Periodically we read about deviance in medicine. Such stories are calculated to frighten those who depend on the medical profession, and who does not at some time in life. Dr Death, the Butcher of Balgalowah and the like are, sorry to say, but recent, local examples of a wider and more general phenomenon. Years ago there was a doctor in Auckland’s Women’s Hospital who did things his way, to the detriment of his patients, and here in Sydney, still earlier, was Dr Harry Bailey with the application of sleep therapy in the 1960s. Many other examples exist. There have been many instances of doctors claiming training and degrees that they did not have and being then empowered to do things for which they had no preparation.
Beyond the immediate shock value, these stories are also windows into some fundamental aspects of social life and institutions. I would like to direct attention to a more abiding matter that they reveal.
Medicine is one of the most highly regulated social activities. Physicians themselves are licensed by society only after an extensive education, which taxpayers finance, that serves beyond the technical skills and knowledge it imparts, to socialize them into the norms and ethos of the profession. Nor does this process stop at some point, but rather it continues through continuing professional education and on-going and close peer review, especially in hospitals, which are in turn another realm of regulation. This regulation is encouraged and made necessary by external stakeholders like governments and insurance companies which pay for treatment both in the doctor’s office and also in hospitals and which therefore depend every more accountability through regulation. Regulation is also demanded by patients, and relatives, and by courts and juries if things go wrong. In sort, it is an extremely highly regulated world this world of medicine. There can few sites more governed than a hospital. The regulation of medical, diagnostic, therapeutic, administrative, financial, sanitary, and more. Simply to walk down the hall in a hospital is to see some of the outward signs of the layers of regulation in the injunctions, prescriptions, directions, and warnings posted on boards and doors, and stuck on the wall about washing hands, wearing gowns, reporting to the floor station, when and when not to press a button, flyers on how to use the bathroom plumbing, and on and on.
Regulation serves many purposes, one of which is to reassure patients when we enter that world with the message that it is directed at our best interests, and of course it is in all but the most exceptional cases. Still the mystery is how can these exceptional circumstances occur in such a governed, even over-governed, environment? How can a cancer specialist withhold standard treatment from hundreds of patients for years in a hospital? The medical histories, the case reviews, the collegial assessments, these standard controls did not work. How can a specialist abuse patients for a decade in a hospital with hundreds of employees and no one notice? Or, if anyone noticed, was there no means to report it. But wait, in each case it was noticed and reported and somehow it still went on, despite these checks. The checks were too few and too weak to stop a single very determined individual. That is the point of emphasis. The elaborate and complex institution that a hospital is sometimes proves too weak to identify, and even when identified, too weak to deter a single individual.
The stock response, the easy response when such a case of medical deviance occurs is to say that we have now corrected the errors, closed the gaps, introduced (implemented, for those who only grok McKinsey-speak) yet more, new regulations. That of course is done, repeatedly, and yet new examples emerge. Ever more government and yet deviance still happens. The cost of compliance with the layers of regulation increases, yet deviance remains. That is the mystery.
It may be that to some degree the ever increased layers of regulations, each with its own priorities, definitions, reporting lines, are such that no one ever in fact takes notice of them. It may that the forest of regulations makes it easier to hide deviance in plain sight, for nearly everything in a hospital is in plain sight, but everything is not seen even if it visible. I am quite sure that the hundreds of reports I filed at the University as a middle minion were seldom, perhaps never, examined in the reporting line. Not filing a report, that brings a reaction, but once filed… that is the end of the story. Though I am equally sure that each report was filed.
While I cannot resolve the mystery of such deviance against such long odds, I do suggest that a mystery like this, though it comes at a price paid by patients, does carry a larger message and that the message is positive. Some good does come from evil, as Max Weber knew, though millions do not, the world is like a marble cake. Cut a slice and good and evil are mixed in that slice.
Mystery it surely is. A vast body of social science research leads inexorably to the conclusion that lone individuals conform to the pressures around them in nearly every case, and that those few who rebel can do little more than vent frustration in negative acts of destruction. Loyalty is the choice nearly all of us make most of the time, when we conform to the expectations, pressures, and the rules and regulations – written and unwritten – governing our lives. A few give voice to their frustrations and some others exit. Few. The mystery is that there are some who remain ensconced, deeply integrated in the webs of the social institutions, and yet work systematically, at least in part, against the norms of the institutions. These are the deviants in focus here.
The chief message of social science is that structure trumps agency. ‘Structure’ refers to the contours of social life and institutions, some of which are expressed and reinforced in the rules of social institutions like education, the medical profession, and hospitals. Though most of structure is internalized by individuals through a slow, steady, and continuous process of socialization as alluded to above. There have been several definitive expositions of this conclusion. The earliest, self-conscious example is Emile Durkheim’s Suicide (1893) in which he concluded from an impressive examination of empirical evidence in medical and legal reports compiled in very Roman Catholic France, that the explanation of suicide lay in the social context of the individuals and not in any of their unique or personal experiences or qualities. A similarly impressive empirical study of another kind reached the same conclusion in the 1970s. Stanley Milgram in Obedience to Authority explained the readiness with which his volunteer subjects inflicted (what they thought was) pain on others by reference to structure, and their weakness as agents. The strength of structure and the weakness of agency he attributed to a general feature of social life to be found everywhere.
‘Agency’ refers to the capacity of individuals to act alone, creatively. It exists in the cracks left by structure, rather like the grass that grows in paved courtyards.
Those maverick doctors are themselves evidence of agency. They prevail for long periods of time, working within very tightly regulated environments, working in the view and other highly trained professionals, working systematically against the norms of the layers of social institutions in which they find themselves. Whatever the motivations of such physicians and whatever the damage they cause to suffering patients, at the least they remind us that individuals do matter – agency exists – and mindful of that, regulation must be more than simply making rules, it must also include enforcing those rules. It may be dark agency, but it is nonetheless agency.
In the late 1980s I noticed some outstanding examples of this kind of deviant behaviour in medicine and collected a few titles, listed below. Being now reminded of them I tried a few searches (Google, web of knowledge, Google scholar, Wikipedia) to find others. I failed because of the plethora of false positive returns. I need to refine my search terms. Any suggestions would be welcome.
Brian Bromberger (1991). Deep Sleep: Harry Bailey and the scandal at Chelmsford.
Sandra Coney (1988). The Unfortunate experiment: Cervical Cancer Treatment at Auckland Women’s Hospital.
Bill Nicol (1989) McBride: Behind the myth.
Skip to content