Journal of medical ethics, I 982, 8, 65-71i

Are pseudo-patient studies justified?

Martin Bulmer Department ofSocial Science & Administration, London School ofEconomics& Political Science

Author's abstract

Pseudo-patient studies are studies in which a medicalsociologist or anthropologist masquerades as a patient.Medical treatment is sought without revealing that the'patient' is really a covert research worker. When access hasthus been gained to a medical setting -typically a hospitalward - social interaction between medical staffandpatients is then observed over a period ofdays or weeks.Important studies have been carried out in this way ofpsychiatric treatment andofthe care ofthe terminaly-ill. Isthe use ofthe methodjustified? What ethicalproblems doesits use raise? How do the undoubted advantages of theapproach compare with the clear drawbacks and objectionswhich can be made to its use?

Observational studies conducted in medical settings bysocial scientists may be carried out in a variety ofways.One dimension of choice is the extent to which theresearcher reveals his identity, and his purposes, tothose whom he is studying. In adopting a research role,there is a continuum from openness to secrecy, from anovert identification as a research scientist to a covertpresence as a pseudo-patient. This paper examines theethical and methodological arguments for and againstsuch pseudo-patient studies.

In a pseudo-patient study a person enters a medicalsetting by adopting the role of a patient, not in order toreceive therapy but in order covertly to observe thetreatment process and the broader medical and socialsetting within which it occurs. D L Rosenhan's classicstudy, 'On being sane in insane places' (i) is anexample.

This study involved sending eight pseudo-patientsto mental hospitals in different parts of the UnitedStates. On arrival, they feigned symptoms of hearingvoices, which they reported as being often unclear butwhich seemed to say 'empty', 'holloW' and 'thud'.Immediately on admission, the pseudo-patients ceasedsimulating any symptoms of abnormality, and there-after behaved 'normally'. All except one patient wasadmitted with a diagnosis of schizophrenia, and whenreleased, after periods varying from seven to 52 days(with an average of 19 days), the diagnosis on releasewas schizophrenia 'in remission'.The purpose of conducting the research was to

examine the process of psychiatric diagnosis and theeffect of this diagnosis upon the pseudo-patient'streatment in hospital. Rosenhan argued that suchresearch could only be done covertly, by feigning thepatient role, since observations of the diagnostic pro-cess as an outside observer would be tainted by 'reactiv-ity', and the presence of the observer would lead tochanges in behaviour ofpatient and medical personnel.The existence of such measurement effects is well-documented in both natural and social science.Most observational field research in medical socio-

logy and anthropology is not done using covertmethods. Usually the role of researcher is assumedmore or less overtly, and those being studied know thatthey have a social scientist among them. To whatextent is it justifiable to conceal the real identity of theinvestigator and the fact that research is being under-taken? It may seem self-evident that such behaviour,involving as it does invasion of privacy and grossdeception, is manifestly unethical and ought not to beundertaken. Nevertheless such covert studies haveyielded original and novel insights into the treatmentprocess and have advanced the frontiers ofknowledge.

Rosenhan's psychiatric study was widely noticedupon publication. In R W Buckingham's covert Cana-dian study of alternative methods of treating terminalcancer patients (2), he spent two periods offour days asa pseudo-patient, the first in a general surgical wardand the second on a palliative care ward speciallydesigned to meet the known needs of dying patientsand their families. His results showed that staff andfamilies spent more time with patients in the palliativecare ward, and that the surgical care ward did notprovide means of coping with distress and offeringadequate comfort. Support for dying patients camefrom other patients, from the patients' own families,from volunteers and student nurses, as much as fromnursing staff or physicians. In particular, the inappro-priateness of doctors travelling in groups, avoiding eyecontact with the patient and not speaking to the patientby name was shown for the treatment of terminally-illcancer patients.Buckingham concludes that 'active treatment wards

. do not offer an optimal environment for the dying.There is a need for comfort, both physical and mental,for others to see them as individuals rather than as

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hosts for their disease, and for someone to breach theloneliness and help them come to terms with the end'(3). This attempt to study the quality ofmedical life fora certain type of patient was made possible throughBuckingham's willingness to enter hospital as apseudo-patient and undergo the rigours which thisinvolved. But was it a justifiable method to use?

There is a lively, continuing debate among socialscientists, particularly sociologists and anthro-pologists, about the merits of covert observationalresearch in studying groups such as social deviants,religious sects or political parties, centres of decision-making and power in large organisations, or voluntaryassociations (4). In several contexts, including themedical, there are situations where the presence of theresearcher as a true participant provides an 'insideview' ofthe setting being studied. Accounts by doctorsof their own experience of illness and medical treat-ment have an unusual interest and importance (5).A recent collection by a group ofmedical sociologists

(6) provides fresh insights into illness, throughaccounts of their own illnesses from professionalswhose work involves studying medicine. R Jobling,for example, provides an analysis of his experience ofsuffering from psoriasis and the treatment regimes towhich he was subjected. S Macintyre and D Oldmandiscuss how they cope with migraine. In suchaccounts, however, the authors are real patients, suf-fering from real conditions, under the care of aphysician because they need medical treatment. Whatof the social scientist who enters a medical settingunder the guise of a patient in order to do research?

The merits of pseudo-patient studies

Several arguments have been advanced in favour oftheuse of pseudo-patient studies. The first, and mostimportant, is that they are a means of gaining newknowledge not otherwise available to the social scien-tist. William Caudill, an American anthropologist,believed this when he undertook a pioneering study 30years ago (7). While holding a research post at YaleMedical School in 1950 he took part in a study ofinterpersonal relationships among psychiatricpatients.

It was decided that Caudill would enter the mentalhospital associated with the medical school in the guiseofa patient. He was admitted to the less disturbed wardof the hospital, and on being assigned to one of thepsychiatrists, he was treated as an in-patient there for aperiod of two months. He lived on the ward, took partin the daily routine and interacted with the otherpatients as ifhe were one ofthem. After the first week,Caudill had going-out privileges each afternoon whichenabled him to leave the ward for a few hours each dayto write up his material. Neither the other patients northe medical staff with whom he was in daily contactknew that he was a social science researcher. His statusas a pseudo-patient was a secret known only to twosenior medical personnel (8). In reflecting later on his

experience, Caudill (like Rosenhan and Buckingham)thought that he had gathered data which would nototherwise have been accessible; in his case on howpatients communicated with each other, on what 'time'meant for the patients, and on a sense of what hospitallife was like.A second argument in favour of pseudo-patient

studies is their naturalism. The use of researcherswhose identities are not known means that the researchsituation remains true to life, and is not distorted by thepresence of (identified) social scientists, whose pres-ence may in turn influence the behaviour of others inthat setting. The problem of 'reactivity' is a besettingone in social research. Any means by which one canmake the observer more unobtrusive will, it is argued,yield more reliable and valid data (9). Particularly inmedical settings where assessments and judgments arebeing made about patients, the possibility of the inves-tigator covertly appearing as a patient rules out themajor source of reactivity he or she would constitute ifpresent as an extraneous and identified observer.

Thirdly, it is also argued that the quality ofdata fromsuch covert studies is superior. Caudill reported thathis covert study 'provided a rich body of data concern-ing many problems, hitherto only incompletely recog-nised, which were faced by the patients as a socialgroup in their life on the ward' (io). Rosenhan main-tains that though concealment was distasteful, it was anecessary first step to studying the process ofpsychiatric diagnosis. 'Without concealment, therewould have been no way to know how valid theseexperiences (as pseudo-patients) were; nor was thereany way of knowing whether whatever detectionsoccurred were a tribute to the diagnostic acumen ofthestaff or to the hospital's rumour network' (ii).A fourth argument draws parallels with muckraking

politicians: and investigative journalists. Medicalsystems which operate on a fee-per-item-of-treatmentbasis, with the fee being then reclaimed, in whole or inpart, from the state or an insurance company, areparticularly liable to financial abuse. In France, jour-nalists presented themselves covertly to doctors withidentical symptoms, and observed the variations intreatment provided, thereby exposing abuses of themedical insurance system. In the United States,Senator Frank Moss, chairman of the US Senate Sub-Committee on Long-term Care, revealed in i976 thathe had acquired a Medicaid card and had secretlyvisited a medical centre, sending aides and Capitol Hillpolicemen covertly to a further 120 'Medicaid Mills' inNew York City.These visits revealed widespread fraud, through the

use of unnecessary tests, extensive referrals and anumber of prescriptions (I2). Such abuses would notcome to light without such undercover inquiries.For American sociologist Jack D Douglas, such

undercover work provides a model for social researchpractice. Writing in the aftermath of Watergate, andenormously impressed by the achievements ofWashington Post journalists Woodward and Bernstein

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(I3), Douglas argues that the world is permeated tosuch an extent by deception and manipulation thatcovert methods are fully justified on the part of thesocial scientist, and moreover rather innocuous in theireffects (14).A final justification for pseudo-patient studies points

to the widespread use of deception of certain kinds inmedical practice. The use ofmisleading statements andeven outright lies cannot be ruled out in certain trans-actions between physician and patient, as Sissela Bokhas shown (I5). Patients are not always given fullinformation about their condition, and in some cases(such as terminally-ill cancer patients) deceptionmay be used to conceal the gravity of the patient'scondition.

In medical experimentation, deception is an integralpart of the research design. 'Double-blind' trials andplacebo treatment conceal from both researchers andpatients what treatment the patients are actually receiv-ing, or whether the patients receive any meaningfultreatment at all. Admittedly, both researchers andpatients know that they are participating in an experi-ment, but they may be actively misled as to what theexperiment is about. Compared to these forms ofdeception, that used in pseudo-patient studies is rathermild.

Moreover, pseudo-patient studies do something toredress the balance in favour of the patient, in that it isthe medical staffwho are most likely to be deceived. InRosenhan's study of psychiatric diagnosis, his eightsubjects at first feared discovery and exposure. Theytherefore made notes secretly of their observations onthe ward. However, as time passed there seemed to beno reason to maintain this secrecy, and they began totake notes openly on the ward. This led many fellow-patients to suspect that they were not patients butobservers. 'You're not crazy. You're a journalist, or aprofessor. You're checking up on the hospital' (i6).No medical staff, however, voiced suspicions about

the true purposes of the pseudo-patients in takingnotes, and in three cases notes recorded in their filesuggested that the writing was pathological. 'Patientengages in writing behaviour' (I7) was a comment onone who was never questioned about what he was doingby the medical staff. The use ofdeception thus results,at worst, in the biter being bit.

The de-merits of pseudo-patient studiesAgainst these arguments favouring the use of pseudo-patient studies may be set several powerful objectionswhich are based on the belief that not only are thesemethods unethical they also tend to produce datawhich lack authenticity.

HARM TO THOSE BEING STUDIEDThe doctor-patient relationship is one based uponmutual trust and confidence. It is personal and confi-dential (i8). To act as a pseudo-patient flagrantlybreaches this fiduciary relationship. Other medical

staff and fellow-patients are also involved. In Caudill'scovert study, when he and his supervisor Fritz Redlichsubsequently revealed what had been going on to thoseat the hospital, the medical personnel were angered.There can be doubt [Redlich later wrote] that the effectof the clandestine observation on the professional staffof the hospital was severe. They felt spied upon. Theywere particularly angry over what they considered wasthe betrayal of [Caudill's] psychotherapist. This goodman himself actually never complained, but main-tained that he had learned something.... The nurseswere particularly angry, because they thought thatCaudill was not only deceitful but did not like them(i9).

The use of deception by-passes the manifold prob-lems of gaining the trust of those whom one is observ-ing in social-science field research, but the sense ofbetrayal which those studied experience when theidentity ofthe researcher becomes known (as it must ifresults are published) is correspondingly muchgreater.

Covert studies also breach informed consentrequirements, which were first developed in responseto the abuse of medical research in Nazi Germany, andwhich are an integral part of ethical practice in medicalexperimentation (20). Those being studied by covertobservations are kept ignorant that they are beingstudied. The voluntary consent ofthe human subject iscompletely lacking. It is true that, where the identity ofthe researcher is known, there are still considerableproblems in obtaining informed consent in ethno-graphic work (2I). Does one walk around a hospitalward asking everyone one meets to sign a consent form,for instance? Nevertheless, this does not justify theviolation of the principle which is involved in secretobservation.

RISK TO THE INVESTIGATORIf the pseudo-patient is mistaken for a real patient andtreated accordingly, the investigator may suffer actualharm. It is not accidental that the majority of pseudo-patient studies have been in the area of psychiatry,where observable physical symptoms are less frequentthan for most other conditions. Even so, patients willreceive treatment that they may not desire. In theRosenhan study, patients were routinely given medica-tion. In total, the eight pseudo-patients were given2IOO pills including Elavil, Stelazine, Compazine andThorazine, while in hospital. Only two of these pillswere actually swallowed. The remainder were eitherpocketed or flushed down the toilet. That this waspossible, Rosenhan attributes to the depersonalisationof patients by nursing staff (22). Nevertheless,pseudo-patients run the risk ofhaving to receive medi-cation which they neither need nor want. In anAustralian study involving hospitalisation of researchsubjects, Winkler reports that Valium and Mogadonwere given to help pseudo-patients sleep, against theirWill (23). Moreover, the fact that as a rule they did not

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receive medication singled out the observers from theother patients who said to them: 'You can't be sick.There can't be anything wrong with you'.

Another problem in psychiatric studies is that non-voluntary pseudo-patients may find themselves con-fined in hospital against their will when faced with, forexample, family emergencies at home. Rosenhanexperienced this problem in his study, though he hadnot at first anticipated it. Stress to the pseudo-patientmay be the result.

In feigning physical symptoms, greater risks to theinvestigator are run. In the Buckingham study, hehimself was admitted in the guise of a patient withterminal pancreatic carcinoma. Prior to admission, heunderwent supra-clavicular incision (indicative of cer-vical lymph node biopsy) and ultraviolet irradiation toproduce erythema over the epigastrium and spine(suggesting radiation therapy to the pancreas) (24).This was to convince medical staff of the genuinenessof his condition. During his stay in hospital he hadoccasion to refuse a nasogastric tube. One reason thathis identity as a pseudo-patient was known to six staffin the entire hospital (25) was to ensure that he was notoperated upon during his stay, in the belief that he wasa real patient.

HARM TO THE INVESTIGATORSuch risks may be minimised by advance planning.What can not be avoided is the possibility ofphysical orpsychological harm to the investigator as a result oftaking the pseudo-patient role. Like the plastic surgeryundergone in Sullivan's pseudo-enlistment study ofthe US army (26), in Buckingham's Canadian study heunderwent the minor surgery and irradiation alreadyreferred to. In addition, his body was made to look thepart by 'puncture sites from intravenous infusionneedles on the hands and arms, a io-kg weight lossinduced by a 6-month diet, patchy beard alopeciarelated to the stress of preparation, and abstinence ofseveral days from washing or shaving' (27).

After the first 48 hours, Buckingham began toexperience pain and sickness for much of the time. Onthe second ward, the palliative care ward, he becameeven weaker and more exhausted. 'He was anorexicand routinely refused food. He felt ill. It took all hisenergy to take a shower. He sat exhausted in a chair.He experienced increasing pain, a constant ache in hisleft leg together with numbness, and restless nightsduring which family members of other patients com-mented sympathetically on his "moaning and groan-ing". M himself [Buckingham] was unaware of thisnocturnal behaviour' (28).The processes involved here are similar to, but more

intense than, those experienced by hypochondriactrainee doctors who diagnose in themselves illnesseswhich they are studying in others (29). The observeridentifies with those whom he is observing, and takeson some of the characteristics of the observed.

Psychological effects are even more common thanphysical effects. In Rosenhan's study all subjects

experienced stress, and all but one wanted to be dis-charged immediately after admission. Buckingham'sanxiety level was evident in psychosomatic symptomsbefore the field-work began and was evident to hiscollaborators during the nine days on the ward.D K Reynolds assumed an imaginary identity andobtained admission to a US Veterans' AdministrationHospital, by claiming (falsely) that he had recentlyattempted suicide on hearing that his wife had left himfor another man. So successful was his simulation ofdepression that after admission he came to feelgenuinely depressed himself, and at one point staged afake suicide attempt. He also attributed constipationduring his hospital stay to the effects of these assumeddepressed feelings (3o).

In William Caudill's case, the documentation is ful-lest. In addition to Caudill himself, two independentobservers confirm that the stresses were so great that allthree doubted whether it would be advisable to repeatsuch a study. His supervisor, F C Redlich, wrote inI973:

There can be no doubt that Caudill found the con-cealed study stressful. At the end for a short time Ibelieve he lost his objectivity as a participant observer,and almost became a participant, a patient....Although Caudill felt there was too much fuss madeover concealment in his own study as well as in laterstudies - such as in Milgram's work - he suffered fromit (3I).

Another view is provided by Caudill's friend Georgede Vos:My memory shifts to another meeting with Bill somethree years later. It was 3.oo am and Bill was expressinga great deal of inner turmoil concerning the unusualresearch role he had been playing at Yale (in the covertstudy).... The strain on Bill between his role as anobjective observer and his human sensitivity to peoplewho were deceived by his dissembling developed into avery severe personal and career crisis. The subsequentpublications from this research revealed little of thisordeal. It was a learning experience for all who partici-pated, and the lesson was the need for caution aboutthe effects of research on the doers as well as thesubjects (32).There is thus clear evidence that acting as a pseudo-

patient can be, at least in the short-term, harmful to theinvestigator.

LEGAL AND ETHICAL PROBLEMS IN AN INSTITUTIONALCONTEXTThe management of pseudo-patient studies posescomplex legal and ethical problems for the institutionsin which they are conducted. In the Canadian cancerstudy, the legal liability of the hospital for anythinghappening on its premises had to be anticipated. InRosenhan's study, provision had to be made to releasepseudo-patients from hospital should they wish to bereleased and be unable to achieve it themselves. In the

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course of the research, as appreciation of the possibledifficulties grew, 'a writ of habeas corpus was preparedfor each of the entering pseudo-patients and an attor-ney was kept "on call" during every hospitalisation'(33).

In other cases, the admission ofa pseudo-patient wasdone in the knowledge of at least one member of thesenior medical staff of the hospital. In Buckingham'sstudy, six knew, in Caudill's two, including his super-visor. This desire to let a few colleagues into the secret(in order to safeguard the position of the pseudo-patient, and to facilitate the research) does, however,create problems of confidence among professional col-leagues. Thus, when Redlich revealed to the staffmembers that Caudill's study had just been concluded,the majority were outraged. One of his close associatescalled it sordid at an open meeting. Several colleagueswere particularly critical of the deception of Caudill'spsychiatrist, which they saw as degrading psycho-therapy (34). The revelation of the research thus, for aperiod at least, diminished trust between professionalcolleagues. In addition to loss oftrust with patients, theuse of the covert approach accentuated problemsamong the researcher's own peer group.

In Buckingham's study, those in the know were foursenior doctors and two administrators. There was thusa potentially explosive situation between these seniorstaff and the housemen, nurses, orderlies and volun-teers on the wards who were not in the researcher'sconfidence. The structural distribution of knowledgein the project was potentially a source oftension. Thosein charge of the study considered that the major prob-lems of secrecy arose less from leaks during the projectthan from 'the socioprofessional position of those whoknew the secret' when the secret was finally madepublic. Reactions of the staff to this revelation are notrecorded (35).

THE QUALITY OF DATA IN COVERT STUDIESOne of the most substantial objections to the use ofcovert methods is that the use of such methods affectsthe quality ofthe data gathered. Far from giving accessto otherwise unobtainable data, it tends to yield lessreliable and valid results than would overt observation.

In the first place, to what extent can the pseudo-patient successfully adopt the role of the true patientand be accepted as such by all in the setting? InRosenhan's study, there was clear evidence in a largeminority of the cases that the other patients (thoughnever the medical staff) realised that the subjects werenot real patients. Subjects in Winkler's Australianstudy were identified as not ill because they read a bookon the ward. Note-taking in particular identifies theresearcher as a researcher and draws attention to hisdifferentness from other patients.The feigning of convincing symptoms as a pseudo-

patient is also difficult. Buckingham found it particu-larly difficult to imitate the passivity and inactivity ofvery sick cancer patients.

A few days after admission, increased activity began toassert itself and the researcher's physical mobility onthe ward became more and more atypical of the normalpatient role. In the palliative care ward where most ofthe patients were bedridden and some even unable tospeak, this atypical mobility was accentuated and wasaccompanied by increasing demands on staff forspecial attention. The investigator himself justified themore active behaviour as a necessary change in theresearch design. He felt that only with increased mobil-ity could he observe and interact with patients and withtheir families, who were permitted free access to thebedside. From the outside observer's vantage point theincreasing emotional load of these demands was moreobvious, and the growing dissimilarity between theinvestigator and other patients in the unit was equallyblatant (36).

Clearly, Buckingham was behaving in ways differentfrom other patients, with (unknown) consequences forhis own perceptions of the situation, and for his inter-actions with medical staff, fellow-patients and thefamilies of patients. He admits, for example, that hebecame emotionally involved with some members ofthe families of other patients, writing poems for themand expressing feelings of grief (37).F Redlich's final judgment on Caudill's study was

that the emotional involvement of the covert observerdetracted from objectivity:Our most important expectation was to obtain maxi-mally objective and detailed information by a scientifi-cally trained observer. To our surprise we found thatCaudill did not remain objective. He became amemberof the patient society and identified with the patients.Temporarily, Caudill really became a 'patient'.. . . Hedeveloped considerable antagonism against the nurses,with whom he got into repeated quarrels, and evenfights.... His most moving, though not necessarilyhis most objective accounts, depicted, almost with pas-sion, the society of patients as a society of under-dogs (38).

Caudill himself subsequently undertook a second,overt, observational study in the same hospital (after aperiod of patient turnover) (39). He concluded, com-paring the data collected on the first and secondstudies, that the second, overt, approach was superior.Both provided rich insights into the workings of ahospital ward and interaction among patients. But thesecond study yielded a wider range of data over whichit was possible to exercise a greater degree of control.He was more satisfied, emotionally and intellectually,with the second study (40).A comparison of Caudill's two studies suggests not

only the distorting effect of playing the covert role, butalso that the need to adopt the covert role in the firstplace may be considerably exaggerated. The ethicaldilemmas posed by the use of the method may be falseones, in the sense that the original objectives may beachieved by other means. A comparison of pseudo-patient studies of psychiatric hospitals with overt

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studies of hospitals such as that of Stanton andSchwarz (4I) suggests that this is indeed the case.Experience in other areas such as the study of crime orpolitics shows that much data can be obtained by overtmethods, even from settings hitherto thought to beinaccessible (42).

ConclusionThe use of pseudo-patient studies as a means of inves-tigating the patient's experience of medicine is suspectbut not to be ruled out altogether. Murray and Bucking-ham conclude that role-playing and covert participantobservation should be used with great care in medicalanthropology.When a choice is available, other methods ofinvestiga-tion are preferable; role-playing should be restricted toonly those field situations in which no other method ofinvestigation can reasonably be expected to yield satis-factory data (43).

Several social scientists who have used this methodsubsequently concluded that its use was best avoided inthe future. That of Caudill has already been cited, andRedlich concurred:We have learned not to take it for granted that researchalways benefits human-kind. If it actually or poten-tially harms rather than helps individuals and popula-tions, we insist today to protect such individuals andpopulations and forego the search for truth (44).Though the risks are smaller in social science than in

biomedical research, the problems offreedom, privacyand human dignity remain subtle. In the light of theseconsiderations Redlich (writing in the year of Water-gate) states that he would not today have undertakenthe concealed study (45).The broader ethical calculus to weigh up the rights

and wrongs of such studies is difficult. Should this sortof study be discarded as a dramatic but unconvincinguse of methods of dubious ethical validity, or does itoffer insights not otherwise available, particularly inunderstanding relationships between people? (46).The arguments reviewed earlier in this paper are on thewhole stronger against such studies than in theirfavour. Nevertheless, in an Australian study ofgeneralpractitioners' approaches to patients with psychiatricsymptoms, Owen and Winkler urge the use of suchmethods to provide a consumer perspective on healthcare, and to provide feedback on the experience ofmedical treatment which is unavailable from othersources (47).Bok considers that there is justification for the

monitoring elements (rather than the mere acquisitionof new knowledge) provided by pseudo-patientstudies. The existence of such monitoring ensures thatstandards are checked and possibly maintained.Relationships between physicians and their patientsare not equivalent to private sexual or religiousbehaviour, and ought to be open to publicscrutiny (48).

The debate will continue, illuminated by the occa-sional empirical study using the covert approach. Theethical and methodological questions raised bypseudo-patient studies are likely to defy definitive sol-ution and remain dilemmas requiring the exercise ofmoral choice.

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