Vignette 36: The Cancellation Conundrum

Dr. Wendy Malik operates an independent practice in a suburban area.  She receives a referral from a physician, with whom she has a positive working relationship.  Dr. Malik contacts the patient, completes a phone screening, and sets up an appointment with Mr. Larry David.

As is her practice, Dr. Malik sends a confirmation email, attaching her version of informed consent.  She instructs Mr. David that he does not have to print it out, only review it and they would discuss any questions at the initial appointment.

Several days later, Dr. Malik checks her email.  In it, Mr. David sent her an email with an attachment.  Mr. David asks Dr. Malik to review his edits on the informed consent document.

While Dr. Malik notes some suggested corrections on the document, Mr. David modified the cancellation policy.  Dr. Malik’s form (and standard policy) is appointments cancelled with less than 24-hour notice will be charged to the patient.  Mr. David added a sentence that if Dr. Malik cancels an appointment with less than 24 hours, Mr. David expects Dr. Malik to pay him an amount equal to her hourly rate.

Flustered by this edit, Dr. Malik contacts you for a consultation.

What are the ethical issues involved in this case?

What are the pertinent clinical issues in this case?

How would you help Dr. Malik work through these issues?

Would you recommend Dr. Malik call to address the issue ahead of the appointment or wait for the initial session?

At this point, must Dr. Malik keep Mr. David as a patient?

If not, does Dr. Malik need to contact her referral source about the issue?

Vignette 30: The Purloined Patient

Dr. Eddy Kessler received a referral from the Office of Vocational Rehabilitation (OVR) to work therapeutically with Enoch Thompson, who suffers with symptoms of a panic disorder.  Dr. Kessler accepted the referral and started to work with Mr. Thompson on his symptoms of panic and anxiety, as these have interfered with Mr. Thompson’s ability to maintain employment.  Treatment started well, with Mr. Thompson developing better cognitive and behavioral skills to manage his anxiety after the initial eight sessions funded by OVR.  With Mr. Thompson’s consent, Dr. Kessler sent a letter to OVR requesting 10 more sessions over the next five months to reinforce the gains made in treatment.  Dr. Kessler viewed Mr. Thompson as moving toward stable employment with ongoing treatment.  As Mr. Thompson was improving, they agreed to meet in two weeks.

Upon his return two weeks later, Mr. Thompson informed Dr. Kessler that he was recently evaluated by his wife’s psychologist, Dr. Gillian Darmody.  As the patient described it, Mr. Thompson took his wife to her therapy session.  Dr. Darmody asked him to join the session.  The outcome of the session was that Dr. Darmody would be able to get Mr. Thompson on Social Security Disability as she “knows how to write psychological reports” in a way that almost guarantees a favorable disability decision.  She also gave him the name of an attorney to represent him.  He also felt positive about the experience as Dr. Darmody agreed to bill his health insurance for the disability evaluation.  He has a meeting scheduled with the attorney in two weeks.  Mr. Thompson also believes that the consultation with the attorney is free, and that the attorney is paid after disability benefits are awarded.

Dr. Kessler inquired as to why he agreed to the disability evaluation if OVR is trying to return him to work.  Mr. Thompson disclosed that the job market is tough, so he wanted a backup plan in case he gets better and cannot find work.  Mr. Thompson stated he disclosed their treatment relationship.  However, Dr. Darmody deemed their treatment relationship to be inconsequential to the disability evaluation.  The session then focused on Mr. Thompson’s ability to manage anxiety via psychological skills.  Dr. Kessler manages his anger sufficiently to get through the session and scheduled Mr. Thompson in two weeks.

After the session, Dr. Kessler phones you for a consultation.  Dr. Kessler is morally outraged at the other psychologist’s behavior, if true.

What are the possible legal and ethical issues involved in this case?

How would you respond to Dr. Kessler’s moral outrage?

How would you explain the issues to Mr. Thompson?

Are these reasons to terminate your treatment with Mr. Thompson?

If you would continue to work with Mr. Thompson would you change your goals?

How would you document this report from Mr. Thompson in your case notes?

Would you withdraw your request for more sessions from OVR?

What are Dr. Kessler’s options?

If you were Dr. Kessler, what would you do and why?

Vignette: 29: A Blog Attack

Psychologist Dr. Shermer learns from a colleague that she has been described in very unfavorable terms in a blog posted by an individual who publicly identifies herself as a patient of Dr. Shermer.

Dr. Shermer reviews the blog information.  The author is likely not a current patient.

The blogger insults Dr. Shermer’s appearance, her style of dress, and her office.  In essence, the blogger combines factual and inaccurate information into a well-formed, yet highly erroneous, description about Dr. Shermer’s role in the community and in the legal system.

There are many descriptions of Dr. Shermer that are blatantly false or misleading. Some of the falsehoods on the blog would be serious violations of the Ethics Code.

Upon reviewing the charts of several possible candidates as the offensive blogger, Dr. Shermer believes the blogger to be someone she evaluated in the past for a national security position.  The likely blogger can be emotionally labile and frequently feels a victim of “the system.” Dr. Shermer indicated a number of pathological characteristics in the report.  Dr. Shermer does not make the determination for the security clearance, but serves as a consultant for the government agency.

Dr. Shermer has a presence on social media and fears how her online reputation may be adversely affected by these ongoing blog posts.  She also fears that if she draws too much attention to the blog, then the blogger will gain greater traction.

Dr. Shermer fears the risk that the information could go to a licensing board and result in an investigation.  Although completely unwarranted, an investigation would add unnecessary stress in her life.  There is also a risk that her reputation could be ruined if the former client’s blog posts gain a larger following.

The psychologist wonders how she can take proactive action.

Dr. Shermer considers hiring an attorney.

Dr. Shermer also considers hiring an online reputation management company.

Dr. Shermer calls you for a consultation.  What are some recommendations that you would make to Dr. Shermer?

How would you feel if you were Dr. Shermer?

Vignette 26: A Political Donation

Dr. Fair performs child custody evaluations.  She is well known in both the legal and psychological communities.  Recently, Dr. Fair received solicitations for contributions from a candidate for judge in her county, Deloris True.  She has worked with Attorney True on numerous occasions and believes that she would be a real asset as a judge in her community.  She clearly wants this individual to be elected as a judge.

However, if Attorney True is elected as judge, Dr. Fair will likely appear before her in court as an expert witness. Will contributing to the campaign of the judicial candidate be contraindicated because it could lead to a perception of bias in future court cases?  Is the contribution warranted because Dr. Fair believes that Attorney True is highly qualified for that position?

In her state, political contributions over $50 are in the public domain and anyone could see that Dr. Fair made the contribution.  Dr. Fair would like to show her financial support by contributing more than $50.  (Dr. Fair has already ruled out giving 10 checks for $49.95.).  Concerned about ethics and reputation, Dr. Fair contacts you for a consult.

What are the potential ethical issues involved in the situation?

What are the competing ethical principles?

What are your suggestions for Dr. Fair?

Vignette 23: A Simple Request

Dr. Smith was treating Mrs. Drapier for depression precipitated, in part, by a separation and pending divorce. There were contentious issues dealing with the custody arrangements of the children. A court appointed custody evaluator performed a child custody evaluation. Among other things, the report contained a psychological evaluation of the patient.

Mrs. Drapier thought it would be good for Dr. Smith to review the report in order to help him with their therapy.  Mrs. Drapier read the report and admitted that she did not understand some of the psychological jargon used in the report and had difficulty understanding what the conclusions of the report were.

Dr. Smith decided to review the report.  He believed that the custody evaluator had made several significant errors in the report concerning the psychological health of his patient.  Additionally, Dr. Smith believed that some of the conclusions were in error, and had little support for those opinions in the body of the report.

Prior to their next session, Dr. Smith calls you for a consultation. 

Dr. Smith asked if he needed to inform the patient of his impressions of the report and the seemingly erroneous conclusions.  He feels stuck between being faithful to the patient and her needs without crossing a boundary as a treating psychologist.

He also wondered if he should contact the patient’s lawyer, with her permission, to disclose his perceptions about the quality of the report and his perceptions about the conclusions.

Dr. Smith also wondered if it was appropriate to bill Mrs. Drapier for his time in reviewing the report.

Dr. Smith also asked if it is ethical to bill the patient’s insurance company to review his impressions of a forensic report during a psychotherapy session. 

Vignette 22: A Duty to Report?

Dr. Tell worked with a woman for several months on issues related to depression, anxiety, and relationship issues. During one session, the patient indicated that her boyfriend has lost interest in sex and became more involved with online pornography. While discussing these issues, the patient suddenly stopped talking. Dr. Tell allowed several moments to pass before asking the patient what was happening. 

The client indicated that she was hesitant to speak about the issue for fear of a breach of confidentiality. Dr. Tell reminded her about confidentiality and the laws in Pennsylvania that would override it. The client continued to struggle. She eventually blurted out that, during a heated discussion, her boyfriend indicated that looking at online pornography was not as bad as what his uncle did. She went on to detail how her boyfriend described how his uncle was involved in collecting and distributing child pornography but remained faithful to his aunt. The client's boyfriend expressed that she should never discuss this with anyone. The client asked if she could just give Dr. Tell the information about the uncle so that she could report it to the authorities and leave her out of the situation. The client is feeling very helpless and vulnerable about this bind. 

Dr. Tell explained that the alleged perpetrator was several times removed from their sessions and she did not believe that she had the obligation to report it. The client then asked if she could invite her boyfriend to the next session so that they could all discuss the information and the best way to handle the situation. 
 

Dr. Tell focused the client on her dilemma as well as the relationship issues with her boyfriend. Dr. Tell agreed to contact someone to discuss whether Dr. Tell had to report this information to the police or Child Protective Services. And, Dr. Tell agreed to determine whether or not reporting this information would put her client’s confidentiality at risk. She also agreed to think about the need to bring in the boyfriend, because inviting him to therapy will not necessarily help the situation.

  

Dr. Tell contacts you with the above scenario.
 

1. How would you feel if you were Dr. Tell?
 

2. How would you feel if you were the consultant?

3. Is Dr. Tell a mandated reporter in this situation?

4. As a mandated reporter, would Dr. Tell report place her client's confidentiality be at risk?
 

5. If Dr. Tell is not a mandated reporter, should Dr. Tell bring in the boyfriend gather more facts so that Dr. Tell can report the alleged crime?
 

6. Is the goal of therapy to help the client manage the situation or is the responsibility now on the psychologist to gather more information about the possible crimes committed with children?
 

7. Can the client contact Child Protective Services anonymously in this case?

8. Can the psychologist contact Child Protective Services anonymously, provided that the client supply the name and address of the uncle?

9.What should the psychologist do?

Vignette 21: A Phone Call from a Friend

Dr. Goodfriend receives a call from Buddy, his very close high school friend. Dr. Goodfriend speaks with Buddy about once every six to nine months. During those calls, the conversations typically focus on careers, family members, and the whereabouts about other classmates.

Buddy phoned Dr. Goodfriend in an apparent emotional anguish by the tone of his voice.  Buddy states that he has been feeling "stressed" over the last month. He explains that he recently lost his job and has been worrying about the financial impact that this is having on his family. Buddy adds that he has had trouble sleeping, has stopped exercising, has little energy, and fleeting thoughts of hurting himself.  Buddy also shares that he has been short tempered with his wife and kids.

During the 90-minute call, Dr. Goodfriend tries to be a good listener, empathizes with Buddy's difficult situation, offers advice on ways that Buddy can better manage his stress, provides him with general encouragement, and suggests a book that outlines stress management and anxiety reduction strategies.

At the end of the call, Buddy tells Dr. Goodfriend that he is feeling much better. Just as he is about to hang up, Buddy says, "Thanks. My wife told me that I should see a therapist but I told her that I could talk with you and that it would be much cheaper."

Dr. Goodfriend is unclear whether Buddy is serious or joking.

If you were Dr. Goodfriend, how do you feel about the phone call?

Does Dr. Goodfriend need to phone his high school friend to clarify his last comment?

Does Dr. Goodfriend need to encourage Buddy to become involved in therapy if symptoms persist?

Should Dr. Goodfriend call Buddy and offer a few referrals?

What factors influence this decision?

Vignette 20: Has the Psychologist Done too Much?

Dr. Plenty lives and practices psychology in a rural area.  She began to provide psychotherapy to Mr. DiMencha, a 52-year-old, who suffered with depression.  After six sessions, Mr. DiMencha suffered a significant concussion while at work.  His impairment is noticeable by Dr. Plenty without any type of testing.  He struggles with understanding concepts and becomes tangential during the next two sessions.

Mr. DiMencha’s co-worker, Janet, helped him find an attorney so that his rights are protected.  Dr. Plenty had Mr. DiMencha sign a release to talk with the attorney as well as Janet.  From a phone call with the attorney, Workers Compensation wants to work out a settlement. However, the attorney has little awareness about how impaired Mr. DiMencha is.  The patient has never met the attorney face-to-face, just by email and phone contacts.

Mr. DiMencha demonstrates a variety of cognitive deficits.  He needs assistance and monitoring with daily tasks, such as home care, shopping, transportation, understanding the settlement process, reading his mail, and paying his bills. He will likely need to go into an assisted living facility. His family lives at a distance and provides minimal help. Workers Compensation refuses to pay for the case management services of an independent social worker. Attempts to find social service agencies able to help him have not been successful. Mr. DiMencha doesn't appear to understand his legal rights or the settlement process.

Prior to providing extra-therapy support, Dr. Plenty had Mr. DiMencha sign a document explaining her fees for the additional services.  She is not sure that he completely understands what is happening or her version of informed consent for the additional services.  The psychologist has been doing much of the case management work, e.g. locating a long-time friend who is willing to help him at home, referring him to a neuropsychologist for testing, engaging in lengthy discussions with his primary care physician and neurologist, participating in multiple conversations with the attorney, and trying to find a guardian or power of attorney.

In the midst of all of this activity, the psychologist contacts you for an ethics consultation.

What are the potential ethical issues with this case?

What are the competing ethical principles?

Is Dr. Plenty acting beyond the limits of her competency?

Is she practicing outside of her scope of her license?

What problems may occur as a function of Dr. Plenty engaging in a multiple relationship role in Mr. DiMencha’s care?

What suggestions would you make to Dr. Plenty?

Dilemma 18: Co-authorship with a Former Patient

Dr. Jordan is a psychologist who typically works with a wide variety of patients.  At the end of the day, he listens to voicemail messages to learn that a former patient is reaching out to him for a request. 

Prior to returning the call, Dr. Jordan reviews the patient’s chart.  The patient had been in treatment for about 10 months on a weekly basis.  The treatment notes indicate that she dropped out of therapy about one year ago.  She stopped therapy because her insurance changed and Dr. Jordan was not an in-network provider.  The therapy focused on depression and anxiety related to work-related issues, interpersonal limitations, and relationship difficulties.  Some of the sessions focused on a sexually abusive relationship between a basketball coach and the patient when she was age 13 to 16.    

Dr. Jordan returns the phone call.  After the initial greetings, the former patient indicates that she has finally started to write down more thoughts, memories, and recollections about her abusive experiences.  She stated that Dr. Jordan recommended that she write down her memories.  She recalled that he agreed that it could make a good book.  She stated she wanted to include some education around sexual abuse and tell her story in a healthy, therapeutic manner.

When attempting to clarify the request, the former patient is not asking to return to therapy, but to have Dr. Jordan become the co-author or a consultant for the book.  Dr. Jordan thanked her for the compliment and indicated that he needed to think about the request.  He promised to call her back within a week.

Dr. Jordan calls you on the phone for an ethics consultation.

What are the ethical issues involved in this case?

What are some possible suggestions for Dr. Jordan?

If you were Dr. Jordan, how would you feel about this request?

Vignette 16: Money Matters

A psychologist receives a call from an attorney wishing to seek services for depression, anxiety and substance abuse.  The psychologist screens the potential patient and she believes that she can help him.  When she asks about insurance, he indicates that he will use cash payments.  The psychologist explains the fee structure for the initial appointment as well as ongoing psychotherapy sessions.  The lawyer-patient comments that this seems low.  The psychologist ignores the comment and finishes by setting their initial appointment.

The psychologist and the attorney-patient meet for the initial session.  At the end of the session, the psychologist asks for the requisite fee as stated on the phone.  The attorney-patient indicates that he earns about 2.5 times what the psychologist asked.  He indicates that, in order for him to benefit from the treatment, he feels a need to pay what he makes an hour.  He also states that if she does not accept what he is offering, he will lose respect for her as a professional and probably not return for treatment.

Not knowing what to do, the psychologist takes the cash and sets up another appointment.  At the end of the day, the psychologist reflects on the interaction between she and her new lawyer-patient.  She does not feel right taking a fee larger than her usual and customary rate.  She is struggling that the situation is not right and feels very uneasy about the arrangement that the lawyer-patient foisted upon her.

Uncertain, she calls you for an ethics consultation.

What are the ethical issues, if any, involved in this case?

What would be your emotional response to this situation?

What factors make this situation potentially difficult for you as a psychologist?

What factors make this situation potentially easy for you as a psychologist?

What do you believe is the best course of action?

Vignette 10: Multiple Relationships Revealed

A female psychologist works with a male patient for about one year in a suburban area.  They agreed to meet weekly for the first four months of psychotherapy, and then they agreed to meet twice per month.  They developed a good therapeutic alliance.  During the course of their work, he discussed significant facts about his troubled past, numerous details about failed past relationships, and sexual fantasies.  The main therapeutic issues are depression and loneliness.

During the current session, the patient related having made a new female friend.  As social isolation, loneliness and depression are regular themes in treatment; the psychologist frames this as positive progress.

As the conversation continues, the psychologist is surprised to learn that the patient’s new friend is the ex-wife of the psychologist’s husband.  The patient reveals that he became aware of that information after several dates and recently felt comfortable revealing this to the psychologist.  He also indicated that the relationship is taking on a more serious tone.

The ex-wife moved back to the area about six months ago.  The psychologist knows that the ex-wife had been struggling with isolation and loneliness as well.  The psychologist, her husband, and his ex-wife are on good terms.  They see her regularly for informal family events and do holidays together with their adult children and grandchildren.

After the session is over, the psychologist has time to reflect on her concerns.  The psychologist feels stuck and overwhelmed by her present situation.  She calls you for an ethics consult.

What are the ethical issues involved?

What would you suggest that she does?

With whom does the psychologist discuss the multiple roles? 

With only the patient?

With the patient and the ex-wife?

With her husband, the patient and the ex-wife?

Can the psychologist continue the treatment relationship with the patient?

Even if they terminate therapy, how does the psychologist cope with family gatherings since she knows significant details about her patient’s life?

Dilemma 8: A Session with the Spouse

Dr. Faye Miller receives a referral for a 35-year-old female, Betty Drapier, who is both feeling depressed and experiencing marital problems.  During the first few sessions, Mrs. Drapier indicates that her husband, Don, is depressed and in treatment.  Part of her struggle is that she sees her husband as more depressed now than when he started treatment.  By Mrs. Drapier’s report, he appears more stressed because of his job and drinking alcohol more frequently.  She reports that his treating psychologist, Dr. Cooper, is working with her husband and has allegedly advised him to discontinue his medication in favor of an herbal remedy (St. John’s Wort).  Dr. Miller suggests that she meet with both Mr. and Mrs. Drapier to evaluate the marital situation.

At that time, Dr. Miller not only wanted to evaluate the marriage, but to evaluate how impaired the husband was, and Mrs. Drapier’s ability to assess her husband and the marriage accurately.

During the next session, Mr. and Mrs. Drapier arrive separately, but on time.  Mr. Drapier acknowledges many cognitive, behavioral, and physical symptoms of serious depression.  Mr. Drapier smelled as if he had been drinking.  Mr. Drapier also admits that his alcohol use has increased.  He also divulged that his risk-taking behavior has increased as well, such as speeding. During the session, Mr. Drapier verbalized suicidal ideation in a flip manner (“Sometimes I think it would be better if I just killed myself”).  The marital situation appears deteriorated and Mr. Drapier appears significantly depressed. 

As the session winds down, Mr. Drapier spontaneously asks for a second opinion about his treatment with Dr. Cooper.  He indicated that Dr. Cooper recommended that he discontinue a psychotropic medication in favor of an herbal remedy.  Mr. Drapier mentions that Dr. Cooper sells St. John’s Wort to him directly.

After reiterating the purpose of the session (which was to assess the marital situation and not to assess his current treatment), Dr. Miller states that she feels uncomfortable with the request, although she is concerned about the psychologist’s reported behavior. She is also concerned about Mr. Drapier’s level of depression, alcohol use, and suicidal statement.

Abruptly, Mr. Drapier looks at his watch and leaves the office explaining that he is late for a business meeting.

What are Dr. Miller's potential ethical issues in this situation?

What are some actions that you, as the treating psychologist, may have done differently?

If you were Dr. Miller, what are your emotional reactions to this situation?

What obligations does the psychologist have to Mr. Drapier, Mrs. Drapier, Dr. Cooper, and the public?

Dilemma 7: An Invitation to Assess

You are checking your email after a busy day. The following email catches your attention.


==================================
From: PsychBuilder – High Tech Psychology at Low Cost
Sent: Monday, November 10, 2011 6:37 PM
Subject: Online Assessment Tool to Promote your Practice

Dear Psychologist,

My name is Dr. Rob West, President and CEO of PsychBuilder Inc. located in San Jose, California. My company has developed a unique opportunity for you and your associates. PsychBuilder Inc. developed the first internet-based administration and scoring of the Personality Assessment Symptom Scale-2, the PASS-2. Psychologists have used the PASS-2 for psychological diagnoses and evaluations for a number of years. The PASS-2 is administered online, from any computer, iPad, or iPhone connected to the internet. The test usually takes approximately 40 to 60 minutes to administer. Results will be available to you and the patient online.

Important to an entrepreneurial psychologist like you, this assessment bridges the gap between psychology and primary care. Numerous patients from family practice offices can be given the internet link (http://www.psychbuilder.org/) and a security code to complete the PASS-2. The test is designed to determine if the patient can benefit from psychotherapy, psychotropic agents, or other psychological services. While it is not a complete assessment, it can guide patients to you for further psychological consultation.

After a patient completes the assessment, an email will be sent to you (based on the security code) and the patient within 24 hours, providing a secure link to review the results of the PASS-2. Patient contact information will be part of the administration process.

The cost of the online administration is $25, to be paid by the patient. For this to be a successful venture, we ask you to promote this program to your referring physicians, nurse practitioners, and physician assistants in order to enhance their ability to identify, evaluate and provide needed treatment for their patients.

We have great data on the PASS-2 for reliability and validity in identifying primary care patients who can benefit from psychological services. Unfortunately, many patients struggling with mental health issues in primary care settings are not properly identified or treated.

Because of busy primary care practices, the PASS-2 can be completed at home, if the office does not have internet access for patient use.

The physician, nurse practitioner, or physician’s assistant will offer patients this important opportunity via a specially designed 4 x 6 card. On that card, there will be information that explains the importance of completing this assessment, the cost, and that a licensed psychologist will review the results and contact the patient by phone within 3 to 5 business days.

An important factor is that there is no cost to you, as the psychologist. You will receive a high quality report that offers diagnostic possibilities, suicide potential, and treatment planning options for new patients.

I encourage you to review our web site at http://www.psychbuilder.com/. If you have further questions, feel free to contact me.

Sincerely,


Robert West, PhD, ABPP
Psychologist

========================================

What are potential ethical issues with this invitation?


What clinical concerns arise for you in this scenario?


What should you do with this email solicitation?


What would you likely do with this email solicitation?

Using Vignettes: A Canadian Perspective

Canadian Psychology recently published an article about using vignettes as a teaching tool.  This article is helpful for those use ethics vignettes.  Below, there is the first and last page of the article to provide some sense of what the article covers.

Can Psych Vignettes

Vignette 4: A Psychologist in Turmoil

You have been treating a fellow licensed psychologist for several months. He presents himself as having a dissociative identity disorder. Although his condition has been deteriorating he continues to maintain a private practice and one of his egos reports that he has been flirting with several of his female patients.

What are possible emotional reactions would you have in this situation?

What would be your best options for this scenario?

To add some additional detail, you live in Pennsylvania where the reporting requirement for impaired professionals does not apply to patients you see in treatment. Therefore, you, the treating psychologist, are not required to report your patient to the licensing board.

Vignette 2: A Suffering Caregiver

A colleague of yours, Dr. Solomon, contacts you for advice regarding a new client she has just seen. The client, Mr. Don Tellanyone, is a 47-year-old man who is seeking services for depression. During the initial phone contact, he asked repeatedly about privacy and wanted assurances that information discussed in session was confidential. The patient repeated this line of questioning during the first face-to-face session.

As the session progressed, he revealed that the source of his depression was the death of his mother one year ago. His mother had suffered from a combination of severe respiratory problems and Alzheimer’s. Mr. Tellanyone had been caring for her and his father in his home for 6 years prior to her death.  During the last two years, she required total care. He revealed that she had been suffering greatly and, out of compassion for her, he gave her an excess dose of her sleeping and pain pills. Medical personnel never questioned the death as the woman had been quite sick and “It was only a matter of time.”

Mr. Tellanyone goes on to explain that he is now caring for his father in similar circumstances, although there is no dementia. His father has declined rapidly since the death of his wife and now requires total care. Mr. Tellanyone reveals that recently he had a conversation with his father in which the father commented how peaceful his wife’s death was and how he hoped for a similar passing.

Mr. Tellanyone is feeling quite guilty about his mother.  Simultaneously, he strongly believes he made the right decision. He would like help to work through the issues. He is also very concerned about confidentiality and wants assurances from Dr. Solomon.

Dr. Solomon, feeling uncomfortable with the situation, contacts you for a consultation about the potential ethical issues for this case.

What are the potential ethical issues in this case?

What would you advise?