Even famous doctors owe something to their patients.

When a mental disorder is accompanied by fame and money, it can become a lure for many evil people. On October 28, 2023, it seems as if Friends Star Matthew Perry was the victim of a group of people who attempted to poison him through negligence, according to a report in the New York Times. At the heart of this group were doctors. For Perry, the poison was ketamine, a complex and vital drug that he desperately sought and that was given to him with increasing frequency despite warning signs. One of the doctors who prescribed the drug has claimed through a lawyer that he was only doing his job.

But to truly understand what happened to Perry, we need to discuss the history of ketamine and depression. We also need to understand what negligence is and why licensed physicians break sacred oaths and cause harm.

From a medical perspective, ketamine's range of effects is extraordinary. The same drug can reduce pain, prevent relapse in alcoholics and heroin addicts in withdrawal, prevent seizures, and reverse asthma attacks. This drug can produce a deep state of anesthesia and amnesia, enough to block the pain of a surgical knife or deliver 400 joules of electricity to restart a heart fibrillation. It famously produces a state known as dissociation, while respiratory function remains nearly normal and negative effects on the heart are minimal. For Perry and thousands of others, the real reason was another property of ketamine – for many, it is an effective treatment for reversing crippling depression.

Ketamine's enthusiasm for antidepressants is relatively new, but this important property has been known for quite some time. In 1975, ketamine was reported to exhibit antidepressant effects in animal studies. On March 5, 2019, the Food and Drug Administration approved a ketamine nasal spray for treatment-resistant depression, but its use was limited to certified physician offices or clinics. Aside from the inhalation method, ketamine is generally administered as an intramuscular or intravenous injection. Ketamine is not absorbed when swallowed.

The pharmaceutical market is dominated by two classes of drugs: selective serotonin reuptake inhibitors and serotonin and norepinephrine reuptake inhibitors. What is notable about these drugs is their relative ineffectiveness in relieving symptoms of depression. Worse, they fail to suppress suicidal thoughts and may even increase the risk of suicide. Ketamine is not associated with increased suicidality and is widely used in emergency departments for people who have attempted suicide or are experiencing severe suicidal thoughts.

Good psychiatrists know when to use antidepressants that have strong promise of success. Melancholic signs predict a higher probability of success. The signal-and-noise problem of antidepressant failure is that they are mistakenly used for unhappiness or trauma of existence. Unhappiness is a common and serious problem, but an SSRI or SNRI will not help a patient who is merely unhappy. True, drug-treated depression is much rarer. The high failure rate of antidepressants may be due to overprescription and subsequent medicalization of the condition.

For treatment-resistant depression, doctors may turn to something stronger. Ketamine is structurally similar to phencyclidine, also known as the street drug “angel dust” among many other names, and like it, it can cause hallucinations and distorted perceptions. Sometimes these hallucinations are pleasant and produce feelings of deep insight. Sometimes these hallucinations are terrifying – known in the medical lexicon as emergence delirium. Up to 55 percent of patients given ketamine experience an emergence phenomenon that closely resembles schizophrenia and increases their risk of injury.

For some users, finding the sweet spot between anxiety and happiness is too tempting. There are case reports from doctors of recreational use of ketamine. Chronic users also develop a significant tolerance to ketamine without experiencing significant physical withdrawal symptoms, and cycling use of very high doses is observed. Perry reportedly struggled increasingly with tolerance and sought ever higher doses to achieve the desired effects.

Perry suffered from a ketamine tolerance and asked for higher doses, but his clinic doctor denied his request. Perry found Salvador Plasencia, an internist nicknamed “Dr. P.” Plasencia teamed up with another doctor named Mark Chavez, who had experience with ketamine. Together they figured out how much to charge Perry for the supply. According to a court document, Plasencia's text messages to Chavez read, “I wonder how much this idiot is going to pay” and “Let's find out.”

When a doctor deviates from the duty of care and measurable harm occurs, we call it negligence. This is a civil offense, and the compensation is money. Central to negligence is the foreseeability of the harm. Sometimes the negligence is so extreme that it can be punished as a crime. Lawmakers have generally left the conversion from civil to criminal negligence vague. The power to decide rests with the prosecutor. Criminal negligence occurs when more extreme actions result in more extreme harm. It is not simply an error of judgment or carelessness. To prove criminal negligence in California, where Perry died, a prosecutor must show that the defendant knew his conduct posed a particularly serious danger to the person he injured. The prosecutor must show that another person in the same situation would have foreseen the danger and refrained from similar conduct. Plasencia and Chavez almost certainly did not intend to cause Perry's death, but his death was predictable. Out of greed and negligence, these doctors failed Perry when they should have known better.

A report from the Los Angeles County Department of the Medical Examiner dated December 15, 2023, listed Perry's cause of death as the acute effects of ketamine. That does not appear to be correct. Contributing factors listed include drowning, coronary heart disease, and the effects of buprenorphine, a drug used to treat opioid use disorder. If Perry had received ketamine while he was on dry land, he may not have died. Ketamine is not as toxic as other drugs. Opioids cause death because when people overdose, they stop breathing and they don't know it. The cause of death is oxygen deprivation.

Ketamine is not an opioid. Some drugs cause direct cardiac arrest, and in this case the drug is more likely to be the immediate cause. Even in high and repeated doses, and all other things being equal, ketamine can be harmful, but it is not predictable to be fatal on its own. When a critically ill patient needs anesthesia, ketamine is often chosen because it does not kill. The fact that ketamine has been evidently and demonstrably lacking fatal toxicity may have raised fewer concerns for Plasencia and Chavez. But that should not absolve them of medical malpractice charges. Because of its powerful effects, ketamine is usually administered under the direct supervision of medical professionals. Perry was injected by his assistant, according to court records read by the Times, and then left alone.

After the Justice Department charged the doctors with several drug-related offenses, Chavez entered into a plea agreement and Plasencia pleaded not guilty. “Ultimately, Dr. Plasencia operated with what he believed to be the best medical intentions,” his attorney said. No one has yet been charged with negligence in connection with Perry's death, either civilly or criminally. But that could still come.

All citizens of civil society are expected to obey the law and uphold the social contract, especially doctors. In exchange for their power, the doctor swears an oath to protect the public from harm. For the moral doctor, beneficence must always trump malice. A state medical board will grant a doctor a license to practice as an additional measure of protection for the public. What perhaps deserves more recognition is the fact that rich and famous people tend to receive inferior medical care. In such cases, the reason is to deviate from the usual way of doing things, to offer something unique and to be part of a more exciting experience that goes beyond the routine of medical practice.

At the heart of the doctor-patient relationship is the doctor's duty to act in the patient's best interests. Sometimes a patient will make an unconventional decision, but if the patient is competent and the request is fundamentally reasonable, the doctor has a duty to comply. Such a request does not require financial support from the patient to induce the doctor to agree, nor should the patient's fame influence decision-making. If a patient is powerful and confused by his illness and the request is unreasonable, an offer of money to that doctor (or the fact that a patient may be charged a high price) does not make that request any more compelling. In that case, the doctor's duty is clear: refuse the money and tell the patient to do so. NO.