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Are AI Chatbots in Healthcare Ethical?

https://www.medpagetoday.com/opinion/second-opinions/102987

Their use must require informed consent and independent review

Within a week of its Nov. 30, 2022 release by OpenAI, ChatGPT was the most widely used and influential artificial intelligence (AI) chatbot in history with over a millionopens in a new tab or window registered users. Like other chatbots built on large language models, ChatGPT is capable of accepting natural language text inputs and producing novel text responses based on probabilistic analyses of enormous bodies or corpora of pre-existing text. ChatGPT has been praised for producing particularly articulate and detailed text in many domains and formats, including not only casual conversation, but also expository essays, fiction, song, poetry, and computer programming languages. ChatGPT has displayed enough domain knowledge to narrowly miss passing a certifying examopens in a new tab or window for accountants, to earn C+ grades on law school examsopens in a new tab or window and B- grades on business school examsopens in a new tab or window, and to pass parts of the U.S. Medical Licensing Examsopens in a new tab or window. It has been listed as a co-author on at least fouropens in a new tab or window scientific publications.

At the same time, like other large language model chatbots, ChatGPT regularly makes misleading or flagrantly false statements with great confidence (sometimes referred to as “AI hallucinations”). Despite significant improvements over earlier models, it has at times shown evidenceopens in a new tab or window of algorithmic racial, gender, and religious bias. Additionally, data entered into ChatGPT is explicitly stored by OpenAI and used in training, threatening user privacy. In my experience, I’ve asked ChatGPT to evaluate hypothetical clinical cases and found that it can generate reasonable but inexpert differential diagnoses, diagnostic workups, and treatment plans. Its responses are comparable to those of a well-read and overly confident medical student with poor recognition of important clinical details.

This suddenly widespread use of large language model chatbots has brought new urgency to questions of artificial intelligence ethics in education, law, cybersecurity, journalism, politics — and, of course, healthcare.

As a case study on ethics, let’s examine the results of a pilot programopens in a new tab or window from the free peer-to-peer therapy platform Koko. The program used the same GPT-3 large language model that powers ChatGPT to generate therapeutic comments for users experiencing psychological distress. Users on the platform who wished to send supportive comments to other users had the option of sending AI-generated comments rather than formulating their own messages. Koko’s co-founder Rob Morris reported: “Messages composed by AI (and supervised by humans) were rated significantly higher than those written by humans on their own,” and “Response times went down 50%, to well under a minute.” However, the experiment was quickly discontinued because “once people learned the messages were co-created by a machine, it didn’t work.” Koko has made ambiguous and conflicting statements about whether users understood that they were receiving AI-generated therapeutic messages but has consistently reported that there was no formal informed consent processopens in a new tab or window or review by an independent institutional review board.

ChatGPT and Koko’s therapeutic messages raise an urgent question for clinicians and clinical researchers: Can large language models be used in standard medical care or should they be restricted to clinical research settings?

In terms of the benefits, ChatGPT and its large language model cousins might offer guidance to clinicians and even participate directly in some forms of healthcare screening and psychotherapeutic treatment, potentially increasing access to specialist expertise, reducing error rates, lowering costs, and improving outcomes for patients. On the other hand, they entail currently unknown and potentially large risks of false information and algorithmic bias. Depending on their configuration, they can also be enormously invasive to their users’ privacy. These risks may be especially harmful to vulnerable individuals with medical or psychiatric illness.

As researchers and clinicians begin to explore the potential use of large language model artificial intelligence in healthcare, applying principals of clinical research will be key. As most readers will know, clinical research is work with human participants that is intended primarily to develop generalizable knowledge about health, disease, or its treatment. Determining whether and how artificial intelligence chatbots can safely and effectively participate in clinical care would prima facie appear to fit perfectly within this category of clinical research. Unlike standard medical care, clinical research can involve deviations from the standard of care and additional risks to participants that are not necessary for their treatment but are vital for generating new generalizable knowledge about their illness or treatments. Because of this flexibility, clinical research is subject toopens in a new tab or window additional ethical (and — for federally funded research — legal) requirements that do not apply to standard medical care but are necessary to protect research participants from exploitation. In addition to informed consent, clinical research is subject to independent review by knowledgeable individuals not affiliated with the research effort — usually an institutional review board. Both clinical researchers and independent reviewers are responsible for ensuring the proposed research has a favorable risk-benefit ratio, with potential benefits for society and participants that outweigh the risks to participants, and minimization of risks to participants wherever possible. These informed consent and independent review processes — while imperfect — are enormously important to protect the safety of vulnerable patient populations.

There is another newer and evolving category of clinical work known as quality improvement or quality assurance, which uses data-driven methods to improve healthcare delivery. Some tests of artificial intelligence chatbots in clinical care might be considered quality improvement. Should these projects be subjected to informed consent and independent review? The NIH lays out a number of criteriaopens in a new tab or window for determining whether such efforts should be subjected to the added protections of clinical research. Among these, two key questions are whether techniques deviate from standard practice, and whether the test increases the risk to participants. For now, it is clear that use of large language model chatbots is both a deviation from standard practice and introduces novel uncertain risks to participants. It is possible that in the near future, as AI hallucinations and algorithmic bias are reduced and as AI chatbots are more widely adopted, that their use may no longer require the protections of clinical research. At present, informed consent and institutional review remain critical to the safe and ethical use of large language model chatbots in clinical practice.

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Is this the corporate entity and its unhappy employees you are entrusting your healthcare to ?

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2022 Letter to the American Medical Association

http://https://www.daily-remedy.com/2022-letter-to-the-american-medical-association/

“The absurdity of our trial is acutely apparent when contrasting our credentials with that of the Government.”

Content has been preserved in its original form and syntax. Modifications were made only to protect the interest of private citizens and to facilitate readability.

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November 18, 2022

 

Re: An Outcry Against the Evil Movement of Scapegoating Physicians

Jack Resneck, Jr., MD, President of AMA

James L. Madara, MD, CEO & Executive VP of AMA

AMA Plaza, 330 N. Wabash Ave. Suite 39300 Chicago, IL 60611-5885

 

Dear Drs. Resneck, Jr. and Madara:

 

I write to express my perpetual concern of the nation’s scapegoating-physician movement. (A few years ago, on several occasions, I had written to AMA, specifically, Dr. Barbara McAneny, the AMA President then, regarding the same issue.)

 

More than a decade ago, in his book, “The Criminalization of Medicine: America’s War on Doctors” (Praeger Publishers, 2008), Professor Ronald T. Libby, clearly articulated this evil scapegoating-physician movement:

 

“The government has made medical doctors scapegoats for the financial crisis of health care in the country and for the failed war on drugs. Physicians’ role as sacrificial lambs follows the long history of political scapegoats in the United States…Physicians have become the enemies of the country’s health care.” (p. 181)

 

“The physician as scapegoat is important to politicians both to blame for a major threat to society and it promises a relatively easy and inexpensive solution. The solution is to eliminate wealthy and corrupt doctors who threaten the nation’s health care. A tough law and order campaign against corrupt doctors therefore creates the illusion that the state is acting as the protector of the citizenry.” (p. 182)

 

The prosecution of Dr. J. Patrick Couch and myself exemplifies the movement of evil witch-hunt by the government. Dr. Couch and I were arrested in May 2015 during the “Operation Pilluted,” where 22 doctors and pharmacists from four Southern States were arrested. In 2016, we were indicted with a myriad of felonious charges including RICO conspiracy, drug trafficking conspiracies, multiple substantive drug dispensing, healthcare fraud conspiracy, kickback conspiracy, etc.. After a lengthy jury trial in 2017, we were convicted as “drug dealers” and “gangsters” and received 20 and 21 years of imprisonment, respectively.

 

Professor Libby in his book correctly pointed out the contributing role played by physicians themselves:

 

“Medical doctors fit the pattern of a group suffering from a collapse of their image. They do not recognize that there is a national political campaign against them for fraud, kickbacks, and drug diversion. Instead, they see themselves as victims of local vendettas by ambitious prosecutors, competitors, and troubled or greedy whistleblowers. Like other scapegoats, they tend to believe that their cases are individual and unique to them. THIS EXPLAINS THE FACT THAT PHYSICIANS TURNS THEIR BACKS ON OTHER DOCTORS who have been egregiously targeted by the government for investigation and prosecution. (emphasis added)

 

Indeed the absurdity of our trial is acutely apparent when contrasting the requisite specialty/subspecialty credentials of ours with that of the Government expert witnesses at our trial. Dr. Couch’s primary specialty was anesthesia; mine was physical medicine and rehabilitation. Both Dr. Couch and I were fellowship-trained in interventional pain management and had practiced full-time for over a decade at our own interventional pain clinic, Physicians’ Pain Specialists of Alabama (PPSA), Mobile, Alabama. Dr. Couch had achieved four board certifications, there of which were recognized by the American Board of Medical Specialties (ABMS); I had achieved eight board certifications, four of which were recognized by the ABMS. Both of us had the academic title of Adjunct Clinical Associate Professor from local medical institutions. Together Dr. Couch and I had over 120 publications under the PubMed.

 

By contrast, none of the three Government medical expert witnesses, namely Drs. G—- (AZ), A—-  (MS), and V—-  (MS), were fellowship trained; nor did they have any academic title. Dr. A—-  was a hospitalist who had completed residency training only in internal medicine. Dr. G—-  had no residency training whatsoever; he only completed one-year medical internship. Collectively Drs. G—-, A—-, and V—- had zero publication under the PubMed. Over the years, however, Drs. G—-  and A—- each had received huge sum of money, namely $320,000 and $325,000, respectively, from DOJ/DEA, testifying as Government witnesses or consultants.

 

Remarkably, none of them were even qualified to testify as a pain expert in civil medical malpractice suits in the State of Alabama, yet they were allowed by the court to testify as “pain .experts;’ at our criminal trial. Their unreliable and biased trial testimony played important roles in misguiding the jury to convict Dr. Couch and myself as “drug dealers” and “mobsters.”

 

On June 27, 2022, the Supreme Court, in a 9:0 decision, reversed and vacated the judgment of the appellate court. The Court emphasized that the Government needed to prove that I knowingly or intentionally acted as a “drug dealer,” i.e. with a guilty intention, when prescribing controlled medicines in treating my patients. The significance of this ruling was discussed in the following attached articles: “The Supreme Court Decision on Federal Prescribing Rules for Controlled Substances,” by Matt Lamkin, JD, MA, published in JAMA (October 3, 2022); and “US Supreme Court Delivers Much-Needed Certainty to Controlled Substances Prescribing,” by healthcare-and-policy law professors, Kelly K. Dineen Gillespie, Taleed EI-Sabawi, and Jennifer D. Oliva, published in “Health Affairs” (November 1, 2022) Candidly, I consider the Court’s ruling a victory of physicians’ autonomy in the practice of medicine.

 

Here the critical question is: What should we do in order to change our image of societal scapegoats? Professor Libby insightfully admonished: “Scapegoats do not see the broader aspects of their collapsed credibility. Societal scapegoats are deemed to have violated a co.de of conduct. A scapegoat is already found guilty before he is indicted or tried; there is a widespread societal consensus that what he did was wrong.” (p. 182)

 

Professor Libby suggested a step-by-step approach in solving this problem:

 

“The history of scapegoats is that once they have been stigmatized, they will continue to be abused by the government in the future. The only way to transform a scapegoat’s public image is to first recognize that they are political scapegoats. This has occurred twice. The first time was during the 1920s when doctors were made scapegoats in the first war on drugs. It happened again in 1990, when MEDICAL ASSOCIATIONS THROUGHOUT THE UNITED STATES SUPPORTED A CALL BY THE AMERICAN MEDICAL ASSOCIATION (AMA) for the resignation of the Inspector General of the HHS for his role in Medicare/Medicaid fraud inspection abuses targeting doctors.” (emphasis added)

 

“In both instances, the leadership of the AMA called a halt to the senseless destruction of doctors’ careers and lives in the government’s vain pursuit of drug addicts who were treated by physicians and to stamp-out medical fraud. The president of the AMA contacted the president of the United States in both cases and demanded an end to the witch hunts.” (p. 183)

 

Needless to say, it is time for all physicians of this country, irrespective of our differences in specialties and subspecialties, to stand together as one, in a collective effort, demanding the halt of government’s evil witch hunt — the rabid criminalization of physicians. Further, we need to come up with a due measure within out medical profession, to condemn and sanction those unethical and unqualified physicians such as G—-  and A—-, who shamelessly betrayed their fellow physician colleagues by becoming Government’s hired mouthpiece to say whatever the Government paid them to say to convict the accused physicians.

 

This is the reason I write to you and your organization. For your reference, I have also taken the liberty of including an earlier letter I wrote to the Alabama Board of Medical Examiners. From these writings, you may see that it was never one way or the other how the specialty of pain medicine was practiced. Rather, it was “Damned if You Do and Damned If You Don’t.” After all the criminal indictment was essentially a pretext or a special permit to allow the Government to seize physicians’ assets.

 

It is imperative that physicians of all specialties or subspecialties unite in protest against this scapegoating witch hunt so as to protect and preserve physicians’ collective reputation as well as the practice of medicine in this country. To fundamentally change the status of social scapegoats, we have to make every effort. Thank you very much for your attention to this matter.

 

Sincerely,

 

Xiulu Ruan, MD

 

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When the first COVID-19 vaccines came around,  I listen, read, watched anything I could find about these so called vaccines that were being created at WARP SPEED.  I presumed that what the public was being told was just a fraction of what reality was. The first RED FLAG was that these vaccines were going to be put into distribution is less than ONE YEAR… when a new medication typically takes 10+ yrs of clinical trials. Over my FIVE DECADE career, I had seen more new meds pulled from the market after 1-2 yrs because of serious issues that did not appear in the clinical trials has always made me not totally comfortable with just released meds from clinical trials.

Second RED FLAG was that Congress passed a law that imdemified all the pharmas from any liability/collaterate damage from these vaccines.

Third RED FLAG was the vaccines were being released and administered with only a FDA EUA (Emergency Use Authorization) – which in” bureaucratic speak” is that hundred of millions of vaccinations administered  basically under a “unofficial clinical trial”

Fourth RED FLAG was that both of the mRNA temperature storage requirement was going to require up to a MINUS 94 F. that takes some special refrigeration equipment that is not necessarily cheap.

The J&J/Jansen version does not require a storage temp outside of what is normally found in your basic residential/commercial refrigerator/freezer and this version of the vaccine is based on the process that we have used to make our annual flu vaccines for years.  Because of all these factors, I chose for us to get the J&J/Jansen vaccination and booster and since only mRNA versions are now being offered as boosters… we are done with COVID-19 boosters.

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This article contains some very interesting facts. a Forensic Scientist (Scott Oulton) over the DEA lab states that OVER 99% of seized opioid tablets contain ILLEGAL DRUGS mostly one or more of the 400 known Fentanyl analogs, and ONLY ONE ANALOG is approved by the FDA for human use. Here is a recent post on my blog where I quoted a member of Congress that the number of tablets confiscated represents 8% to 15% of what actually comes into our country.  when DEA facts and statistics don’t “add up”… what is really the TRUTH ?

The question has to be asked, if this Forensic Scientist that is working for the DEA claims that 99%+ of opioid poisoning/OD are from illegal substances… why is the DEA still raiding and prosecuting prescribers and Oulton wants to be clear: The problem Isn’t with pills prescribed by your doctor and dispensed by a pharmacy – it’s the pills on the illicit market.

Recently, prescribers that the DOJ/DEA has taken to court have been found NOT GUILTY and it is coming to light some of the shenanigans the federal prosecutors and judges do to get a conviction of innocent prescribers.

Also this article only addresses Opioid poisoning/OD up to age 44 y/o. Does this suggest that the rate of opioid poisoning/OD DROPS OFF SUBSTANTIALLY in our older population, because that is where painful diseases begin to impact all of us as we age and people are more interested in attempting to regain and/or maintain some quality of life  and deaths from opioid poisoning/OD drops off substantially and/or what deaths that do involved a opioid- especially one that has been prescribed to the pt… is the opiate that shows up in their toxicology – suggesting that the pt exercised their final option to end their  torturous level of pain that they were forced to live/exist in and committed suicide.

Scott Oulton, deputy assistant administrator of the DEA’s Office of Forensic Sciences: The problem Isn’t with pills prescribed by your doctor and dispensed by a pharmacy – it’s the pills on the illicit market.

https://www.cnn.com/2023/02/02/health/dea-secret-lab/index.html

Sitting among the warehouses of Dulles, Virginia, is one of the US Drug Enforcement Administration’s forensic labs. It’s one of eight across the country where scientists analyze illegal drugs and try to stay ahead of what’s driving deadly overdoses.

Starting in the late 1990s with overprescribing of prescription narcotics, the opioid epidemic has continued to plague the United States for decades. What has changed is the type of drugs that have killed more than half a million people during the past 20 years.

CNN was granted rare access to the secret lab where the DEA tests seized illicit drugs to understand what’s coming next.

“The market is constantly changing, so we are trying to do everything we can from a science base to keep up with that,”

Scott Oulton, deputy assistant administrator of the DEA’s Office of Forensic Sciences, told CNN Chief Medical Correspondent Dr. Sanjay Gupta.

Holding a white bag of fentanyl precursor powder – one of the chemicals used to make the opioid – Oulton explained that the illicitly made painkiller continues to be a dominant presence in the drugs officials are finding.

“This kilogram can be converted into fentanyl to make approximately 800 grams,” he said. “So it doesn’t take that much material, it’s fairly cheap, it’s inexpensive to obtain.”

Fentanyl is the deadliest drug in the United States, and it’s often found in combination with other illicit drugs, including cocaine and heroin. But increasingly, fentanyl is showing up in illicit pills disguised as common prescription drugs like oxycodone, hydrocodone, even Adderall.

Users buying drugs on the street that look like prescription pills may end up with a highly potent, potentially deadly drug they never intended to take.

“Over 99% of what we see are fake. They contain fentanyl,” Oulton says of the pills that the agency is seizing.

The 800 grams of fentanyl that Oulton held could be turned into 400,000 to 500,000 potentially lethal pills.

‘He was murdered’

As more and more of these lethal pills circulate, the opioid epidemic is reaching more of the population.

Deena Loudon of Olney, Maryland, is among those living with its effects.

“I truly love sharing Matthew with the world,” Loudon says as she flips through pictures of her son.

One of her favorite memories is Matthew playing hockey – what Loudon calls his happy place.

“He was using Xanax to help self-medicate himself and I think to help get rid of some of that angst so he could live somewhat of a normal life,” Loudon said.

Matthew was always honest, almost to a fault, Loudon says. “He told me he tried everything. Like everything. Heroin, meth, crack, you name it, cocaine, whatever – until I guess he found what made him feel the best, and it was Xanax.”

And as much as a mother can worry, Loudon says, Matthew always tried to reassure her. “I know what I’m doing,” he would tell her.

She had heard about fentanyl showing up in pills in their area.

“But you don’t ever think it’s going to happen to you,” Loudon said.

She said they even had a conversation about fentanyl the day before he died. “I was sort of naive, wanting to stick my head in the sand and thinking ‘I bet he does know what he’s doing.’ ”

On November 3, 2020, she found 21-year-old Matthew on the floor of their basement.

Matthew’s autopsy report lists his cause of death as fentanyl and despropionyl fentanyl intoxication.

“I don’t say he overdosed. I say he died from fentanyl poisoning. … Truthfully, like, at the end of the day, to me, he was murdered, right? Because he asked for one thing. They gave him something different. And it took his life.”

For a parent, she said, the hardest thing is burying their child. It’s a pain she speaks out about in hopes of keeping other families safe.

“You never know what you’re gonna get,” she warns them.

‘It’s Russian roulette’

When the overdose epidemic began in the US in the late 1990s, it was driven primarily by the overuse of prescription opioids like OxyContin and hydrocodone, which were essentially based on the same chemical structure as heroin.

About 2010, heroin became more easily available, and a surge in heroin-related overdoses followed. Within just a few years, a rise in synthetic opioids – mostly driven by illicitly made fentanyl – led to skyrocketing overdose deaths, reaching record levels in 2021.

That year, the US Centers for Disease Control and Prevention counted more than 106,000 people dying from drug overdose, an increase of nearly 15% from the previous year. Those with the highest rates of overdose deaths were adults 35 to 44, while young people ages 15 to 24 had among the lowest rates.

Yet even though they have lower rates of overdose deaths overall and drug use among middle and high school students has remained fairly steady over the past decade, overdoses among young people have been climbing.

According to a CDC report, among people 10 to 19 years old, the number of monthly overdose deaths increased 109% from 2019 to 2021, and deaths involving illicitly manufactured fentanyl surged 182%. Counterfeit pills were present in nearly 1 in 4 of those deaths, and about 40% of the time, teens who overdosed also had evidence of mental health conditions.

Duke Burress of Fairfax, Virginia, has lived those numbers. His son Richard was 22 years old when he died from a fentanyl overdose.

Richard, or Will as his dad like to call him, had struggled with drug use since he was prescribed Xanax in middle school. It soon led to him buying it on the street. He had been in and out of rehabilitation and eventually was living in a recovery house less than a mile from home.

In September 2020, police following up on a call from concerned neighbors found Will’s body in his apartment. Duke Burress says they told him they immediately suspected fentanyl – something that acted fast – noting that Will still had his phone in his hand when they found him. The police also found blue pills that looked like Xanax.

“They can very readily mix fentanyl with the pill and press it, and it’ll look like a true blue pill,” Burress said.

He says he owes it to other families to speak out, to be an advocate and warn others.

“It’s Russian roulette,” he said. “You’re endangering your life.”

One pill can kill

The number of pills the DEA has seized skyrocketed in just three years, from 2.2 million in 2019 to 50.6 million in 2022.

The sheer volume of pills has been one of the biggest challenges for the DEA’s lab, Oulton says. As the fentanyl threat continues to grow, the Virginia facility is expanding to accommodate the analysis needed.

The lab can test for something as simple as the presence of fentanyl, but something called the purity of the pill also offers important insight. This means how much fentanyl is actually in one of these illicit pills.

“Lately, we’ve been seeing a purity increase over the last year, where we used to say roughly four out of the 10 seizures that we were receiving would contain a lethal dose of greater than 2 milligrams. As of October last year, we started reporting that we’ve seen an uptick. Now we’re saying that six out of 10 of the seizures that we’re receiving contain over 2 milligrams,” Oulton said.

He says they’re finding an average of 2.3 milligrams of fentanyl in each pill.

Two milligrams may be the cutoff for what is considered lethal, but Oulton says that doesn’t necessarily mean a pill with 1.99 milligrams of fentanyl can’t be deadly.

“One pill can kill” is his warning.

“The message I would like to send out is, don’t take it,” he said. “Don’t take the chance. It’s not worth your life.”

More pills, new drugs

Oulton says he and his team are constantly finding new and different drugs and substances in pills – things they’ve never seen before.

One machine in the lab is almost the equivalent of an MRI in a medical office, showing the structure and detail of a pill.

“We will do what we call structural elucidation to determine that this is a different version of a fentanyl that’s got a new compound and molecule that’s been added to it,” Oulton said.

They’ve seen “hundreds and hundreds of unique combinations,” he said.

“We’ll see one that contains fentanyl, one with fentanyl and xylazine, one with fentanyl and caffeine, one with fentanyl and acetaminophen, and you don’t know what you’re getting.”

Xylazine, a veterinary tranquilizer, poses a unique problem. It’s not an opioid, so even when it’s mixed with fentanyl, drugs designed to reverse an opioid overdose may not work.

Narcan or naloxone, one of the more common overdose-reversing drugs, has become increasingly necessary as the prevalence and potency of illicit drugs increases. About 1.2 million doses of naloxone were dispensed by retail pharmacies in 2021, according to data published by the American Medical Association – nearly nine times more than were dispensed five years earlier.

Oulton wants to be clear: The problem Isn’t with pills prescribed by your doctor and dispensed by a pharmacy – it’s the pills on the illicit market.

Those, Matthew’s mother warns, are easy to get.

“The first pills [Matthew] got was in high school. And it was just flipping out, floating around, and it was easy for him to get his hands on,” she said.

Loudon’s message for parents now: Keep your eyes open.

“Just be mindful of what your children are doing. You just just have to keep your eyes open. And even sometimes, when you keep your eyes open, you can miss some of the warning signs, but I think a parent knows their child best, so just keep talking.”

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Lawyers should never ask a Georgia grandma a question if they aren’t prepared for the answer.
In a trial, a Southern small-town prosecuting attorney called his first witness, a grandmotherly, elderly woman to the stand. He approached her and asked, ‘Mrs. Jones, do you know me?’ She responded, ‘Why, yes, I do know you, Mr. Williams. I’ve known you since you were a boy, and frankly, you’ve been a big disappointment to me. You lie, you cheat on your wife, and you manipulate people and talk about them behind their backs. You think you’re a big shot when you haven’t the brains to realize you’ll never amount to anything more than a two-bit paper pusher. Yes, I know you.’
The lawyer was stunned. Not knowing what else to do, he pointed across the room and asked, ‘Mrs. Jones, do you know the defense attorney?’
She again replied, ‘Why yes, I do. I’ve known Mr. Bradley since he was a youngster, too. He’s lazy, bigoted, and he has a drinking problem. He can’t build a normal relationship with anyone, and his law practice is one of the worst in the entire state. Not to mention he cheated on his wife with three different women. One of them was your wife. Yes, I know him.’
The defense attorney nearly died.
The judge asked both counselors to approach the bench and, in a very quiet voice, said,
‘If either of you idiots asks her if she knows me, I’ll send you both to the electric chair.

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