Plea of war doctor who shot dying woman

AN ADELAIDE surgeon who shot dead a young mother at the site of a massacre to save her hours of agony has called for euthanasia to be legalised in Australia.

Dr Craig Jurisevic, a cardio-thoracic surgeon and author of the memoir Blood on My Hands, volunteered as a doctor and then became a combatant with the Kosovo Liberation Army during the Balkans war in 1999.

On patrol, he came across a civilian woman who had been shot through the legs and partly disembowelled by Serb paramilitaries.

She was moaning in pain and begged him to end her suffering. He says he knew he could not save her, so he put a blanket over her face and shot her with his pistol.

Dr Jurisevic says he has never performed euthanasia in Australia but says it is common: ”You may not get people to come out and admit that it happens, but it happens all the time. Patients with terminal cancer, for example, who aren’t in severe pain but who are uncomfortable and suffering have morphine infusions, and as the dose of morphine is increased their respiration slows down until they stop breathing and they die ?

”That’s why there are people on morphine infusions who aren’t in pain. It happens frequently in terminally ill patients.”

His comments add to similar calls from doctors at a conference of the World Federation of the Right to Die Societies in Melbourne this week.

Dr Jurisevic fears euthanasia laws could be abused by people who want to prevent euthanasia, and by people who want to use it inappropriately, but on balance he believes it is better to have the practice out in the open.

”Now that people are living longer, they are developing cancers and other terminal conditions, which mean they will suffer for a lot longer, too, leading up to their death. Part of our ethos as medical professionals is to ease suffering; not just to save life, but to ease suffering.

”And if we’re to be told that we’re not allowed to ease a terminally ill cancer patient’s suffering because it’s against the law – that they should be forced to suffer in pain and without dignity for weeks or longer – then that’s terrible.”

He has no regrets about his shooting in Kosovo but admits he acted illegally. ”Euthanasia wasn’t legal in Yugoslavia, as it was then, so that was a criminal act. That’s an argument a lot of Serb journalists within Serbia have used. They called me a criminal because I killed that poor Albanian woman. I said, ‘Well, who put her there in the first place?’ ”

Surgeon at arms

THE soldiers could hear a woman crying out in a house at the other side of the village. Two of them peeled off to investigate. Unluckily for them, Serb paramilitaries had left a booby-trap.
In Kosovo, Muslims take off their shoes before they enter a house. It is a gesture of respect for the home. But during this Balkans war, Serbs used shoes at the doorstep to disguise a tripwire that triggered fragmentation grenades. The moaning woman had been spared for one reason only: as bait to lure whoever would come next to this hamlet, site of a massacre by advancing Serbs.
Craig Jurisevic is an Australian doctor who had volunteered as a medic to help the victims of the Balkans War. This day, for the first time, he had picked up guns to go on patrol with soldiers of the Kosovo Liberation Army. He realised this was the moment when he crossed the line to become a soldier who could practise surgery, rather than a surgeon who knew how to hold a gun. What he did not know, when he holstered his pistol that morning, was that the doctor in him would feel forced to use it on a patient.
Hearing an explosion, he raced over to the house. He checked their pulses and confirmed the deaths of the soldiers and the woman. He had already found 15 bodies of women and old people riddled with bullets. He moved cautiously towards a second house that held another woman whimpering in pain. He inspected the doorway carefully; yes, there was the wire. It was snipped and he entered.
The woman was sitting up against a wall. Near her lay the body of her husband, his head in a pool of darkening blood. In her arms she cradled a dead child, a boy of about four or five — the age of Jurisevic’s own son, back home in Adelaide. The child had been garrotted.
The woman had been shot in both legs to prevent her moving and was sitting in a massive pool of blood. She had been partly disembowelled and the coils of her innards spilled from the gash.
“The wound to her lower abdomen is meant to cause enough pain to make her cry out without killing her too quickly,” Jurisevic later wrote.
She clutched his wrist and begged him to bury her son before the next day, as is Muslim custom. Then a soldier translating for her said, “Doctor, she is asking us to kill her.”
“To kill her?”
“Yes. That is what she is saying. Doctor, I am sorry, I cannot do this.”
Jurisevic knew he must be quick because the Serbs would have heard the explosion and would return. If they found her still alive, he was sure, they would torture her even more.
In his book Blood on My hands: A surgeon at war, this is how Jurisevic describes what happened next: “I move the woman as gently as I can and place her beside her dead husband. From the bedroom I fetch a thick blanket. I think she sees clearly enough what is to follow, and she nods and manages something like a smile. I turn her head to one side, gently place the blanket down on it, point the barrel of my pistol down and pull the trigger. I wait for a few seconds, then reach for the woman’s wrist. The pulse is gone. I slide the pistol into its holster and take my leave.”
That was 11 years and half a world away. Today, Jurisevic sits at an outdoor cafe in Adelaide, his camouflage gear swapped for an immaculate navy pinstriped suit — he has been in his consulting rooms all morning — looking every inch the successful medical man. We are in the shade but all through lunch his eyes are hidden behind mirrored sunglasses, the dark, shiny lenses reflecting the outside world and shielding the responses of his inner one. Despite his ready answers to questions, the shades give the impression of a surgeon who doesn’t fancy the prospect of a journalist cutting too deeply into him.
At 45, Jurisevic is still lean and handsome, with chiselled cheekbones, blue eyes that crinkle at the corners when he laughs and teeth that must be the despair of his dentist; they seem to be quite naturally Hollywood-perfect. Here, as on the battlefield, he makes quick, decisive choices; this cafe, this table, this chair are all picked out in very short order. He immediately notices any need and swiftly moves to fill it; a glass of wine, a menu, the salt and pepper, tomato sauce for the burgers. He radiates energy, and action provides opportunities to release it. It also seems that, if there’s a need or a problem, Jurisevic believes it is up to him to solve it.
This deeply seated sense of responsibility has combined with what he calls an “adolescent hunger for stirring times in exotic climes” to make for an exciting life — but a life with episodes that he sometimes looks back on with doubt and remorse. Not putting the pistol to that poor woman’s head. The decision was so clear-cut that, in a book where he debates every other moral dilemma he was faced with at the front, this incident is only briefly described.
“It wasn’t as hard as most people think,” he says, “because, if you take away the method I used, it would just be euthanasia for someone who is dying. But because it wasn’t a drip with morphine, because it was a pistol, people say it’s terrible . . . She would have been dead in a few hours. She’d been shot in both knees and she’d lost a huge amount of blood. She’d been cut open and her bowels — ” he gestures expansively. “We had no blood, and we would have had to carry her, and we couldn’t carry her. I had just a little bit of [anaesthetic] but I was going to keep that for the people who would survive. Also because she had lost a lot of blood, there was no way you could put a drip in and then wait for her to die with [anaesthetic]. And besides, we had to get out within minutes because the Serbs were coming . . . they would have tortured her more.
“I knew, it was instinctive, that’s what I had to do. She wouldn’t have suffered . . . It would have been a lot harder if she didn’t consent or didn’t ask.”
But he concedes that even if she hadn’t begged him, he would still have considered putting her out of her misery. “Even if I was a rampant anti-euthanasia activist, I can’t see how I could not have ended her life. I couldn’t have walked away saying, ‘I feel good about myself because I believe euthanasia is wrong, so I am walking away and leaving her to suffer more and to be tortured again, but I can live with that.’ You couldn’t!”
Jurisevic feels strongly driven to be a good man, and his idea of manhood was powerfully shaped by his childhood experiences. Although they later reconciled, he was estranged from his father for some time. He changed his surname from his father’s name, McLachlan, to his mother’s maiden name, Jurisevic.
His mother was a Yugoslav refugee who taught herself English and trained as a psychiatric nurse in Australia. It was she who told him inspiring stories of the wartime heroism of his Slovenian grandfather, Franc, who “put his life on the line for a cause, and was sent to concentration camps, then came back and saw corruption in Yugoslavia and spoke out against that, and was put in prison again by the people for whom he’d fought. So he had a very strong hatred of injustice.”
JURISEVIC volunteered to work with the International Medical Corps in the Balkans after being moved by the suffering of thousands of refugees pictured on TV news reports. He had previously done a stint with the Israelis, including about 40 medivacs in Gaza; there, too, he had picked up a gun because he came under fire when rescuing the wounded. “I saw taking up a weapon and using it to protect the patients as just part of my job, an extension of treating the disease,” he says.
What of the doctor’s Hippocratic oath, which warns, “First, do no harm”?
“When they say ‘do no harm’, it’s in reference to do no harm to your patient, not do no harm to anyone,” he argues. “So if somebody’s trying to kill the patient, you have to defend the patient. You can’t just say, ‘Sorry, do no harm,’ and stand by. That’s just ridiculous.”
Jurisevic has decided views; words such as “terrible”, “ridiculous” and “absolutely” punctuate his sentences. He says he is drawn to war zones because he has an abhorrence of injustice. He was alerted to the potential of this war when the Serbs began using medical terms and the phrase “ethnic cleansing” as euphemisms for atrocity.
He writes, “Whenever national leaders start applying metaphors of ablution and disinfection to human beings, you can expect killing on a large scale to follow . . . [they rationalise] murder by talking of cancer . . . of scalpels and intervention.”
When he arrived in the Albanian town of Kukes, 200 kilometres north-east of Albania’s capital, Tirana, Jurisevic was appalled. His gorge rose at the stench of untreated gangrene even before he entered the decaying ruin of a hospital. Inside, blood spattered the theatre walls, equipment was dirty, instruments were rusty and nurses were drunk, drugged or cruel. He caught a doctor hacking with blunt scissors at exposed muscle and tendons in the hand of a small child who had been given no anaesthetic. When the boy screamed and writhed, nurses slapped him.
He spent long days operating on refugees — women, children, old people — with horrific wounds. “So many amputations!” he writes. “Reports of casualties don’t fully convey what war does to people. Imagine if I were to give a weekly surgeon’s report to the news services and display the limbs that had been lost, the metres of bowel discarded, the eyes blinded.”
At times he found it hard to hold on to the surgeon’s clinical distance. Of retrieving wounded children from a bombed kindergarten littered with body parts, he writes: “I’d like to vomit or tear my teeth out or shut my eyes and fall to my knees.”
Jurisevic could not understand why supplies were so poor despite a flood of international aid. He learned that medicines and equipment were shut away in cupboards, to be sold on the black market. Patients with no money were turned away. The hospital chief was in cahoots with the local mafia, and they were using the flood of wounded as a revenue stream.
Jurisevic exposed the corruption with the help of the American military magazine Stars and Stripes. He was then warned the mafia would kill him, so he resigned from the International Medical Corps and accepted an offer from the KLA to run one of their field hospitals. There, he was alarmed by the lack of training that left the idealistic, untried young soldiers around him utterly unprepared for what they were to face. He set up his own combat training. The doctor there to save lives taught recruits the art of killing. He was practised with guns from his teenage years when he hunted and culled goats, roos and rabbits in the hills around Adelaide.
He puzzled over how to reconcile all this with his role as a healer. He decided to amend the Hippocratic oath with a principle laid out by Bassanio in The Merchant of Venice: “To do a great right, do a little wrong.”
JURISEVIC learned that the young volunteer soldiers at the front, Mount Pastrik, had been abandoned by their commanders and their doctors, who feared for their own lives. His book paints ultra-nationalist Serb troops as alcohol and amphetamine-fuelled war criminals, but he slams the KLA too, for cowardice.
Jurisevic decided that he would go to the front himself. He set up his own aid centre in a cave on a ridge line at Mount Pastrik, sometimes evacuating the injured down the mountain under a hail of sniper fire. At night, he slept with dead bodies in the cave waiting for burial. Day and night, he endured the Serb shelling.
And it was at this point that he made the decision that would trouble his sleep long after he returned to Australia. Jurisevic led a small patrol closer to the Serb positions. He mapped their co-ordinates in detail and sent the figures off to NATO troops. The next morning, those Serb units were heavily shelled by NATO. Later that day, a ceasefire was declared.
Years later, Jurisevic discovered that that last round of NATO shelling had killed up to 600 people. “I still don’t know whether or not the co-ordinates I gave resulted in that bombing,” he says. “And whether or not that bombing in the area of Pastrik ended the shelling, or whether it was just the ceasefire that resulted in the end of the shelling. But up to 600 people died. It’s still not a good feeling, even if they were all war criminals and baby-killers.”
Then his language hardens, and suddenly he is using the same ugly euphemisms he heard on television in Adelaide: “I realised that certain paramilitaries in the area were a hard bunch. They had no respect for human rights. So basically — it sounds terrible — I saw them as a disease. They were inflicting harm and illness on innocent civilians so they had to be stopped.”
The book makes clear that Jurisevic did suffer some kind of post-traumatic distress after he returned. He says, “One thing that I’ve realised is that I still can’t actually remember arriving in Adelaide and seeing [my wife and my son]. I still can’t remember several days, which can’t be a good sign.”
He did not seek professional help but found writing the book was therapeutic. He says he has had death threats since its publication, mainly from ultra-nationalist Serbs living in Australia. It is not because he shamed them, he says: “If you expose war crimes they don’t deny the war crimes, or even express remorse. They say ‘Yes, this happened, we did this because this happened 800 years ago.’ You can’t justify crimes against humanity now by crimes against humanity in the past.”
Jurisevic has now joined the Australian Defence Force reserves and has been to East Timor and Afghanistan but says he would like to spend the next few years in Australia with his wife and three sons.
He is on another campaign, though: he wants to mount a class action against the federal government to force the banning of cigarettes. As a cardiothoracic surgeon, more than 90 per cent of his work involves trying to remove lung tumours from smokers. He says tobacco kills up to 18,000 people a year but the government won’t ban it because it earns $4 billion more in taxes than it costs in healthcare.
“Of all lung cancers diagnosed each year, only 15 per cent will be early enough to be cured by surgery and chemo-radiotherapy . . . The death rate from lung cancer has not changed significantly in the past 30 years,” he says. “The greatest threat to Australian lives today is not terrorism, road trauma or knife crime. It is tobacco.”
The man who loves causes will never lack for one.
Blood on My Hands: A surgeon at war, by Craig Jurisevic, $32.95, e-book $11.25 from

BORN 1965.
FAMILY Married Donna, also a medical specialist; three sons.
WORK IN CONFLICT ZONES Israel and Gaza 1992-3; Albania and Kosovo 1999; East Timor 2006; Afghanistan 2008.
CAREER Cardiothoracic surgeon, senior lecturer at the University of Adelaide, member of the International Humanitarian Law Committee of the Australian Red Cross.

A lot of noise over silence

Sharon Duchesneau was deeply hurt when her father told her that, if she ever had children, she should check with a geneticist to assess the risk that the baby would be deaf, like her. “I felt put down, like it would be bad if my child was deaf, or it was a negative thing to bring a deaf child into the world,” she says. “I took it personally.”

The personal has now become political. Duchesneau and her female partner, Candy McCullough, who is also deaf, are at the centre of an ethical storm over their decision to conceive children using a deaf sperm donor to increase the chance of the children being deaf. To many hearing people, it sounds like one of those stories that could only come from America, that land of the free and home of the bizarre.

But the chairman of Melbourne IVF, John McBain, says a Victorian deaf couple approached his service three years ago wanting help to conceive a deaf baby. “They didn’t have a fertility problem, they just wanted to maximise the possibility of having a deaf child,” he says. “We couldn’t help them . . . We didn’t know how to increase their chances of that. We were able to take the coward’s approach and say there was nothing we could do.”

To many deaf people, the media debate about Duch-esnau’s choice is offensive because it implies that deaf people are defective. The issue for them is not designer-disability but designer-difference. They do not see themselves as people with a disability but as members of a minority cultural group with its own language (auslan), values and community.

Simon Andersson, a deaf man who is an actuary and secretary of the Victorian Council of Deaf People, says: “I get the feeling that people who object to a deaf couple having a deaf baby are objecting to deaf culture. There’s nothing wrong with being deaf. Deaf is fine. Deaf is OK.”

That is not a new concept to ethicists, who have been debating for some years cases like Duchesneau’s. Several examples of deaf children deliberately conceived through embryo selection have been reported overseas, says bio-ethicist Nicholas Tonti-Filippini. But for the wider hearing community, Duchesneau’s stand is confronting. Is it arrogant for “normal” people to assume their lives must be better than the lives of people who lack hearing or sight or mobility? Or has the rebadging of “disability” as “difference” turned into denial, making Duchesneau’s children victims of what one British columnist called “parental psychosis” and “genetic imperialism”?

The case also throws up new questions about reproductive autonomy in an era where lovemaking can be separated from babymaking. Until now, the fear has been that pre-natal selection would be used to try to create high-achieving, near-perfect children. Now we must ask, does the right to choose include the right to choose disability/difference? Do parents have a responsibility to maximise their child’s potential?
Duchesneau had a 25 per cent chance of bearing a deaf child if she conceived with a hearing donor but a 50 per cent chance if she used a deaf donor. When American sperm banks refused her request, she turned to a deaf friend who had several generations of deafness in his family. Five years ago she gave birth to a deaf daughter, Jehanne, and last November she had a son, Gauvin, who is profoundly deaf in one ear but has some hearing in the other. The two women have decided he will not be fitted with a hearing aid unless he wants it himself when he is older. Their story caused an uproar when published in an American newspaper last week.

Andersson’s wife, Karli, who is also deaf, trained as a counsellor with McCullough at an American university for the deaf. Karli says Duchesneau “seemed a very warm, responsible and caring mother”.

Karli is surprised by the media response. Like Andersson, she believes the problem for deaf people is not lack of hearing but the way it is treated by the mainstream community. “I understand (Duchesneau and McCullough’s) decision, and I think they were discriminated against when they went to sperm banks to ask for a deaf donor,” she says. “What’s the difference between that and a black person asking for a sperm donor that was also black?”

Andersson uses a similar analogy when asked about deafness as disability. He returns to his insistence that deafness is not an innate problem and only becomes difficult because of discrimination, just as “women are discriminated against, but being a woman is fine”.

Tonti-Filippini says Duchesneau’s choice is a logical consequence of allowing prenatal selection. “If an IVF team is prepared to do selection in order to eliminate a child who has some kind of difference like dwarfism, on what principled basis could they reject a parent who wanted to use IVF to have a child who was deaf? Either they say they are governed by choice, or they must admit that the only ethical principle should be a eugenic one, to eliminate genetic abnormalities and difference.”

He says he finds Duches-neau’s decision horrific, but not because it was used by deaf people. “I condemn out of hand the fact that selection is allowed for anybody,” he says.

Julian Savulescu, an ethicist with the Murdoch Children’s Research Institute and professor of ethics at Melbourne University, disagrees with the women’s choice to have a deaf child but supports their right to do so.

“There are two principles that you need to apply here,” he says. “Has the child itself been harmed by what they did? No. If they had had a hearing sperm donor, then some other child would have been born. This child can’t complain that he wished they’d used a hearing donor because then he wouldn’t have been born . . .

“The second principle relates to how we should control or regulate reproduction. I personally believe that it’s better to be hearing than deaf . . . so I think what this couple has done is the wrong thing. I personally think you should try to have a child that’s going to have the best opportunities in life. But the fundamental principle that I think should operate here is one of respect for procreative autonomy, respect for people’s own decision about the kind of children they want to have.”

He says he used to believe deaf couples should not use IVF to make a deaf baby but has now changed his mind. He also thinks that, ultimately, parents should be permitted to choose traits such as intelligence or sex, and he agrees with some disability groups that selection only to eliminate abnormality is discriminatory. “You either allow genetic testing for whatever couples think is a relevant characteristic or you don’t allow anything . . . The downside is that sometimes people will choose in ways that you disagree with. That’s the price you have to pay for freedom.”

Savulescu says ethicist Peter Singer, currently in America, disagrees with him. “I asked him about this. He thinks couples should be prevented from using IVF to do this because he thinks it reduces the amount of wellbeing in the world; the world is better off if the child is better off . . . I think that’s based on an arrogance about knowing what’s best for people.”

Rosemary Robins has taken that principle and extended it to a more extreme scenario for her students in history and philosophy of science at Melbourne University. She asks them to debate the question: “Should a deaf couple be permitted to terminate a hearing child?”

“It’s fascinating what the students make of it,” she says. “Mostly they start out saying, ‘Absolutely no way; you shouldn’t terminate the child, there’s nothing wrong with it’. But then they start to think about why we privilege our (hearing) culture over another culture. We allow abortion for social reasons all the time. I can go and have an abortion just because it’s inconvenient for me now because I don’t have a partner; there I am, terminating a healthy foetus. How is it different?”
Since the 1980s, many members of the deaf community in America and Australia have been galvanised by the idea of deafness as a cultural identity involving pride and self-acceptance rather than a medical disability. They call themselves Deaf, with a capital D, and often reject attempts to turn them into “broken hearing people” with the use of hearing aids or cochlear implants.

Lynn Gillam, a lecturer in health ethics at Melbourne University, has been researching the attitudes of deaf people to the termination of deaf foetuses. They do not condemn it, but are puzzled by it because they feel their lives are happy and fulfilled. She says only a minority of deaf people, usually those born deaf, believe deafness is a valuable part of their identity in the capital-D way. Such attitudes are not restricted to deaf people – she knows a wheelchair-bound person and a blind person who both say they would not want to be cured – but she says that deaf people’s separate language has made the phenomenon stronger in their community.

She is not surprised that Duchesneau and McCullough decided against a hearing aid for Gauvin. “If you have chosen to have a deaf child, you are clearly not going to augment what hearing is there because then you are going back on the decision you have made.”
Savulescu says society tends to overestimate how badly disability affects a person’s life, but that some disability groups try to underestimate its impact. He believes Gauvin should get his hearing aid because he should be given every chance to interact with the hearing world. “I don’t accept this view that you’re either in the deaf culture or the hearing culture. I don’t think you have to exclude other cultural influences to maintain your own culture,” he says.

It is something that Karli and Simon Andersson, who grew up as deaf children with several deaf relatives, are starting to come to grips with. Their 10-month-old baby, Bernhard, can hear.

“Having a hearing baby was a little bit of an issue for me, as we have to work hard to ensure that his hearing culture needs are met,” Karli says. “My husband jokes that he is a special-needs child as he requires things that deaf children don’t, like, for example, music; we bought a Mozart CD for him.

“Still, I love him, and I can’t imagine loving him any differently than a deaf baby. Every child is special in their own way.”

First published in The Age.

The love that dare not speak its name

KEVIN and Hannah like going into town together to do the shops and have a bite to eat. He loves her very much and buys her flowers and chocolates and takes her away for romantic weekends. They have sex every Saturday night – he’d like it more often, but she’s often tired from work during the week – and they don’t have to worry about contraception because she’s had her uterus removed.

They sound like your average child-free suburban couple; well, perhaps a bit happier than the average. But Kevin and Hannah have intellectual disabilities, so they live in a special accommodation house. This meant their romance had a rocky start under the stern gaze of staff charged with their care.

The first time they tried to sleep together, Kevin told La Trobe University researchers, “A staff member knocked on the door and found us together. She said, `Get into your own bed’. I didn’t like her much doin’ that, because we’re two adults and she should have let us do it.” Kevin and Hannah forced the issue: “We left one night and we had sex somewhere. When we came back they had a talk to us and they said, `You can move into a room together’.”

From Kevin’s point of view, he and Hannah were a modern-day Romeo and Juliet, with public servants playing the obstructive Montagues and Capulets. But the situation for carers is not so simple; they must try to balance the human rights to sexual expression of their clients with intellectual disabilities with the duty to protect them from hurt or danger. What if Kevin was coercing Hannah? What if one gave the other a venereal disease? Would their families be horrified to learn that their adult children with disabilities were having sex, and if so, whose moral values should prevail?
Kevin and Hannah’s story is one of 25 detailed sexual and life histories recorded in a report launched this week by the Minister for Human Services, Christine Campbell. The report, People with Intellectual Disabilities Living Safer Sexual Lives, was designed to follow up overseas research that found people with disabilities had much higher rates of sexual abuse and sexually transmitted diseases than others.

It said people with disabilities were often wrongly stereotyped either as eternal children who did not develop sexual feelings, or as potential risks to the community because they were unable to control themselves. One of the authors is Dr Kelley Johnson, research fellow with the Centre in Sex, Health and Society at La Trobe University. Johnson argues that carers’ anxieties leave them either denying sexuality is an issue, and therefore providing no education about it, or practising strict surveillance to keep it from being expressed.

She says lack of privacy forces disabled people to hide their sexual activity, lack of information leaves them having unsafe sex, and lack of education about their rights and the power dynamics of sexual encounters leaves them vulnerable to abuse.

The report tells of Hussein, who didn’t use condoms because the men with whom he had sex didn’t like them. When Neville was institutionalised, he was often sexually abused by male staff, but when he tried to form a relationship with a woman living in the institution he was severely punished. “He learned that abusive sexual relationships were condoned but
that other relationships were forbidden,” the report said. (The names of all the people interviewed were changed.)

Jennifer Evans is president of the Health and Community Services Union, which represents the staff of community residential units. She says decisions about how to deal with sexual matters vary from one unit to another. “I think it’s a matter of (a), recognising your own values and morals, and (b), working out how not to inflict them on the people you are working with. Some carers believe it is their role to be a moral caretaker as well. I don’t see that.”

Evans says, for example, that she disagrees with the department’s ruling that staff are not to facilitate brothel visits by clients: “Other carers would strongly disagree with me, but I believe I am there to facilitate that person’s integration into
the community in whatever way that needs to be done, whether it’s as a visit to a massage parlor or to a local coffee shop.”

But even Evans has been confronted with situations that have made her uneasy. One unit’s residents were all young people in their teens and early 20s who had grown up together in an institution. When they moved to a community residential unit they began sexually experimenting with each other: “Their relationships were almost what I would term (emotionally) incestuous…because they were all like siblings to each other.” She still offered them sex education and condoms.

One of the girls was later found having sex with her boyfriend on an oval in a park: “She considered that more private than her bedroom. If she brought the boyfriend home, then everybody in the house would know about him, but in the park, she felt that nobody knew her.” Evans does not accept the notion that some carers fail to deal with sex because it is too confronting: “I don’t think it should be any more uncomfortable than helping people with other aspects of life that we’re not normally confronted with, like assisting them in the toilet or the bath…I think it’s more to do with the fear that if something happened, staff will be responsible for whatever goes wrong. I have worked with staff who have a very protectionist kind of attitude towards residents and don’t allow them to make mistakes they might learn from.”

A complicating factor in protecting them from abuse is that sometimes fellow residents are sexual offenders. “One chap in particular was very predatory,” Evans said. “He actually wanted to go back to living in institutions, where he had been abused himself and then became an abuser, because living in the community curbed his behavior. He used to say, `I’d get the ones who can’t speak because then they can’t do anything about it’.” Evans said it was decided he was never to be allowed out without a staff member, and other residents’ bedroom doors were alarmed at night to keep them safe.

For Johnson, the most striking thing to emerge from the research was that the yearnings of people with disabilities are just like everyone else’s, even if their chances of fulfilling them are lower. “Most of the people in the group we talked to desperately wanted close, intimate, loving relationships with somebody else. And that was really difficult for them to find because of the ways their lives were constrained and because of the kind of rejection they experienced from the community.”

Kevin is determined to hold on to his Hannah. “The only one I want to spend all my life with is Hannah. I love her that much. I don’t want to lose her,” he told researchers.

“I’m hoping to marry Hannah one day. Yeah. Hoping to.”

Also see: Marriage, Love, Sex … Not a Disability

First published in The Age.

Marriage, love, sex … not a disability

Sarah has sworn off men since she became a single mother. Tom uses massage parlors because he doesn’t know how to meet women. Luigi, who prefers girls, believes that toilets are the place where sex happens because that’s where men ask him for it. Alicia has been happily married for five years.

All of these people have intellectual disabilities. Their stories are told in a report to be released today that concludes that community attitudes leave many intellectually disabled people vulnerable to rape, forced to lead secret sexual lives and practising unsafe sex.

The report, People with Disabilities Living Safer Sexual Lives, contains the detailed histories of 25people interviewed by La Trobe University’s Australian Research Centre in Sex, Health and Society.

Researcher Kelley Johnson said the project was partly in response to British findings that about 70per cent of women with an intellectual disability had experienced sexual abuse, and that both men and women in this group had a higher than average rate of sexually transmitted diseases, including HIV/AIDS.

Of the 25 people interviewed for this study, 18 (11men and seven women) reported sexual abuse. This occurred while they were in institutions, in independent or supported living in the community, or while they were living with their families.

Many still had active sexual lives and wanted a long-term relationship. Some had found partners and had children; one woman was lesbian and one man was gay.

Dr Johnson said the understandable anxieties of carers and families of disabled people often led them to deny sexuality was an issue or to try to prevent sexual activity. This violated human rights and drove the behavior underground.

“That doesn’t just happen to people with disabilities; it happens to the young and to the elderly, too,” she said. “People who have been married for 50years are often separated if they have to enter nursing homes.

“But for people with disabilities, the surveillance is life-long. Service providers and families are very concerned about safety and protection, which is of course legitimate. But the problem is the way it is often managed; people didn’t let them have information for fear it might lead to experimentation, or sometimes disabled people were just told, `This is not part of your life.”‘

Some disabled women were forbidden sex because of concerns about pregnancy, Dr Johnson said. “Some of them said, `Well, my mum didn’t want to have to raise another child and she thought she would (if I had sex),’ or `Mum thought if I had a child it would be like me.”‘

Janice Slattery and Amanda Hiscoe, who both have an intellectual disability, were members of the reference group advising researchers (they were not among those interviewed for the study). Mrs Slattery agreed that carers have to learn that “people do have their own freedom as well as being protected. There’s too much protection. They don’t get the correct information to protect them from sex, and they have to learn the hard way and that can be scary for them.”

Mrs Hiscoe said she hoped the project would force the rest of the community to take off “the horse’s glasses” (blinkers) they wear when looking at people with disabilities and realise “they deserve the same respect and same dignity and same rights
as being the very so-called normal people”.

The best outcome, said Mrs Slattery, who has been married for 15years, would be for a more open approach to “give other people with disabilities the opportunity to achieve what we’ve achieved; a happy marriage”.

The study recommended that services for disabled people develop policies in human relationships and sexuality, and that professional carers, families and people with disabilities be offered education about the issues.

The report was funded by the Victorian Health Promotion Foundation and will be launched today by the Minister for Human Services, Christine Campbell.

Also see: The Love That Dare Not Speak Its Name

Helping doctors to help themselves

WHEN applied to women, it’s called the madonna/whore syndrome. It’s an inability to see a group of people as they really are, with their mix of flaws and virtues; an over-idealisation whose flip side is an equally unrealistic denigration. And it underlies many people’s attitudes to doctors.

We all want them to be kind and clever, caring and capable. According to whether or not they live up to our expectations, we see them as saints or sinners. No wonder doctors feel so misunderstood.

But there is one consistent element of criticism of the profession: it is the perception that medicine is a club whose members sometimes have greater allegiance to each other than to the community they serve. Doctors are believed to close ranks to hide or minimise colleagues’ mistakes or misdeeds. It is a perception that the Medical Practitioners’ Board of Victoria must work harder to dispel, and the State Government’s review of the act that governs the board creates a chance to debate how best to do this.

The medical board stands between vulnerable patients and the doctor who is overservicing, unethical, misusing drugs or alcohol, incompetent, sexually abusive or impaired through mental or physical illness.

Nine of the 12 members of the board are doctors themselves. Their (admittedly narrow) brief is to set minimum standards and to protect the community, not to punish doctors for misdemeanors.

But sometimes the board seems to interpret even these basic notions of “minimum” and “protection” very narrowly. Take the case of a psychiatrist who developed a therapy that the board found to be unethical and destructive of some patients’ mental health. The board’s interpretation was that the community was safe if the doctor received a short suspension and promised to stop the therapy. Patients might wonder whether a therapist who could be so gravely misguided and oblivious of harm was equipped to influence the emotional lives of others for the better.

The board’s hearings are not always constituted in a way that preserves the perception of impartiality. Is it appropriate that a member of the board sit on a case involving a defendant with whom he has even a referring relationship? Is it appropriate that the board accept and rely on expert testimony (as opposed to character evidence) from doctors who have had close professional relationships with an accused doctor?

This kind of link between the parties would not be tolerated in most arenas in which allegations are adjudicated. It can only reinforce any suspicion that the rules of the “club” favor collegiality over impartiality, the doctor over the patient.

Cross-pollination by related professions would help. A psychiatrist sits on the psychologists’ registration board; a psychologist would bring to the medical board similar ethical concerns as doctors but a decreased likelihood of close links with defendants. The board also needs at least one member with a background in patient advocacy to ensure the consumer’s viewpoint is strongly represented.

The board has a problem with gender imbalance in some hearings. Women make up the majority of complainants overall and nearly all complainants in sexual misconduct cases. But one recent sexual misconduct case (in which the women’s complaints were dismissed) was heard by a panel of four male doctors and one woman.

The panel’s makeup was sharply criticised in private by mental health professionals not associated with the case, who believed it left the board open to charges of gender bias.

Other problems relate to the inadequacy of legislation governing both doctors and psychologists. Struck-off psychiatrists and psychologists have been able to set up shop again instantly by calling themselves “counsellors” or “therapists”.

Successive governments have been stymied because they didn’t want to accidentally ban others who use those descriptions, such as financial counsellors and beauty therapists. The New South Wales health complaints commissioner, Merrilyn Walton, has suggested that one possible solution would be to ban the use of those terms only by those who have been de-registered by a professional body.

There are also gaps in the protection the law offers doctors when they report colleagues. Doctors cannot be sued for defamation if they report another because he shows signs of having becoming mentally or physically ill. But if a doctor reports a colleague for sexual misconduct or potentially dangerous incompetence, the reporting doctor has no legal protection.

The law should be changed to cover all three categories. We can’t expect doctors to speak out to protect patients knowing that their own career, good name or financial wellbeing might then be sacrificed to the quirks of the legal system.

Most doctors are neither heroes nor villains. They’re like the rest of us, decent people who try to do the right thing in difficult situations, succeeding better some times than others. It’s their responsibility to struggle with implicit biases they might have in coming to ethical decisions about the public interest. It’s our responsibility to create a system that supports them in that task.

First published in The Age.

The forbidden zone

God and the doctor we alike adoreBut only when in danger, not before

— John Owen c. 1563-1622

SHE IS fast-talking, intense, impassioned. He is calm, quiet, restrained. He is accustomed
to being the stillpoint of other people’s storms; that’s what psychiatrists do, day after day. This day, too, his clinical remoteness serves to distance him from the surrounding drama.

He has argued that this very quality is the reason she is so maddened. To be maddened is to be angered – or to go crazy. She claims her anger is justified; that he seduced her in his consulting room when she was at her most fragile, abusing her trust as a patient. “Dr MQ” denies it.

He claims “Mrs A” has a personality disorder and is angry with him because he maintained his professional distance when she longed for something more.

He speculates that she escaped into erotic fantasies to ward off a depression that she found terrifying. He says she turned the fantasy into fact to punish him and her husband for their perceived shortcomings, or because she unconsciously hoped one of them would stop the therapy she found so painful; that she then became so trapped in her web of lies that she had to pursue the claims to save face.

So they sit, this fine February evening, two rows apart, respective spouses at their sides, waiting for the verdict of the Medical Practitioners’ Board on charges of sexual misconduct against him.

There was a time when this kind of claim against a pillar of the profession might not even have made it to a hearing. Even a decade ago, many women who claimed that their psychiatrist, psychologist or doctor had sexually abused them were dismissed as hysterics, neurotically vengeful femmes attempting to be fatales.

But the professions are slowly – sometimes reluctantly – coming to the painful realisation that the truth is more often the reverse of this stereotype, with only 10 per cent of serious complaints turning out to be false. Of 44 cases of sexual misconduct allegations studied by Sydney psychiatrist Dr Carolyn Quadrio, 40 were substantiated.

Sexual misconduct is more prevalent than anyone would like to believe. American surveys have found that between 5 per cent and 12 per cent of medical professionals and psychologists anonymously admit to sexual contact with patients.

In Australia, “there is a high incidence, and I think it is much higher than we think,” Professor Richard Ball told a Medical Practitioners’ Board seminar in 1997. Ball is a member of the board, former professor of psychiatry at St Vincent’s Hospital and the head of Caselink, the Catholic Church’s counselling service for victims of clerical abuse in Melbourne.

He said: “I think what we are facing is something like what happened with the priesthood and so on, that it was all very quiet and then there was the beginnings of revelations about sexual misdemeanor and then it exploded, and now it is all over the place, like the wisteria.”
The MQ case is as tangled as any rampant vine. It has been the board’s longest and most tortuous: 40 days of hearings over two years, 4000 pages of transcript; his clinical notes, her voluminous diaries; her unyielding accusations and his flat denials. Murder trials have been dispatched with more ease.

The character witnesses for Dr MQ, a senior psychiatrist, have been a who’s who of Melbourne. There were the psychiatrists, the cardiologist, the neurologist, the sex therapist, the lawyer, the QC and the judge. They said the doctor, who is married with children, was a man of integrity. The allegations were unthinkable.

The main complainant is also married with children. She is educated, intelligent, articulate and well-established in her own profession. How could the stories of two such people be so at odds?

The answer lies partly in the peculiar nature of the psychotherapeutic relationship, in which rules apply that bear no resemblance to norms outside the consulting room. Psychiatrists and psychologists are more at risk than other health professionals of engaging in what one author has called “sex in the forbidden zone” – and of being falsely accused of such by patients.

Like the sorcerer’s apprentice, psychotherapists can find they have unleashed forces they cannot control. Sometimes one or both parties become so overwhelmed by their emotional and sexual yearnings – their internal realities – that they lose their grip on the external reality of the professional relationship.

If sexual boundaries are breached, the consequences for patients can be catastrophic. Quadrio found that most of the women in her study finished up with post-rape trauma syndrome and suicidal depression. Several were admitted to hospital, some involuntarily and some almost continuously for up to four years. Others lost their marriages and some previously successful women were unable to resume work and had to live on invalid pensions. One in a hundred will kill herself, says Melbourne psychiatrist Dr Sandra Hacker.

Patients pay money for the consultations that lead to all this. Sexual misconduct involves not just emotional abuse but Medicare or insurance fraud when patients are billed for sessions that consist largely of sexual or social activity.

Such encounters take different forms, but they often involve “love”. Not the kind of which the poets write – although it can feel like that – but the kind that Freud noticed in his patients when they took his “talking cure”, psychoanalysis. Clinicians call it “transference”. It develops to some degree in any relationship in which a person trusts, admires and depends on an authority figure, such as a GP or a priest.

In a rape case, the victim’s consent is a central issue. It is not with professional sexual misconduct. A recognition of the power of transference in psychotherapy is why Mrs A’s claims were seriously examined, even though it was clear she had been intensely attracted to MQ and longed for, as well as feared, a genuine sexual encounter with him. The fantasies in her diaries read like the erotica of Anais Nin. She claimed that the doctor had helped trigger this in her by interpreting some of the material she brought him in an unduly sexual light.

Transference is one of the reasons why even our criminal law holds that, when it comes to sex between mental health professionals and those in their care, consent is no excuse. Transference makes psychotherapy patients intensely vulnerable to sexual overtures by a therapist. Its destructive side – the patient’s reliving of infantile rage at perceived neglect or abandonment – leaves therapists vulnerable in other ways, including to false charges about what went on.

ASSESSING such cases can be difficult. Psychiatrist Dr Garry Sheehan, who spent 78 sessions with Mrs A, said she suffered from depression and, after her time with Dr MQ, post-traumatic disorder. She told her story to him slowly and with great embarrassment: “I didn’t get any sense of exaggeration.” His early notes recorded that her story rang “with pain and authenticity” but also that Mrs A had a curious smile, which led him “to feel the destructiveness of this woman”. He told the hearing that she did not have borderline personality disorder.

Dr Hacker, who had studied thousands of pages of Mrs A’s diaries, said she did have borderline personality disorder and that these patients made up the majority of false complainants. She said Mrs A’s diaries showed that at times she had trouble distinguishing between fantasy and reality.

Analytic psychotherapies, like the one MQ offered Mrs A for more than five years, are done with mirrors. The therapist tries to act like a blank screen, calm and remote. On to this emptiness, patients start to project feelings from much earlier relationships; they “transfer” those feelings to the therapist.

Patients “regress”, re-experiencing childhood traumas and developing the childlike vulnerability and intense emotional dependency on the therapist that they had to their parents or other significant adults when they were little. Like a small child, they can come to believe that they will not survive if they lose their attachment to this powerful figure. Sexual feelings for the therapist are common.

Tricky at the best of times, the transference situation can be disastrous if the therapist fails to deal with counter-transference – the feelings the patient awakens in him.

American writers Len Gabbard and Eva Lester say transference and counter-transference can feel just like romantic love; only the context is different. In their book Boundaries and Boundary Violations in Psychoanalysis, they write: “There is something inherently humbling in the notion of transference. The analyst must reluctantly acknowledge that forces are at work that transcend his or her irresistible magnetism. If any other analyst were sitting in the chair, similar feelings would appear.”
Therapists are supposed to be alert to the dangers. “If you fall in love in the middle of therapy, then you ought to be going off and having some supervision,” says Hacker, who is also federal vice-president of the AMA.

“Once upon a time, I used to wake up every Tuesday morning actually thinking about what I would put on, as opposed to just reaching into the wardrobe for whatever my hand fell upon. I thought, `This is funny, who am I seeing on Tuesdays that I want to get dressed up for?’ I made an appointment to go and see a colleague.”

Clinicians are honor-bound not to exploit the effects of transference. Abusers use it to manipulate patients into sex.

Zena Burgess, a psychologist and member of the Psychologists’ Registration Board, says: “It starts off with the therapist ringing to see how the client is between sessions, or he suggests that since the session was so distressing, perhaps they could
go for coffee or a walk in the park.

“Then it moves to being lunch before the session, or a hug after the session to reassure you that you’re OK. More and more, the boundaries between therapy and social contact are blurred, and then the sexual and the social becomes blurred … The client is groomed.”

A different psychiatrist, “Dr John Doe”, whose real name cannot be used for legal reasons, clearly used his skills to abuse his patients, according to evidence given at a medical board hearing. The patients said that if they protested at his behavior, he told them they were neurotic; he used his authority to set the rules of the relationship, denying their subjective experience and forcing them to accept his.

“Cathy” said she had gone to “Dr Doe” with severe anorexia and depression. She weighed 38 kilos, was a virgin and was terrified of sex. In evidence to the medical board, she said that he started by holding her hand: “I’d sort of be timid and he’d say, `It’s OK, I’m just consoling you’.” After a time, he took her to his house, and then to his bed, where she would lie beside him all night fully clothed, frightened by his nakedness.

Eventually, he told her she would have to provide sex or he could not see her any more. She feared losing her therapy, on which she felt her life depended, so she agreed. “(He) ripped off my top and sort of pulled me close to his naked body and I screamed and cried and he said, `It’s OK. Just hang on and get used to it. Just confront it … He would just tell me that I should face my fears.” During sex, “He would always say, `I’m not your father’, because I would be distressed and sometimes angry and flinching …”

Much of the sex happened during “consultations” in his rooms. Afterwards, “(he would) unlock the door and … push me out because I would be afraid and I used to say, `I don’t want to go out there. You can’t do this to me and just send me out there.’ And he said `you have to go out and learn to face the world’.”

If he dumped her out of his car miles from home, it was because “he would teach me how to survive and I should be independent”.

Another complainant told the board that she confided to “Dr Doe” that she had lost her father as a child and had badly missed having a daddy to read her stories. “Doe” would read children’s books to her before having sex with her.

After complaints by four patients the medical board deregistered “Doe”, calling him “amoral, lacking in any conscience and exploitative in the extreme … an evil person”.

THE TERM “sexual misconduct” covers a multitude of sins. There is assault of patients under the guise of clinical examination or treatment, usually the preserve of the disturbed GP. Some doctors have used hypnosis to try to disarm victims; others have used intravenous medication. A country GP was struck off last November after he fled following a pensioner’s report that he raped her while she was undressed on the examination table.

There is the professional-patient affair. A depressed practitioner who is lonely and vulnerable might be unwise enough to seek solace with a patient, as did one of Melbourne’s senior gynaecologist/obstetricians.

Things tend to proceed unremarkably until the professional tries to end the relationship – or until the patient finds out she is not the only object of his affections. Hurt and enraged, she reports him. Hacker says drily that advice from one medico-legal source to doctors contemplating such an affair is, “Don’t. But if you do, don’t stop”.

About 30per cent of offenders fall into the third kind of case. Their colleagues call them “sexual psychopaths”; devoid of empathy or remorse, they calculatedly prey on patients’ vulnerabilities. “They turn their consulting rooms into brothels,” Hacker says grimly.

More than 90per cent of sexual misconduct cases involve a female patient and a male professional, although all gender combinations have been reported. In 1996 a male psychologist was struck off the Victorian register for sexually abusing male patients, and in 1990 a leading Sydney psychiatrist and psychoanalyst, Dr Winifred Childs, was struck off for sexual misconduct over separate relationships with a female and a male patient.

Several cases – in Melbourne, Sydney and Brisbane – have involved leading figures who had been highly respected before they were exposed. In Quadrio’s study of offending therapists more than half were “high-status, high-profile, senior, and/or charismatic. They were qualified psychotherapists whose training had included both supervision and personal therapy. At the time of the offence at least two offenders were in therapy and another two were in supervision – both supervisors were offenders.”
While there is consensus that the responsibility for a sexual breach lies with the professional, there is debate about the degree to which some patients are “pre-programmed” to be seductive, particularly those who have been conditioned by childhood
sexual abuse to believe that they will not be cared for unless they offer their bodies.

Hacker says: “It’s part of your job to understand that, and the appropriate thing to do is to attempt to get the person to understand that this is a problem, and that they are going to continue to be victimised because of some of the messages they send out.”

At the same time: “It’s very difficult for you and me to sit here, being female, and understand what it must be like for some of these blokes, sitting in these chairs day after day. Some of my colleagues have told me about women disrobing themselves in front of them, offering them sex … It doesn’t happen all the time, but it does happen.”
In the case against Dr MQ a second complainant, Ms B, told the panel she had several times thrown herself at MQ: taking off some of her clothes, hugging him, trying to unzip his trousers.

The charges relating to this patient did not allege that the doctor tried to initiate physical contact, merely that he responded inappropriately with kisses and once, she claimed, an erection underneath his clothes. She said he told her, “I’m a man. I’m not made of wood, you know,” and “Come back when you’re not my patient and then I’ll kiss you.” The doctor strongly denied that he had responded in this way.

Quadrio emphasises that she found this kind of provocativeness rare in the substantiated cases she studied. She says the women she interviewed were not flirtatious or provocative but did long to be special. Many intensely idealised their therapist and it is this, she suspects, that offenders find “seductive”: “I think it has more to do with the ego of the person being admired than the people doing the admiring.” Like Narcissus, the offending therapist falls for the reflected image of himself.

It has been argued that patients might not be the only ones who enter therapy looking for love. Gabbard and Lester write: “Many individuals who choose careers (in psychotherapy) feel they were insufficiently loved as children, and they may unconsciously hope that providing love for their patients will result in their being idealised and loved in return … the desire to cure and the desire to be cured are two sides of a very thin coin.”

Self-analysis is a tool of this trade. The people who spend their working lives analysing other people’s dark corners turn searching lights on their own in the relative privacy of their professional forums. At the medical board’s seminar on sexual misconduct there were some telling exchanges as speakers struggled to understand why there is sometimes a gap between how fellow professionals should ideally respond to the issue, and how they actually do.

HACKER told the seminar she knew of three sexual psychopaths who had been supported by their peers: “A number of my colleagues behaved in what I consider to be extraordinary ways, had farewell parties for one of the doctors involved when he left the
hospital … (He was) not drummed out in any way.”

A female psychiatrist asked her what this might be due to; surely not just the feminist argument of a male hierarchy springing to the defence of men? Voyeurism, perhaps, suggested Hacker: “There is an enormous titillation involved in these cases and I suppose that our profession as a whole is pretty voyeuristic, really. I mean, we sit around listening to stuff which would burn the ears off most people …”

Professor Ball had another interpretation: “I would call it vicarious living, sometimes; of living out our fantasies through someone else’s behavior.”

And then, of course, there are external factors. Professionals’ reluctance to act can only be reinforced by cases where disbelief of allegations turns out to be justified.

In general, fantasy is assumed to be normal, even indicative of psychological stability and health … The pathological aspects … are restricted to those cases in which the fantasy becomes delusionary or when it dominates a person’s mental life and serves as a retreat from reality rather than an adjunct to it.

– Penguin Dictionary of Psychology

DR MQ was acquitted. Comprehensively. Ms B left the hearing room early, as it became clear that the medical board’s judgment was going against her. Mrs A stayed to the bitter end, alternately tearful and, along with her husband, derisory.

The panel saw Mrs A’s allegations as highly unlikely. She had claimed to have copulated on a rug and bare boards and the doctor’s room had always had wall-to-wall carpet; interruption would have been likely, given that his consulting room had no lock and could be partly viewed from another room; and the
doctor’s notes showed that therapeutic treatment had continued throughout their relationship.

When this unlikelihood was coupled with Dr MQ’s professional standing and personal integrity, the panel reached the required degree of confidence that “the alleged incidents simply did not happen”.

Dr MQ’s version of events was accepted over Ms B’s partly because much of his subsequent conduct, such as referring her to group therapy and to a female psychiatrist, “would appear ludicrous if the allegations were seen to be true”.

The doctor slowly unwound from the hunched-over frozenness he had maintained throughout. The panel members stood and began to file out of the room. The main complainant stood, too, and cried out: “Except you have lost the truth in what you have said!” But in this case, the verdict was that she had lost the truth, long ago.

The forbidden zone (Part 2)
Closing ranks
THE MEDICAL BOARD’S finding that the psychiatrist we have called “Dr Doe” was “evil” raises as many questions as it answers. So does other evidence to the board that suggested “Doe’s” exploits had been dinner-party gossip for years.Why is it that a trade that sells itself on its ability to understand what’s happening inside other people can’t keep itself free of dangerous misfits? Do professionals protect offenders by closing ranks, or by denying the significance of sexual misconduct?

Dr Carolyn Quadrio’s study (see main story) found that: “Women who pursued official complaints procedures were frequently thwarted by licensing bodies, medical boards and professional organisations which appeared to close ranks to protect therapists
… Some women were rejected by subsequent therapists.”

Says NSW Health Complaints Commissioner Merrilyn Walton: “They do close ranks. I think there’s still a culture – and it’s not just doctors – that (reporting) is like dobbing in a mate, and also they fear it will damage the profession broadly. The third reason is that they’re not sure that they themselves trust the system.”
A male friend of one of “Doe’s” victims told of going to a party at a psychiatrist’s house at which he raised the victim’s situation in abstract terms. He said, “The wife of the psychiatrist, who is one of my close friends, said, `I know who that is.’ And the psychiatrist said, `You have no evidence’ …. and then (the wife) actually said his name and it, in fact, was (`Dr Doe’).” The witness said he also raised his concerns more concretely with two other psychiatrists, neither of whom asked for the doctor’s name or suggested reporting him.

A second “Doe” victim said that her social worker “knew what he was like and she rolled her eyes and said, `Oh no, he’s at it again. Watch out. Watch out.’ And she said to tell him not to do it and tell him it’s illegal. So I wrote it all down on the palm of my hand … And I told him not to touch me and he just burst out laughing.”

A third reported that the male psychiatrist she saw after being abused by “Doe” seemed uninterested in her experiences; he was more focused on asking how “Doe” managed to afford his expensive hobby on a doctor’s income.

There is a big gap between the number of alleged offences that are known about and the number that reach a formal hearing. The president of Victoria’s Medical Practitioners’ Board, Dr Kerry Breen, believes there is a significant number the board never sees. In 1996 and 1997, a total of 13 doctors were disciplined for sexual misconduct.

But Quadrio says studies indicate that 50percent of Australian professionals have received at least one disclosure from a patient of abuse in a previous treating relationship.

Some doctors do not recognise what they are hearing or are not aware that an individual complaint relates to a pattern of behavior. Take the case of “Dr Bloggs” (not his real name), a GP whose registration was suspended after he admitted he had sexually assaulted up to 30 patients over 10 years.

He was finally exposed when two psychologists sent a letter to a female partner in his practice saying that they had just received their eighth complaint about him. The partner discovered that another local psychologist had received two complaints and a psychiatrist a further two, making a total of 12. Some of the partners had received individual complaints over the years but had not mentioned them to each other.

Even doctors who try to act can find themselves stymied. Dr Sandra Hacker, the federal vice-president of the AMA, told the medical board’s sexual misconduct seminar that two patients walked into her consulting room with complaints about the same psychiatrist. Hacker sought advice and was told that she could not report to the board because neither woman would be identified.

“There was a view that the college (of psychiatrists) would report to the board if there were further allegations … I was not actually given to understand what the critical number would be, or how many other psychiatrists had to ring up the college and say, `So-and-so is at it again.”‘ By 1997, the year she made these comments, things had moved “a quarter of an inch. The college now believes that it has the legal protection of qualified privilege.”

Today, the college’s code of ethics says psychiatrists must take “appropriate action” if they receive a complaint but does not specify what that is. “That’s because it may vary from case to case,” says Dr Joan Lawrence, inaugural chariwoman of the college’s professional conduct committee. It’s hard for doctors to act if the patient does not want to lay a formal complaint, she says.

Hacker says doctors might fail to act because they are uncertain what they should do, are reluctant to repeat allegations that they cannot verify, or fear being sued for defamation. Breen agrees that defamation is an issue. Doctors are protected from being sued for reporting suspicions that a colleague is impaired but have no immunity if a report of sexual misconduct is found to be unsubstantiated. A State Government review of the act that governs the board is considering the question.

The Government is also examining the problem of the struck-off practitioner. There is nothing to stop deregistered psychologists or psychiatrists from calling themselves “counsellors” and continuing to practise. “Dr Doe” did so for at least a short while.

Breen encourages doctors to call the board and discuss any concerns informally – anonymously, even – so that the board can at least get a sense of whether multiple patients are complaining about certain practitioners. It has also tried to reduce the trauma for all parties by employing counsellors to support them emotionally.

The task of disciplinary boards, though, is essentially to mop up the mess after the damage has been done. The question of how to prevent it remains.

Hacker holds out little prospect of detecting the conscienceless psychopath in time: “There are psychopaths in all walks of life, and they are charming chaps. Some of them are very bright and get to very senior positions in the judiciary, in politics. Medicine is not immune from these people.”

Professor Ball doubts that psychological testing would help with screening: “One of my worst murderers had had batteries of tests (because) he was in the military services. They were all perfectly normal; none of them picked up that he had been dangerous since he was 15, writing sadistic fantasies and so on. And there are books now telling you how to fake personality tests.”

Professional education might help. Researcher Heather Gridley asked GPs how they would respond to a complaint of sexual misconduct. She said they knew little of the procedures and tended to believe, mistakenly, that it was their job to question the complainant and verify the allegation before taking it further. “The women doctors were certainly much more prepared to be advocates for the patient. I think that’s a straight-out identification thing.”

Gridley, a senior psychology lecturer at Victoria University of Technology, sees a potential conflict of interest with registration boards run by professions. They try to protect the public, but, she says, “It’s like trying to do it with the handbrake on. There will always be a tendency to defend your own. It’s harder for professionals, even if they are aware of the issues, to take the position of the client.”

She believes the NSW system is worth considering. There, the Government’s Health Complaints Commission investigates claims and prosecutes charges before the boards. Here, the boards perform all those functions.

Professionals can only be dealt with formally if victims are willing to endure a public hearing (although their names may not be published). That might be before a registration board or in a criminal court (Section 51 of Victoria’s Crimes Act forbids mental health practitioners from having sex with patients). Patients have also successfully sued for civil damages.

Sometimes doctors believe the patient is too fragile to face a formal inquiry, although “many of us work hard to support victims when they do go forward,” says psychiatrist Dr Andrew Stocky. He’s not sure what can be done to make the system more complainant-friendly without impinging on practitioners’ rights to a fair hearing, but the current adversarial process troubles him: “I think it is very unfair that (damaged) patients are somehow being used to maintain our practice standards.”

Philippa Bolton also wants professionals to take on more of the responsibility for policing offenders. Bolton is still recovering from her years with one of Sydney’s most prominent psychiatrists, Dr Alexander Craigie Macfie. Macfie had been regarded as a “charming and talented” psychotherapist, according to colleagues, before sexual allegations by Bolton and others in 1996. The allegations remain unresolved because he left Australia to work overseas.

“I think it’s outrageous that health professionals don’t make complaints on patients’ behalf,” Bolton says. “The sheer weight of numbers should count for something. A medical board is not a criminal court; they’re not going to jail. People who are murdered don’t complain; evidence can be found in other ways.” And if a patient knows she is supported by many other informal complaints she will feel more able to lay a formal one, she says.

Bolton is cynical about the concern that reporting against patients’ wishes further “disempowers” them: “That argument lets the therapists off the hook – both therapists. It’s a matter of harm reduction. Just look at the statistics about the number of others who will be harmed if the offender is not stopped.”

Bolton supports the introduction of mandatory reporting. Victoria’s Health Services Commissioner, Beth Wilson, suspects it is inevitable but sees disadvantages: “It may be that the victims won’t come forward.”

Breen believes it would be destructive but acknowledges there are problems. “I think there may come a time, if we can’t get the profession to do better than they’re doing at the moment, that society might say, `Too bad; we’re going to mandatory reporting’.”

First published in The Age.


Don’t tell Mum, please!

She’s 15. She’s pregnant. And she arrives in a GP’s surgery, boyfriend in tow, asking for an abortion – ASAP. She and her boyfriend have talked it over at length and decided they are too young to have a baby. She asks the doctor not to tell her parents because they are religious and would never agree to the procedure. What should the doctor do?

Doctors themselves disagree. Seventy-nine per cent of GPs responding to a recent survey said they would respect the girl’s confidentiality and not talk to her parents without her permission.

Most – 82 per cent of women doctors and 75 per cent of male doctors – also regarded her as competent to make her own decision about having an abortion.

They were not so sure about their own competence. More than 70 per cent of the 300 doctors who answered the survey felt ill-informed about the legal issues underlying such cases, and 26 per cent felt that they had too much responsibility for serious decisions about underage patients.

Some parents, such as Mary Helen Woods, of the Australian Family Association, would agree with them on the latter point. She argues that doctors should inform guardians of serious physical or emotional problems in a young person. Many parents (and some doctors) would be surprised to learn, though, that the law says parents do not necessarily have a right to know.

Raising awareness of this issue was one of the reasons Terry Bartholomew, a lecturer in psychology at Deakin University, conducted the study, Young People and Informed Consent. The project was run in conjunction with the Centre for Adolescent Health and was funded by the Commonwealth Department of Health and Family Services. It surveyed 1000 GPs, of whom 300 responded.

Bartholomew asked doctors about four typical scenarios (including the pregnant teenager) in which teenagers asked for confidentiality or the right to make their own decisions regarding treatment:

The parents of “Adam”, 17, take him to the doctor when they discover he has been using heroin on and off for six months. They want him to see a psychiatrist; he rejects that idea and asks for some pills to ease his anxiety. “Liz”, 14, goes to her family doctor looking for birth control. Sixteen-year-old “Josie” presents with tonsillitis but is found to be suffering weight loss and an eating disorder.

Bartholomew says such situations are legally, medically and ethically complex. “Doctors are highly accountable, highly exposed and highly vulnerable,” he says. “It’s hard for them to err on the side of caution, because what’s the side of caution? They wonder, ‘Can the young person take me to court?’ ‘Will there be trouble from the family if they find out?’ ”

There were big differences in doctors’ responses, Bartholomew says: “Seven out of 10 doctors found Adam competent to make that decision. Three out of 10 didn’t. That’s an amazing discrepancy. These are significant levels of difference. Imagine if you went to doctors suspecting a broken leg, and seven out of 10 said ‘Absolutely!’ and the other three said ‘No way!’ ”

Doctors took the same factor and used it differently to come to opposite conclusions. In the Josie scenario, the girl admits her eating and exercising patterns have become problematic, but promises to stop dieting. “Her acknowledgement that there was an issue was interpreted in different ways,” Bartholomew says.

“The first was to decide that ‘Because she’s insightful about her problem, therefore she is competent’. The second was to say, ‘She’s pretending to have insight in order to manipulate my perceptions of her. That’s a classic tactic of someone with an eating disorder. She is not competent and needs help’.”

Other doctors argued that the very fact that Josie had symptoms of an eating discorder meant that she was “fundamentally pathological” and so could not possibly be competent to make decisions about her own care.

Doctors who arrived at the same conclusion often did so via different routes. Some decided confidentiality and competence simply on the basis of the patient’s age; others, according to whether they had a relationship with the young person’s family.

The law says parents do not have an automatic right to be informed. It is up to the doctor to decide whether the teenager is a “mature minor” capable of understanding the consequences of his or her choices.

The principle was established in 1985 in a British case involving Victoria Gillick, a Catholic mother of 10, who was seeking just the opposite. She took a doctor to court for having provided her 14-year-old daughter with a prescription for the pill. She lost the case in 1985 when the House of Lords ruled against her.

The “mature minor” principle was affirmed in Australia in 1992, when the High Court agreed with the Lords that “parental power to consent to medical treatment on behalf of a child diminishes gradually as the child’s capacities and maturities grow, and this rate of development depends on the individual child”.

The High Court said parental rights derived from parental duty and existed only as long as they were needed to protect the child: “The common law has never treated such rights as sovereign or beyond review and control.”

Mary Helen Woods is concerned that a single professional’s assessment of a teenager is all that is needed to determine their maturity. “GPs are often very overworked. Many of them are great people and they do a fantastic job, but you do hear stories of people in and out in five minutes, and there are GPs who are not particularly vocationally orientated in their outlook. These people, who may not have the best interests of the patient at heart, should not be allowed to make these decisions.”

Woods believes it would be dereliction of duty for a doctor not to inform parents of a condition that has the potential to be fatal and says any teenager suffering anorexia or taking drugs “could very well not be competent at all”. She goes so far as to argue that a responsible GP who feels uncomfortable withholding information from parents should tell the young person to find another doctor.

She says: “We are very sensitive to the rights of young people, but we also need to be sensitive to the rights of the parents who have brought them into the world and devoted their lives to them for 14 or 15 years. And, ultimately, it will almost certainly be the parents who will keep these children alive in such difficult, complex situations.”

But professionals working with adolescents emphasise the importance of confidentiality in maintaining the young person’s trust. Dr Danielle Mazza, medical director of Family Planning Victoria, says young women seeking advice about an unplanned pregnancy, for example, “often tell you they have enormous fear of reprisal, of being kicked out in the street. One of the reasons they come to see us is because of the confidentiality we offer them”.

The association’s policy is that if a young woman has sufficient awareness of the issues to seek out counselling, she also has sufficient awareness to make her own decision.

Dr Margaret Kilmartin, president of the Australian College of General Practitioners, says difficult issues with underage adolescents are a constant part of the GP’s work, with underage pregnancy one of the most common problems.

Nothing good would come of breaching confidentiality, she says, and doctors would be obliged to do so only if the situation involved danger to the patient or society.

While doctors should not usually ring up the family, they should encourage the young person to reach out: “You work with the young person to see if they can bring themselves to confide in their parents. The major problem for a lot of these young people is that there are no parents available to them.”

Dr Kilmartin believes troubled adolescents tend to seek her out partly because she is female. Bartholomew’s study confirms female doctors are twice as likely as males (15 per cent compared with 7.4 per cent) to report often facing decisions about underage competence.

That may be partly due to another of the study’s findings: that there is a gender gap in attitudes to young people. Female doctors (and younger doctors) were generally more likely to be liberal. Ninety per cent of female doctors found “Liz” competent to request a prescription for the pill, compared with 76 per cent of males. “Liz” was found competent by 97 per cent of doctors aged 25-34, but only 56 per cent of doctors aged over 55.

Bartholomew intends to follow up the survey with focus groups of interested doctors to discuss the issues and help him formulate, with the Centre for Adolescent Health, written guidelines for doctors to use.

He warns, though, that no guideline can cover every eventuality, and that no matter how carefully “objective criteria” are applied, in the end, individual doctors will still have to make personal judgments: “There will always be a subjective element
to the decision.”

First published in The Age.