Welcome to the Nexus of Ethics, Psychology, Morality, Philosophy and Health Care

Welcome to the nexus of ethics, psychology, morality, technology, health care, and philosophy
Showing posts with label Fiduciary. Show all posts
Showing posts with label Fiduciary. Show all posts

Thursday, December 19, 2019

Where AI and ethics meet

Stephen Fleischresser
Cosmos Magazine
Originally posted 18 Nov 19

Here is an excerpt:

His first argument concerns common aims and fiduciary duties, the duties in which trusted professionals, such as doctors, place other’s interests above their own. Medicine is clearly bound together by the common aim of promoting the health and well-being of patients and Mittelstadt argues that it is a “defining quality of a profession for its practitioners to be part of a ‘moral community’ with common aims, values and training”.

For the field of AI research, however, the same cannot be said. “AI is largely developed by the private sector for deployment in public (for example, criminal sentencing) and private (for example, insurance) contexts,” Mittelstadt writes. “The fundamental aims of developers, users and affected parties do not necessarily align.”

Similarly, the fiduciary duties of the professions and their mechanisms of governance are absent in private AI research.

“AI developers do not commit to public service, which in other professions requires practitioners to uphold public interests in the face of competing business or managerial interests,” he writes. In AI research, “public interests are not granted primacy over commercial interests”.

In a related point, Mittelstadt argues that while medicine has a professional culture that lays out the necessary moral obligations and virtues stretching back to the physicians of ancient Greece, “AI development does not have a comparable history, homogeneous professional culture and identity, or similarly developed professional ethics frameworks”.

Medicine has had a long time over which to learn from its mistakes and the shortcomings of the minimal guidance provided by the Hippocratic tradition. In response, it has codified appropriate conduct into modern principlism which provides fuller and more satisfactory ethical guidance.

The info is here.

Tuesday, January 22, 2019

Kaiser settled 2014 patient-dumping class-action suit earlier this year

Michael McCough
The Sacramento Bee
Originally posted December 20, 2018

Kaiser Foundation Health Plan recently settled a 2014 class-action lawsuit stemming from two allegations that it dumped patients with severe mental illness.

Plaintiffs Douglas Kerr and Barbara Knighton alleged that in separate incidents, Kaiser psychiatrists told them their sons needed to be transferred to locked residential facilities called IMDs (institutions for mental disease) for treatment, according to court documents. Knighton and Kerr claimed they were both told they should remove their children from their Kaiser health plans in 2014 to be transferred to these county-run institutions — a change that shifted the costs of treatment from Kaiser to government-funded programs such as Medi-Cal.

Despite the settlement, Kaiser said in a statement it continues to dispute some of the claims included in the lawsuit.

“In certain relatively rare cases, Kaiser Permanente members entered a specialized type of locked mental health facility that often preferred Medi-Cal coverage to private insurance,” Kaiser Vice President of Communications John Nelson said in an emailed statement. “In some of these cases, cancellation of Kaiser Permanente coverage was required to enter the facility. However, this was not Kaiser Permanente’s requirement, and we cover many members’ care at such facilities. Any decision to cancel coverage was made by a court-appointed conservator.”

The info is here.

Wednesday, January 17, 2018

Do Physicians Have an Ethical Duty to Repair Relationships with So-Called “Difficult” Patients?

Micah Johnson
AMA Journal of Ethics. April 2017, Volume 19, Number 4: 323-331.
doi: 10.1001/journalofethics.2017.19.04.ecas1-1704.

Abstract

This essay argues that physicians hold primary ethical responsibility for repairing damaged patient-physician relationships. The first section establishes that the patient-physician relationship has an important influence on patient health and argues that physicians’ duty to treat should be understood as including a responsibility to repair broken relationships, regardless of which party was “responsible” for the initial tension. The second section argues that the person with more power to repair the relationship also has more responsibility to do so and considers the moral psychology of pain as foundational to conceiving the patient in this case as especially vulnerable and disempowered. The essay concludes with suggestions for clinicians to act on the idea that a healthy patient-physician relationship ought to lie at the center of medicine’s moral mission.

The article is here.

Wednesday, January 21, 2015

Laws that Conflict with the Ethics of Medicine: What Should Doctors Do?

By Dena S. Davis and Eric Kodish
Hastings Center Report 44, no. 6 (2014): 11-14.
DOI: 10.1002/hast.382

Here is an excerpt:

Medical ethics has always asked doctors to put their patients first, even at some risk to themselves. “Medicine is, at its center, a moral enterprise grounded in a covenant of trust,” writes Christine Cassell. “This covenant obliges physicians to be competent and to use their competence in the patient's best interests. Physicians, therefore, are both intellectually and morally obliged to act as advocates for the sick wherever their welfare is threatened and for their health at all times.”[19] Physicians are expected to care for patients with infectious diseases, even at risk of their own health. Physicians are expected to do some pro bono work, to take on some patients who are not financial assets, and so on. Physicians should be advocates for the health of all people, above and beyond even their own patients. The AAP is “dedicated to the health of all children.”[20] The imperative to act on this ethical norm clearly suggests that physicians should challenge these types of laws. On rare occasions, individual doctors may be ethically justified in disobeying or breaking the law.

The entire article is here.

Friday, November 28, 2014

Therapist and Patient Share a Theater of Hurt

By Corey Kilgannon
The New York Times
Originally published November 5, 2014

Here is an excerpt:

Dr. Dintino said that her behavioral approach to Ms. Powell’s condition allows for a more personal relationship with the patient than conventional psychotherapy, and for looser guidelines when it comes to patient-therapist relations.

Ms. Powell was willing to bare all as a patient, and both women felt the risks were outweighed by the potential therapeutic value, as well as the attention that the show could bring to the disorder.

As for the notion that the decision constitutes a breach of ethics, Dr. Landy said, “With certain forms of mental illness that do not respond to conventional treatment, we need a more radical approach, which therapeutic theater can provide.”

The entire article is here.

Wednesday, July 4, 2012

The Fiduciary Heart of Ethics


By Ed Zuckerman, PhD


We have all heard the word “fiduciary”bandied about during the ongoing mortgage and banking crisis and probably thought it meant something about money. Not true.

In your first day in professional school, when they talked about the helping relationship, you were probably told something like, always put your client’s needs ahead of your own. As soon as you nodded to that you became a fiduciary.

The fiduciary duty then is an obligation to act in the best interests of another party. In any relationship it is imposed upon the stronger (more knowledgeable, richer, smarter, whatever) as a duty to the weaker. Stealing candy from a baby is a breach of this duty and so is insider trading–using non-public information gained because of one’s special position to buy stock for a gain not available to the public. In one sense being a good parent is fulfilling a fiduciary obligation to a child - doing what is in the child’s best long-term interest instead of what is convenient for the parent. 

However, stockbrokers only have to offer what is suitable - likely to be beneficial -  to the client. They do not have to offer what might be in the clients best interest or what is less profitable for the broker. Similarly, and closer to therapy relationships, a lawyer cannot represent both plaintiff and defendant in a dispute - the lawyer cannot act for two principals and be loyal to both.

A “fiduciary is, in law, a person who is obliged to discharge faithfully a responsibility of trust toward another. Among the common fiduciary relationships are guardian to ward, parent to child, lawyer to client, corporate director to corporation, trustee to trust, and business partner to business partner.” 
The Columbia Electronic Encyclopedia Copyright © 2004.

And psychologist to client. A cornerstone of counseling is the moral principle of trust, the client’s belief that the clinician will be honest and tell the whole truth, will not conceal any important relevant information, and will maintain the confidentiality of what is entrusted to the clinician. Underlying all of these is the principle of fiduciary responsibility - to not take advantage of the client for the benefit of the clinician. Although it may not always be apparent, concealing some facts, inadequate documentation, or breaching confidentiality would only be done for some advantage to the clinician. The promise of non-exploitation provides the safety to reveal and explore thoughts, feelings, history, plans or anything else which would have to be concealed out of fear of the consequences to the client.

“In a fiduciary relation one person justifiably reposes confidence, good faith, reliance and trust in another whose aid, advice or protection is sought in some matter. In such a relation good conscience requires one to act at all times for the sole benefit and interests of another, with loyalty to those interests.” Wikipedia, accessed December 17, 2009.

Respect and autonomy

While such efforts are legally and ethically imposed they also can be empowering of the client and clinically useful in the therapy.

The fiduciary principle expands the principles of respect and trustworthiness in specific and helpfully guiding ways. It recognizes the multiple differences between the parties and extends that knowledge into ethical rules. The fiduciary duty requires one to explore, identify and recognize differences. It requires one to weigh and to adapt to these differences; to respect and dignify them. 

With respect for the other comes trust by the other in our loyalty to them. The enactment of such trust can be seen in at least  two relevant and related ethical responsibilities placed on clinicians: 
to ensure fully informed consent about all aspects of the therapeutic relationship both initially and as the relationship evolves and is extended, and 
to make every necessary effort to ensure and protect the privacy of the patient’s information.  

Multiple relationships

We have an ethical obligation to avoid harmful multiple relationships. But why? 

First, because each role has obligations and expectations and these may be in conflict. Multiple roles require choices of actions and the therapist might choose to meet his or her needs or wants before the needs of the client or just be seen by the client as putting his or her needs first. Simply put, a fiduciary may not and does not have a conflict of interests. 

A second element is that by foregoing any relationship other than client to therapist we absolutely prevent even accidental breaches of confidentiality. If we are not members of the client’s work setting or deal with relatives of the client we cannot even accidentally reveal information vouchsafed to us with the expectation of confidentiality (that we will not share it with another).

Among our responses can be a withdrawal from one role or the seeking of informed consent to allow limited role overlap. For example, we can inform about the ways a friendship would conflict with therapy and ask for consent to forego the friendship’s benefits. If we fail to resolve he conflicted interests we will breach our fiduciary duty and thus be open to both accusations of ethical failure and the possibilities of malpractice suits. 

In our work, preserving privacy, respecting differences, and supporting autonomy are aspects of our fiduciary duty. Carrying out this duty consistently and thoroughly - professionally - enables us to deserve the trust of those who seek our help.

Appreciation to Sam Knapp for his helpful comments.
December 17, 2009 and June 26, 2012.