Jackson Case Highlights Medical Ethics

Two prominent doctors in the field of pain management reflect on the malign influence of celebrity.
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The King of Pop and the World's Greatest Womanizer have more in common than you might think.

Michael Jackson's death last month, like that of Howard Hughes in 1976, revealed the hidden side of a famously reclusive figure, one that involved elaborate schemes to obtain prescription drugs. Both men began a regiment of painkillers after an accident: Hughes' plane crash in 1946 and Jackson's burn on the set of a Pepsi commercial in 1984. Over time, each developed a tolerance for narcotics that enabled them to consume otherwise lethal doses.

What followed the death of Hughes, like many others each year, may very well follow Jackson's death: a criminal trial against one or more of the pop singer's doctors. Hughes' case wasn't the first and Jackson's certainly won't be the last. Such cases invariably shine a spotlight on medical ethics and the influence of celebrity.

The investigation in the Jackson case has so far focused on the star's personal cardiologist, Dr. Conrad Murray, who was present when Jackson died.

Dr. Forest Tennant served as an expert witness in the 1978 case against Dr. Wilbur Thain, who was accused of illegally prescribing Hughes, and the case in 1981 against Dr. George Nichopoulos, who was charged with over-prescribing Elvis Presley, Jerry Lee Lewis and seven others. Both doctors were acquitted of criminal charges and kept their medical licenses. A medical board later sanctioned Nichopoulos, dubbed "Dr. Nick" by the press, for ethical violations.

"Famous people like Jackson, Howard Hughes or Elvis Presley had enough money, enough privacy and severe enough medical problems that they had the need to have physicians at their beck and call," said Tennant, who treated his own share of famous people over the years as a Los Angeles physician and former medical director for the National Football League. "The willingness of physicians to take on this role, in my experience, is tantamount always to having to violate ethical standards."

For a physician to be convicted of criminal wrongdoing, the prosecution must prove that the doctor willfully over-prescribed drugs or knew that prescriptions were falsified. For instance, California authorities earlier this year charged two doctors who cared for actress and model Anna Nicole Smith, who died of a drug overdose in 2007, in part because the doctors allegedly wrote prescriptions for Smith under pseudonyms.

"When physicians get put in these positions, corners are going to be cut," Tennant said. "It's pretty obvious right now these things happened in the Jackson case."

How else to explain at Jackson's bedside bottles of the anesthesia drug Diprivan (brand name Propofol), which under normal circumstances doesn't leave the hospital?

"It's absolutely out of this universe," said Dr. Lynn Webster, who publishes a guide for practitioners called Avoiding Opioid Abuse While Managing Pain and is on the board of Zero Unintentional Deaths, which works "to eliminate the harm and unintended deaths associated with prescription pain relievers." Webster said for a patient to reasonably require Diprivan as a painkiller, he would have to be terminally ill and paraplegic.

"If what I hear out of the news is remotely correct, this is an individual who has become really addicted to multiple medications and cannot escape this without continued feeding of near lethal levels of medications," Webster said. "The window between what Michael wanted or felt like he needed and death was probably very narrow."

Unlike the Hughes case, the legal and regulatory machinery in the aftermath of Jackson's death has yet to complete its mission. Still, some clues can be divined from various media reports. According to TMZ.com, a former Jackson bodyguard told investigators that Jackson was taking 10 Xanax pills per night. The same bodyguard said at one time Jackson might have taken 30 to 40 pills per night of the anti-anxiety medication.

"There is no one who should ever have 10 Xanax a night even if that's the only thing he's taking," Webster said. Press reports following a search of Jackson's home also indicated he was taking a host of other painkillers including Demerol and Oxycontin, some in his name, others without labels or under different names. Assistants were said to obtain drugs from multiple pharmacies.

In 1978, the trial against Thain revealed similar plots by Howard Hughes. The subject line of a 1958 "operating memorandum" submitted as evidence in the trial and obtained courtesy of Tennant says, "Instructions from HRH regarding securing and processing prescriptions."

"When the call comes in to the office following the doctor's call to Mrs. Hughes and it is something that can be telephoned in, then OK," the memo reads. "Try to prevail on the doctor not to require a confirmation of the prescription. It would be well to put the prescription in Mrs. Melba Doss' name, as Mrs. Hughes would like that better than using another name she doesn't know."

Webster sympathized with doctors who get lured into the world of celebrity. "It's unfortunate because physicians can sometimes get pulled into situations like this that seem to be very exciting because of the people they are working with, and they forget the principles they are supposed to follow," he said.

Based on media reports, Jackson saw more than a dozen doctors since 1993. The Los Angeles Times quotes a longtime Jackson associate as saying the pop singer had little trouble finding a doctor who would prescribe drugs.

"They rotate in and out," the article quoted the source, who requested anonymity. "There were a lot of doctors over the years. ... They liked to be known as Michael Jackson's doctor."

Investigators in recent weeks subpoenaed medical records from multiple doctors who treated the singer, including Dr. Arnold Klein, Jackson's dermatologist for nearly 25 years.

Webster advises doctors who prescribe controlled substances to maintain detailed medical records and visit personally with patients to closely monitor their condition. "All of us get fooled, but the good physicians are always on guard for individuals who are out there to try and deceive them. For somebody to be deceived for 10 years would be extraordinary."

And of course, such abuse is not solely the province of celebrities. More than 8,500 Americans died from prescription drug overdoses in 2005, the latest year figures were available, according to the Office of National Drug Control Policy. From 2001 to 2005, unintentional overdose deaths due to prescription drugs increased 114 percent.

Public policy and drug enforcement actions over the past decade to combat abuse of painkillers have led to prescription drug monitoring programs in 33 states, including California. The programs work by tracking prescriptions of controlled substances through pharmacies.

To avoid detection, doctors might stockpile drugs in their office. Using aliases and diverting drugs from other patients are difficult to detect. And doctors might choose to skimp on the note taking in the name of privacy, especially when it comes to extremely reclusive figures such as Jackson and Hughes.

Their deaths took place in far different eras more than 30 years apart, but the issues remain the same when doctors succumb to the influence of celebrity. Early autopsy results said track marks scarred Jackson's arms. The autopsy of Hughes revealed a much more shocking detail: Five glass syringes, used to inject codeine, were found embedded in his upper and lower arm.

The only difference is the times.

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