Medical Justice provides consultations to doctors facing medico-legal obstacles. We have solutions for doctor-patient conflicts, unwarranted demands for refunds, online defamation (patient review mischief), meritless litigation, and a gazillion other issues. If you are navigating a medico-legal obstacle, visit our booking page to schedule a consultation – or use the tool shared below.
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all. Here’s a sample of typical recent consultation discussions…- Former employee stole patient list. Now a competitor…
- Patient suing doctor in small claims court…
- Just received board complaint…
- Allegations of sexual harassment by employee…
- Patient filed police complaint doctor inappropriately touched her…
- DEA showed up to my office…
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- How to avoid reporting to Data Bank…
- I want my day in court. But don’t want to risk my nest egg…
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- Can I safely use stem cells in my practice?
- Patient’s results are not what was expected…
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In case you missed this archived case report from Leentjens AFG, et al. Manipulation of mental competence: an ethical problem in case of electrical stimulation of the subthalamic nucleus for severe Parkinson’s disease. Ned Tijdschr Geneeskd. 2004 Jul 10;148(28):1394-8. Assuming you speak fluent Dutch.
A patient with severe Parkinson’s disease failed traditional treatments. He was bedridden, captive to a serious movement disorder. As a last resort, his physicians inserted electrodes in his subthalamic nuclei and initiated deep brain stimulation.
Three years later, he was admitted to a facility to address stimulation manic episode. This behavior did not respond to mood stabilization agents. He experienced “chaotic behavior, megalomania, serious financial debts, and mental incompetence.” The symptoms are not dissimilar to reports of hypomanic or even manic behavior from dopamine D2 and D3 agonists, such as ropinirole. From the American Journal of Psychiatry:
In clinical trials, the dopamine agonist ropinirole has produced hallucinations and confusion rated as mild. We provide evidence here that ropinirole may induce or exacerbate severe, acute psychosis in a patient without Parkinson’s disease. This case is not conclusive in part because of the use of quetiapine. However, the rapidity and degree of improvement weigh in favor of a strong role for ropinirole, and the likelihood of such an effect with this medication stands to reason. Given the recognized relationship of dopaminergic function to psychosis, best known through the strong antipsychotic effects of dopamine antagonists, such an effect of exacerbating psychosis by a dopamine agonist seems almost predictable. We suggest that ropinirole, like all other dopaminergic agents, be used with caution in psychotic patients and those vulnerable to psychosis.
In managing dopamine agonist psychosis or mania, changing the dose of the medication may mitigate the effects. Adding an anti-psychotic agent may also soften the suboptimal outcome.
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In the case report, there was no therapeutic margin between the two states – (a) alleviation of Parkinson’s symptoms but associated with mania and/or psychosis, versus (b) normophoric state with return of capacity of judgment and insight, but with significant exacerbation of motor symptoms, leaving him bedridden.
The question was which of these two states was preferable. To the patient, there was no middle ground.
The patient’s doctors concluded that only with the stimulator turned off was the patient competent to make an informed decision. Meaning, his doctors posed the question of preference with the stimulator off; in the normophoric, bedridden state.
The patient’s verdict – he preferred to be admitted to a psychiatric ward in a chronic manic state. There, he’d have acceptable motor function and reasonable activities of daily living. He shunned the option of normal cognitive / mood function at the expense of being bedridden.
Mental competence and informed consent can be affected by our treatments. If treatment is clouding judgment, the patient as a participant in his decision-making should be afforded the opportunity to have that cloud lifted, even if his final decision is to let the cloud return.
The patient in this case lived in and was treated in the Netherlands. It’s possible that the process and outcome in the United States would have been different.
What do you think?
Medical Justice provides consultations to doctors facing medico-legal obstacles. We have solutions for doctor-patient conflicts, unwarranted demands for refunds, online defamation (patient review mischief), meritless litigation, and a gazillion other issues. If you are navigating a medico-legal obstacle, visit our booking page to schedule a consultation – or use the tool shared below.
“Can Medical Justice solve my problem?” Click here to review recent consultations…
all. Here’s a sample of typical recent consultation discussions…- Former employee stole patient list. Now a competitor…
- Patient suing doctor in small claims court…
- Just received board complaint…
- Allegations of sexual harassment by employee…
- Patient filed police complaint doctor inappropriately touched her…
- DEA showed up to my office…
- Patient “extorting” me. “Pay me or I’ll slam you online.”
- My carrier wants me to settle. My case is fully defensible…
- My patient is demanding an unwarranted refund…
- How do I safely terminate doctor-patient relationship?
- How to avoid reporting to Data Bank…
- I want my day in court. But don’t want to risk my nest egg…
- Hospital wants to fire me…
- Sham peer review inappropriately limiting privileges…
- Can I safely use stem cells in my practice?
- Patient’s results are not what was expected…
- Just received request for medical records from an attorney…
- Just received notice of intent to sue…
- Just received summons for meritless case…
- Safely responding to negative online reviews…
Jeffrey Segal, MD, JD
Chief Executive Officer and Founder
Dr. Jeffrey Segal, Chief Executive Officer and Founder of Medical Justice, is a board-certified neurosurgeon. Dr. Segal is a Fellow of the American College of Surgeons; the American College of Legal Medicine; and the American Association of Neurological Surgeons. He is also a member of the North American Spine Society. In the process of conceiving, funding, developing, and growing Medical Justice, Dr. Segal has established himself as one of the country’s leading authorities on medical malpractice issues, counterclaims, and internet-based assaults on reputation.
Dr. Segal was a practicing neurosurgeon for approximately ten years, during which time he also played an active role as a participant on various state-sanctioned medical review panels designed to decrease the incidence of meritless medical malpractice cases.
Dr. Segal holds a M.D. from Baylor College of Medicine, where he also completed a neurosurgical residency. Dr. Segal served as a Spinal Surgery Fellow at The University of South Florida Medical School. He is a member of Phi Beta Kappa as well as the AOA Medical Honor Society. Dr. Segal received his B.A. from the University of Texas and graduated with a J.D. from Concord Law School with highest honors.
In 2000, he co-founded and served as CEO of DarPharma, Inc, a biotechnology company in Chapel Hill, NC, focused on the discovery and development of first-of-class pharmaceuticals for neuropsychiatric disorders.
Dr. Segal is also a partner at Byrd Adatto, a national business and health care law firm. Byrd Adatto was selected as a Best Law Firm in the 2023 edition of the “Best Law Firms” list by U.S. News – Best Lawyers. With decades of combined experience in serving doctors, dentists, and other providers, Byrd Adatto has a national pedigree to address most legal issues that arise in the business and practice of medicine.
Considering that in the Netherlands they will euthanize a child for a mental disorder at the child’s request (possibly even against the parent’s consent) I think we can safely say that processes are somewhat different. Maybe that’s why they call it the “Nether”lands…
However, this does have one interesting parallel with US law. Under the ADA, if you have a disability, you are not required to “fix” that disability…. .in fact, your employer and everyone else is required to find an accommodation that will allow you to function, with certain restrictions. UNLESS of course you are a physician. If a regulator CREATES a disability in you by labeling you as “potentially impaired”, then you are in for very expensive “fixing”…. after you are forced to consent on pain of losing your license.
Wow what a perfectly twisted case. IF the patient was psychotic and manic, of what danger did he pose to society? In his normal hypo manic state he posed no danger to society and was bedridden. No surprise he did not want to be bedridden. He wanted to be manic and active.
But then the treatment was drugs?
Why not other brain mapping and stimulation of other brain centers to try to establish some degree of control on the psychotic and manic sides of the stimulation, rather than trying to treat this with drugs.
In addition, as to the informed consent, it sounds like they tread carefully and correctly.
But could we as a society handle all of the overstimulated manic, psychotic people?
Would we do brain stimulation on others if we knew that the mania and psychosis was the end result? One could argue that we as physicians took an oath to do no harm, and that turning multiple patients into psychotic manic patients is doing harm to them as individuals and the society and therefore is unethical. It sounds to me based on this case of one, that the treatment is not achieving the desired results, and therefore is a treatment failure as well, not to be replicated until some better outcome is available.
” A better outcome”? How is that defined? To the surgeon or to the patient? Yes, this is really a difficult and very unusual case, and that is why Jeff used it for discussion. All opinions and results are both good and bad.
I am a simple man but with some level of intuition or understanding. It is no surprise to me that this patient would chose mania even with significant problems or side effects.
Richard B Willner
The Center for Peer Review Justice
One of the conflicts that occur when we have a technological society that actually can perform “medical miracles” we have to expect the unexpected when we tamper with our physiology. So, the pendulum in this case swung wildly to the other direction.
About a year ago, when we were at a great live show in Vegas, I saw an older woman sitting at a table close to me that was suffering VERY severe tremors that were remorseless. I don’t know if she enjoyed the show or not but watching her left me exhausted and heartbroken. I said a short prayer for her while watching her “shake.” She was with other people, probably her husband who did not take notice of her. I didn’t speak with her.
If the result of her “successful” treatment included a manic state, my guess is that she would still gratefully accept it. I also wonder if vigorous exercise might contribute to reducing mania, if performed regularly.
In my opinion, she would still better off trading her tremors for mania. This also reminds us at how enormously blessed and lucky we are. For me, that is the lesson. I am profoundly grateful. That feeling permeates my consciousness daily. Nor do I have any idea why I deserve any of this.
Michael M. Rosenblatt, DPM
PD-5 programme from natural herbs centre has done wonders for me. I even learned a few simple exercises I do daily to keep my back from hurting. It didn’t take very long before I started to get relief.