Thursday, 10 November 2011

Reflections on the Michael Jackson case

I'm not surprised that the jury found Micheal Jackson's doctor guilty. Using a drug that is pretty much a general anaesthetic, as a sleeping aid, always seemed unwise. The pity of the whole thing is that there has been little exploration of the deeper issues. I suspect that if the doctor had refused to use this drug, or something similar, then he would simply have been fired. Very rich people, who live in a bubble to protect them selves from the downside of their celebrity, have an inevitable tendency to surround themselves with yes men. There are probably yes women involved as well; I don't want my use of the cliché to be sexist.
This is not just true of pop stars or tycoons in general; politicians suffer the same problem. When you are in a position of power, it is most important to surround yourself with people who will tell you the truth, whether or not it is uncomfortable. The Jackson trial at least does all the underdogs in that situation a favour. We can at least imagine a conversation where the next Dr Murray says, "No I won't give you that drug. Look at it this way, if I do, I might get four years, but you will be dead. Your choice."
Of course Dr Murray may have factored all that into his calculation, maybe he figured he would be fired before he accidentally killed Micheal Jackson. Maybe he figured that if he got four years, probably out in two for good behaviour, then he was still being paid pretty well on average, plus of course he will have plenty of time in prison to write the book and that will bring in a dollar or two.
OK I am lapsing into cynicism, it seems that Dr Murray is actually being foolish enough to spend some of his hard earned money on appealing. If he is not careful the lawyers will have all his money before he even gets the book written. It would be better to blame Jackson and announce to the world that he is sorry that he succumbed to the pressure of the money, the celebrity and everything else. Substantial parts of the media still call Micheal Jackson, "Wacko Jacko". There must be an argument for Murray along the lines of, "you have no idea how crazy it was, I regret that I was sucked into it all, I should have been stronger, I cared for him a great deal, I thought that if I quit then he would just hire someone less competent who would be persuaded to take even bigger risks, I'm sadder and wiser now." Something along those lines would probably get him back on the medical register. Maybe he should retrain as a psychiatrist.
Despite that, Dr Murray does deserve a lot of what has befallen him, because one way or another he brought some of this on himself. It doesn't matter exactly what happened. I remember the professor of anaesthetics saying to us "Once you give patients these drugs you have taken over responsibility for keeping them alive." Murray either never had that lecture, or he forgot. Whether Jackson in a semi comatose condition took some extra drug, or whether Murray gave too much, does not matter. Anyone using a drug that powerful, takes on a responsibility to make sure that nothing goes wrong. That means continuously monitoring what happens. Murray’s defence was futile; by admitting that he was not in the room, he had effectively admitted guilt. If the right level of observation had been in place then Jackson could not have given himself more of the drug. Equally, if proper monitoring had been in place someone would have seen that Jackson had stopped breathing and done something about it. 
The trial had to focus on what happened and who was to blame, but trials can sometimes ask the wrong question. If we ask instead "What would it have taken for this not to happen?" we get a very different answer. I am paraphrasing that question from something that was said to me by a man who investigated airplane crashes. I think it is a very powerful question because it tends to focus on learning and solutions rather than blame.
What would it have taken? It needed a doctor who could stand up to Michael Jackson's foolish demands. Someone who would not use a general anaesthetic as a sleeping pill. Of course if he had had such a doctor Jackson might well have fired him. It would take someone who not only stood up to Jackson, but also managed to do so in such a way that he wasn’t fired.
It is tough for an individual doctor in such circumstances, do you quit, or get fired, knowing that your patient may well take even bigger risks with a new doctor; or do you soldier on trying to walk the line between safe practice and not getting fired. This is only really a problem in private practice. In an institution, like the NHS, or a large hospital, an individual doctor could appeal to higher authority, to someone not connected with the individual case, who could impart wisdom and insist on sensible practice. This sort of system is called clinical governance, and that was what was lacking in Dr Murray’s case. He was accountable to no one, and supervised by no one, until the court case.
Politicians and the media often rail against medical institutions and make it seem as though an individual private doctor is the top of the range as far as care goes. Sometimes it is, sometimes it isn’t, but unless you are sure you can tell the difference, no matter how rich you are, you are safer with a system or an institution.


  1. Not sure you're right; what about all the antibiotics that doctors in this country handed out inappropriately because of patient pressure? Valium too. They were, like Dr Murray, taking the line of least resistance.

  2. Yes it's true that there are doctors who take the line of least resistance on things like antibiotics but that is not in the same league as giving intravenous anesthetics at home. The other important point is that we know about the antibiotics because GPs prescribing is monitored, if they get way out of line someone comes to discusss it with them. It's not perfect, Shipman got through, but there is a system and the worst offenders are weeded out or re-educated.

  3. The key is that the powerful have two choices. Pay for the best advice/care or pay for what they want.

    If the latter it seems that the practitioner needs to cover themselves by documenting their objections. Had Murray been able to provide documented notes or a consent form that says I don't think this is the best but you are insisting he may have got fired but he may have saved himself from incarceration.
    "To give you that drug I need a consent form" - effectively a reverse consent - I have advised you that this isn't the best treatment but you specifically insist. OK as far as it goes, but then not monitoring I can't see as other than negligent.