Alice Dreger reflects on the role of Twitter in medical ethics.

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What happened this week has had me thinking about Twitter and what it means to the ethical culture of medicine. First thing Wednesday morning, I found a post by Dr. Alison Barrett (@DrAlisonBarrett). It read, “Anyone else worried about the ethics of this? Anyone?”

Barrett’s question grabbed me, because I try to listen when someone asks, “Does anyone care about this medical ethics travesty?” So I hit the link.

It was an essay at KevinMD.com, a blogging website, written by “Hope Amantine,” a pseudonym for someone claiming to be a surgeon in rural America. Amantine described a “teaching moment” from her own training, when a mentor, impatient with Amantine’s hesitance during a surgery because Amantine was afraid of accidentally cutting the patient’s inferior vena cava, purposefully cut a 1-inch hole in that very vessel, leaving Amantine to deal with it. A cut like that can kill you, quickly.

After I finished reading it and pulled my eyebrows off the ceiling, I retweeted Barrett’s tweet, adding, “Jesus. How is this not attempted murder in the OR?” I copied @Skepticalscalpel, my go-to guy for surgical ethics. He retweeted it, adding, “If this really happened, it’s a huge ethical issue. I’m appalled.”

The thing quickly took off. I tried directly engaging Amantine, who then had an account, @HopeAmantine, which she has since turned off. I asked her, “How is what you describe here not a crime that required reporting to authorities?” She asked what crime? I answered assault. (Lawyers later corrected me: battery. Assault is when you’re awake.)

Others started weighing in. Smart comments came from lawyers, including a doctor-lawyer and a prisoner rights’ lawyer, from internists and surgeons, and from medical ethics folks. Surgeon Gwynedd Pickett (@gpsforthebrain) weighed in to say she had never seen anything like what Amantine was describing: “Floored any surgeon (even arrogant) would create” a purposeful cut in the vena cava.

Surgeon OJ Nilsen (@OJNilsen) pointed out to Amantine this kind of stuff gets practiced on animals like pigs, not humans. Amantine answered that human anatomy is different, as if that justifies what her mentor did. Disgusted, Nilsen asked in reply, “Why not stab the liver next time? Or the intestines?”

I tried getting the owner of KevinMD, Dr. Kevin Pho (@kevinmd), to pay some attention, but I guess I’m not a big enough deal for him to bother. Meanwhile Amantine started defending herself on Twitter and in the comments thread of her article. Sample tweet by Amantine, to lawyer Deborah Golden (@DebGoldenDC): “I did not MAKE the cut in the cava, I did not agree with the tactic, but I had to fix it. That is the point.” She also insisted that the patient didn’t die, as if that made the ethical and legal questions about the situation moot.

Funny all that defense of her actions on her part, because not long after, Amantine claimed it was all fiction. She posted a new note at the end of the essay: “This is a fictional article. No one was harmed, then or ever, in my care or in my presence.” I wonder if this claim came because, at least on my feed, we were talking about how to figure out who the sick surgeon was and whether he might still be practicing, so that we could alert the authorities.

In any case, as internist Mike McInnis (@DrMcInnisDIT) pointed out, this disclaimer itself was unbelievable; no one was ever harmed in her presence? Impossible in surgery. Was Amantine essentially lying the first time, presenting a fake story as if it was true, or lying later in saying it was fiction?

By Wednesday evening, Amantine’s twitter account was gone, as was her personal blog. By this morning, her post at KevinMD had also been removed. Kevin Pho apologized “for publishing the story” and added that he “will obviously learn from this experience.”

But what will Pho learn? He hasn’t explained why he published it in the first place—did it not occur to him the author was describing a crime? He hasn’t explained why he let it stay up even after the “it’s just fiction” addendum when he did not “know whether the story is really true or not.” He has left up the rest of Amantine’s essays without any note.

Here’s what still worries me: We don’t know if what Amantine described actually happened. If it did, we haven’t brought the surgeon to justice, nor found a way to tell the patient what happened. (Paging Kevin Pho’s moral conscience: it’s not too late.)

But one good thing I learned from all this: At its best, Twitter crowdsources moral behavior, particularly in medicine. It has the potential to actually improve the ethical culture of medicine.

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Alice Dreger is a Professor in Medical Education and Medical Humanities and Bioethics at Northwestern University @AliceDreger.

A longer version of this essay appears at her homepage blog: click here.