a mechanic operating on inanimate objects, his "handiwork" was the insides of a person. Letting vanity get to your head and signing your initials inside of them is a gross violation of the autonomy of that person -- they never consented to such a thing.
The insides of a person loose a lot of there holyness and gloriousness, that law ascribes to the object, when you have it in your hands every day- and if the plumbing doesent work out close the lid on some meatsack with sticks in it.
His "stupid decision" shows a complete lack of judgement. I would never trust anyone with my life if they are capable of doing something as absurd as this.
People who are specialists in one thing might make terrible judgements in other things. Your excellent judgement in designing software doesn't make you an excellent driver.
Except this isn't how we make decisions in our society. What if he hits a kid with his car, should we let him off the hook there too because 'he is needed by society'
That's a poor analogy, because people driving super drunk have the potential to cause very great harm.
If we're sticking to car analogies he wrote his name in the dirt on the back of a truck, but the dirt was abrasive and so he also scratched his initials into the paint.
It is part of a bad culture among medical doctors, where they both torture themselves and apparently others as well.
The profession as a whole should really wake up or they will face a similar reaction as taxi drivers did with the introduction of Uber and Lyft. Nobody want’s to be forced to be a customer in businesses that supersede customer trust for ego.
I think that depends on your definition of "harmed". If I used a laser to burn my initials into your underarm in a place that no one would ever see it.... would you say that I harmed you?
Is it certain that a couple inches of laser beam scar tissue in a liver has not, and will not in the future cause any medical issues for the patients in question?
I got laser surgery done and that left a big scar on my neck, can confirm 10 years later I'm still functioning properly. Now the liver is different but from reading the article it seems this was just a stupid non-life-threatening decision taken by a surgeon who thought he was painting on canvas
Yes, but my question wasn't "What if you had an unavoidable scar from laser surgery", my question was "would you feel harmed if I burnt my initials into some not-normally visible part of your skin" for no other reason than to say that I was there?
Even minor scarring adds to the bodies burden in healing, so I think it's hard to definitively say that the laser inscribed initials did not cause any harm or increased risk at all. After all, these were not strong, healthy people -- they were sick enough to require liver surgery... and one of them had to have followup treatment which is when the initials were discovered.
> Is it certain that a couple inches of laser beam scar tissue in a liver has not, and will not in the future cause any medical issues for the patients in question?
It could well lead to Cirrhosis of the liver. Not to mention Adhesion that could become painful. I'm not too sure how likely either issue is, however I wouldn't like to assume that scarring your liver is going to be completely free of complications... Though by the time you're having an intraoperative procedure done on your liver, you're already not free from complications.
>It could well lead to Cirrhosis of the liver. Not to mention Adhesion that could become painful.
Do you have any medical background ? Did you ever use a coagulator ? Or ever saw a liver with your own eyes and the eventual scars those get because of routinely occurring small infarctii or such ? I doubt so, as this is utter bullshit.
It's not intended to be a permanent scar. These marks are routinely used to mark out areas of the liver to be worked on, and they should normally heal.
In this case he did it to a patient and the marks didn't heal. (By definition he works on patients who's livers are less likely to heal), but it didn't cause any further harm.
Honestly if he had asked for my consent, I might have thought about letting him brand my organ, it's not like anyone will see it or care. It might mean he takes more pride in his work and thus do a better job.
I understand a professional wanting to "sign off" on their work; programmers, scientists, artists, engineers and so forth really like putting their name on things so why not doctors?
If he were forthcoming maybe only 10% of patients might agree to it, but that should probably be enough to scratch some egotistic itch.
I cannot phantom a reason to put your health at a risk just to accomplish the ego of someone who should just do his work. I personally find it humilating. Care to explain better? Sometimes I'm really curious about how someone can have such a radically different view from me on such simple arguments, and I always love finding the reasoning behind that.
I can see this argument its not exactly burried. The article states there was no associated health risk. The more general point is a surgeon that openly requires signing your organ, is better than one less well trained surgeon in the world. From a utilitarian pov. Not everyone would necessarily care, like you do. Which is definitely true if you look at the range of responses on here. That this guy did it without consent is what's properly bad, tangibly more than the physical result of his breach of ethics.
You assume that signing means the doctor takes more pride in his work. That is just an assumption. You don't know for sure.
It's possible he takes less pride too. For example, he might notice that out of 50 patients, only you consented to him signing on your organs for his ego. So it is possible that from his point of view, you don't care that much (compared to the other patients). So maybe try other things on your organs that he has been thinking about, maybe play around a little in other ways, test the boundaries a bit. Throw a few harmless things in there just for fun. Why not? You'd probably consent anyways.
Why risk trying those things on other patients when he can try it on you, the person who consented?
An engineer signing on her work, is different from a doctor signing on a human organ.
One is signing on a piece of object, and one is signing on a live human being. An object and a human being are hugely different things.
That would be like saying, well I can write my name on my own piece of paper, why can't I tattoo my name on your back? No one can see it.
Also, one is a "creation", and one is just "fixing". An engineer signing a circuit board that she created, is very different from a doctor signing on a person that she did not create.
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.
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.
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.
Reality is, tons of doctors have all kinds of issues (my fiancee is a doctor in one of the biggest hospital in Switzerland). As mentioned - substance abuse, tremendous pressures at work and massive overtimes (suicides aren't that rare, some just quit profession or downgrade to become a nurse).
Ever thought that when you are admitted, doctor will quickly check youtube to look FOR THE FIRST TIME how to perform some minor (or not) procedure? Ever thought that patients would die or get seriously, permanently injured just because somebody forgot to do some checks? You thought that most senior surgeons are just workoholic egomaniacs, dependant on various legal or illegal substances that healthy person shuldn't touch, ever? And this is Switzerland.
In ideal world, you're completely right. In real world out there, where ALL OF US make mistakes all the time, including doctors, this is really 'meh' category that I wouldn't mind at all on me, as long as doctor's performance is consistently solid.
Maybe slap on the wrist in form of demotion / ban of practice for a year or two. Put a mandatory psychological treatment for true reason of this behaviour (we're society after all and should help each other, not banish them to hell for any mistake). Otherwise, if your would apply super high standards consistently across all staff, you would see plenty of people dying due to no staff in hospitals. Sad but real.
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.
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.
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.
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.
> 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.
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 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)
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?
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.
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:
> 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.
They had several options: they could have prevented him from working; they could have required him to take action to prevent re-occurance.
Can't believe anyone is defending this creep. What if your nanny wrote "FUCKSTICK" in washable marker on your baby's face but made sure to wash it off before you came home?
I mean really, I'd probably find that funny but I'd be inclined to fire the nanny. Although really I'm not sure why I'd have a nanny in the first place, that would probably be my first line of investigation in this scenario.
This isn't the first time I've heard of such a thing. From When the Air Hits Your Brain: Tales from Neurosurgery by Frank Vertosick Jr:
> “He’s a big fan of yours, too, pal, ever since the bone flap thing.” The bone flap incident had occurred early in Gary’s chief year. Fred and Gary were performing a cranial operation to remove a benign brain tumor. Fred had performed the entire operation himself—a grave insult to a chief resident, known as “stealing the case.” After Fred left the OR, further irritating the chief by dumping upon him the tedium of closing the wound, an angry Gary had engraved the phrase “Fred sucks” with the electrocautery knife on the inside of the bone flap, the plate of skull bone that is temporarily sawed away to gain access to the brain. He had then wired the flap back into place, thinking that the inside of the patient’s skull would never again see the light of day. Unfortunately, the bone flap developed a staph infection and had to be removed a week later. Once contaminated with bacteria, the free piece of skull must be removed to cure the infection. The soft spot is filled in with plastic several months later. Gary coerced me into assisting Fred with the surgical removal of the infected flap. I’ll never forget the almost unintelligible stream of invectives that spewed forth when Fred saw Gary’s skull graffitti. Fred was too embarrassed to send the discarded flap to the pathology department as it was, and we spent an hour drilling the message off the bone before allowing it to leave the OR.
Considering the type of personality that surgery attracts, I see why this happens. That said, I don't think this is a common occurrence. (And it should go without saying, but such actions are unethical, unprofessional, and worthy of criminal charges.)
Great passage, thanks for sharing. It's a bit unnerving that this kind of thing may not be as rare as it might seem (engraving bones during a brain surgery of all things).
The branding itself is bad enough --to put another burden on the system of patients who are already in a bad enough state to need a transplant is just cruel-- but this also means that he prolonged the operation just to satisfy his vanity, possibly risking further complications, and wasting time that could benefit other patients.
Argh I don't know enough abut medical ethics to know where the line is but for all the people rejoicing in the guy resigning, losing his license, being convicted of a crime, or any other horrible outcome ...
Please, please, really consider what it means to ruin someone's life when advocating for a certain punishment. There's a whole range of reactions between "eh, no big deal" and "destroy his career!"
Whatever the man did, what he didn't do was kill anyone or permanently curtail someone's professional life or put someone in a cell for days/months/years.
All of the punishments discussed also remove a functioning surgeon from being a contributing member of society.
I'm just saying, it's worth thinking about.
I feel like we all get so self-righteous and don't think about how much impact these punishments have. It's like, a friend of mine always argued we should really bring back public spanking. Sounds like a joke, but her point was there should be a type of punishment that is the equivalent of society yelling a whole bunch at you very very sternly and making you feel very very embarrassed and then you moving on with your life and continuing to contribute to society.
No matter where the line is, "branding a patient's liver" is clearly on the wrong side of it. I agree that the appropriate response is not "branding" the guy in return, by making sure his name is so tarnished that he'll never get a proper job again, but there has to be a strong reaction to what he's done. If he just gets a slap on the wrist he's probably tempted to do something similar again (since there seems to be some urge inside of him that made him do it in the first place).
> Whatever the man did, what he didn't do was kill anyone or permanently curtail someone's professional life or put someone in a cell for days/months/years.
I don't have much of a problem with very severe punishments for things that (1) the person knew they weren't supposed to do; and (2) can't be done by accident.
> her point was there should be a type of punishment that is the equivalent of society yelling a whole bunch at you very very sternly and making you feel very very embarrassed and then you moving on with your life and continuing to contribute to society
This sounds more like the stocks than a public spanking (spanking?).
A public shaming works better when everyone agrees on what's shameful. As soon as you have groups who honor getting thrown in the stocks, a lot of the point of throwing people in the stocks disappears.
I know enough about medical ethics that this guy is lucky to get away with just losing his license, being convicted of a crime would be a nice touch.
Keep in mind that you're on an operating table, passed out and 100% dependent on those working on you. To treat you like a graffiti wall is not only disrespectful, it wastes time under narcosis which carries some minimal risk, and potentially could lead to complications (though not related, complications were the reason this was discovered in the first place).
Let's say that treating this guy like a trendsetter would definitely not have my vote. I've been operated on a couple of times in my life and I'm pretty sure that the surgeons that did that would be far more angry about this than a patient ever would be because this guy damaged all of the medical profession for his personal gratification.
It seems to me that this form of "public spanking" would really earn the opposite of what you claim for: when you leave the judgement to the crowd, you are basically fomenting hatred and revenge (because for some psychological reason in such a case every one feels entitled to have a revenge, even when they are not involved in the case), which in turns leads to a punishment that cannot be controlled any more. This is why judgement should be left to professionals that (should) take the appropriate time to listen to both parties, review the legal basis and take a well-thought decision, trying to not put too much feeling in it. I'm not claiming this works perfectly, but it is definitely better that leaving the matter to the crowd. There are many cases of people whose guilty-appearing position was overexposed, for example by media, later proving innocent or less culpable that the initial situation might have suggested, but condemned forever to unjust public shaming.
On the act itself, I am in the number of those who think this should be taken extremely seriously and it is good ground for losing the license and criminal charges. Scarring someone's body (against their own will) has been for long (and until a few decades ago) a sign of property and slavery, and although I do not think this was what this surgeon intended, it still must be considered an extreme humiliation. Also, a surgeon's professional position usually entails an important amount of responsibilities and power, so violation of the public's trust in them are very important matter.
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