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

Monday, October 31, 2011

Ethics, Diversity, and Multiculturalism

Samuel Knapp, Ed.D., ABPP
Director of Professional Affairs

Recent years have seen an emphasis on multiculturalism and diversity issues within psychology* both by addressing the ability of professional psychologists to serve the health care needs of cultural minorities, and by increasing the number of psychologists from ethnically diverse backgrounds. The two strategies may be synergistic. For example, graduate programs with a critical mass of diverse students may find that the minority students will teach (even if informally) the European American students to become more culturally competent.

This movement has a foundation in the underlying ethical foundations of our profession. Sometimes psychologists use the word ethics to refer to the minimal standards of conduct that apply to all psychologists and that could be the basis of a disciplinary action by a licensing board or malpractice suit. The enforceable Standards of the APA Ethics Code specifically state that psychologists should not discriminate unfairly (Standard 3.01, Unfair Discrimination) nor harass (Standard 3.03, Harassment) based on age, gender, gender identity, sexual orientation, race, culture, national origin, language, religion, disability, or socioeconomic status. In addition, psychologists should ensure that they are competent when working with diverse populations (Standard 2.01b, Competence); ensure that they use tests Awhose validity and reliability have been established for use with members of the population tested@ (9.02b, Assessments); interpret tests with consideration of linguistic and cultural differences (Standard 9.06); and ensure that consent is obtained when using interpreters (9.03c).

Ethics also refers to the General or Aspirational Principles that follow the Preamble in the APA Ethics Code. Unlike the enforceable Standards, which can be the basis for a disciplinary complaint against a psychologist, the General Principles are guides for psychologists on how to excel in their professional roles. They can also inform the ethical decision making process. The General Principles state, among other things, that psychologists Aare aware of and respect cultural, individual, and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origins, religion, sexual orientation, language, and socioeconomic status.@ (Principle E, Respect for People=s Rights and Dignity).

Finally, ethics refers to personal overarching moral perspectives derived from philosophical or religious instruction or study which inform our day-to-day behavior. The enforceable Standards, General (Aspirational) Principles, and personal sense of morality can overlap considerably. For example, a psychologist who has a personal moral perspective, perhaps based on religious instruction, who believes in the universality of human rights and dignity, would easily see that reflected in General Principle E, and operationalized in the directive to avoid unfair discrimination or harassment of individuals based on incidental demographic factors.

Few psychologists end up being disciplined specifically for violating enforceable ethical standards related to diversity or multiculturalism. In that sense, diversity and multiculturalism have only a small overlap with ethics. However, many psychologists struggle over how to implement the General (Aspirational) principles and their personal sense of morality when providing professional services to diverse populations. In that sense, diversity and multiculturalism are deeply intertwined with ethics.

The emphasis on a diverse or multicultural perspective appears to rest primarily on two overarching ethical principles. First, diversity or multiculturalism is justified on the basis of justice, in that it helps ensure a more equal access to quality psychological services to persons from traditionally marginalized groups who otherwise would not find them available.

Also, diversity and multiculturalism are justified on the basis of beneficence and nonmaleficence in that psychologists with a diverse or multicultural perspective will do better at treating patients and will reduce the likelihood that they will harm patients. Although many authors have argued that a diverse or multicultural perspective will improve outcomes, this relationship was verified by the meta-analysis of Griner and Smith (2006) who found that interventions targeted to specific cultural groups were more effective than generic interventions provided to heterogeneous groups. AOverall, culturally adapted interventions resulted in significant client improvement across a variety of conditions and outcome measures@ (p. 541). In other words, psychologists should be able to upgrade the quality of their services to multicultural patients by accommodating multicultural perspectives into their treatment.

Striving for excellence requires more than just good intentions; it requires a conscientious effort at self-reflection and training. For example, consider the experience of one psychologist supervisor who was trying very conscientiously to develop a supervisory relationship based on her deeply held moral values of trust and empowerment. This supervisor was very committed to feminist ideas of equality and power sharing. She told her internship students that they should feel free to challenge her during supervision. For some students this was very empowering and helped them to become more comfortable in sharing their thoughts openly. For another student, the comment created anxiety because it is normative in her Asian culture to show great respect for hierarchy and not to challenge authority directly. Fortunately, the student was able to receive advice on how to approach her supervisor about this issue.

Here is another example from my personal experience. About 30 years ago I temporarily worked in an urban mental health clinic after working in very rural mental health centers for several years where I commonly introduced myself to my adult patients by my first name and used their first names as well. However, when I took a job in an urban inner city mental health clinic, in my effort to be egalitarian, I continued to introduce myself to my adult patients, who were mostly African American, by my first name and used their first names as well. However, an African American social worker explained to me that African American males are used to being called by their first names by all Whites, regardless of their age or status. It would be more respectful, she explained, if I called them by their surname and later asked permission to use their first name. Therefore, I became aware of a personal blind spot. I learned that my greeting style, which appeared appropriate and egalitarian in rural Pennsylvania, came across quite differently with inner city African American patients.

Or consider this last example: A psychologist sometimes worked with Spanish-surnamed patients and was always careful to ensure that they were comfortable using English (or getting an interpreter if they were not). One patient with a Spanish surname reported that she felt comfortable conducting psychotherapy in English. She related a background of substantial trauma and strife, but did so in a detached manner. However, research shows that the affect associated with a traumatic event can be captured more intensely through the use of the patient's primary language at the time that the trauma occurred. Relating the trauma in a language that was learned subsequently does not evoke the intensity of feeling or vividness of imagery as it would if the patient had used the original language. A psychologist who was not aware of this fact might miss the emotional significance of certain past events.

These are just a sample of the issues that can arise and where a knowledge of cultural or diversity factors can improve relationships and outcomes. Many questions arise, such as how can psychologists evaluate the functioning in a diverse family without unfairly pathologizing culturally normative relationships (e.g., averting eyes in some cultures is not a sign of shyness, but a normative sign of respect)? What teaching technique can help psychologists become more alert to their blind spots (e.g., well meaning people may have implicit prejudices outside of their conscious awareness; Knapp, 2007)? How should psychologists respond when patients make racist, homophobic, or sexist remarks? How, or can, English speakers supervise trainees who treat patients where English is not a primary language? How does diversity inform effective practice? When or how to incorporate folk healing remedies or strategies into therapy? How to accurately evaluate refugees in light of stressful or traumatic experiences that they may have encountered? How to respond when patients’ religious beliefs appear to harm their functioning or adjustment? Continued reflection, dialogue, and training will help conscientious psychologists address these issues, and help them to fulfill their aspirations to be just and helpful health care professionals.


Griner, D., & Smith, T. (2006). Culturally adapted mental health interventions: A meta-analytic review. Psychotherapy: Theory, Research, Practice, 43, 531-548.

Knapp, S. (2007, January). Implicit prejudice: The bad news and the good news. Pennsylvania Psychologist, 6-7.

*The words diversity and multiculturalism are sometimes used synonymously. However, many use the term multiculturalism to refer to ethnic or racial groups, whereas diversity is a broader term that includes multiculturalism and other aspects of identity such as religion, gender, sexual orientation, disability, or socioeconomic status.

Sunday, October 30, 2011

How Should Psychologists Respond to Hateful Comments?

Samuel Knapp, Ed.D., ABPP
Director of Professional Affairs

Conventional words for ethnic groups vary over time, and what is acceptable for a group in one period of time would be viewed as offensive in another time or context. However, at times patients will use words or comments directed at others because of their race, gender, or sexual orientation that clearly offend standards of decency. How should psychologists respond in such situations? Should they ignore the comment or directly confront the patient about the terms that were used?

Discretion is needed to determine when a word is intended as offensive or not. For example, Hawaiians refer to European American residents of Hawaii as haole (pronounced “howlee”). At times it is delivered as a factual statement, “He is a haole” (a white person who lives in Hawaii), and European American residents of Hawaii commonly refer to themselves as haole. However, it could be used as an insult if it were combined with certain adjectives, voice intonations, or hand gestures (Rare storm, 2011).

The conduct of psychologists in addressing hurtful speech, as in other aspects of professional behavior, should be guided by adherence to overarching ethical standards. So, when a patient makes an ethnic slur, the response of the psychologist should be guided by the principles of beneficence (acting to promote the well-being of the patient), nonmaleficence (acting to avoid harming the patient), general beneficence (acting to promote the welfare of the public in general), or other ethical principles.

The context of the comment may be relevant. It is important to know if the comment is related to the patient’s presenting problem, or activated as a function of the perceived characteristics of the therapist (Bartoli & Pyati, 2009). However, I am aware of a few situations where patients have made such intense hate-filled and vitriolic comments (addressed towards groups represented by the psychologist) that a decision was made to refer the patient elsewhere.

In some situations the principle of beneficence (welfare of the patient) may be operative. For example, a young person may use an ethnic term in a manner that an adult considers offensive. Here it is most likely appropriate for correction or feedback because the person might not understand the implications or ways in which the words come across. An educational or non-judgmental exchange could help the young person understand the implications of this speech and how it might impair their social relationships in the future.

The overarching ethical principle of general beneficence holds that psychologists should act to protect the public in general. Consequently, it would seem that, according to this principle, psychologists should address hate-filled comments. However, this ethical principle should be balanced with concerns about beneficence or the welfare of the patient. One patient of mine made a derogatory comment about an ethnic group which I corrected, with as much tact as I could manage. The patient was embarrassed, apologized, and corrected himself. However, if the comment were made in the context of a psychotic episode, disclosure of suicidal intent, or other indication of serious emotional crisis, I probably would have ignored the comment altogether and focused entirely on the patient’s well-being. If the patient had made the comment in response to a particularly upsetting or stressful event, I might have deferred addressing the issue to a time when the patient could get more perspective on the situation.

It is often best to avoid assuming that there will always be a false dichotomy between general beneficence and beneficence. Except in extreme circumstances when patient welfare is at stake or when the hateful comments represent extreme social deviance, psychologists can often find a way to address the issue without harming the therapeutic relationship. Anger and judgmental attitudes should be avoided. Patients are more likely to respond positively to comments made in a calm and direct manner (e.g., “let’s use another word, it makes you come across as prejudiced”).


Bartoli, E., & Pyati, A. (2009). Addressing clients’ racism and racial prejudice in individual psychotherapy: Therapeutic considerations. Psychotherapy: Theory, Research, Practice, Training, 46, 145-157.

Rare storm over races ruffles a mixed society. (2011). New York Times. Retrieved from here

Saturday, October 29, 2011

Adults With Mental Health Issues More Likely to Be Uninsured

Uninsurance Among Nonelderly Adults With and Without Frequent Mental and Physical Distress in the United States

Psychiatr Serv 62:1131-1137, October 2011
doi: 10.1176/appi.ps.62.10.1131

Tara W. Strine, Ph.D., M.P.H., Matthew Zack, M.D., M.P.H., Satvinder Dhingra, M.P.H., Benjamin Druss, M.D., M.P.H. and Eduardo Simoes, M.D., M.P.H.

OBJECTIVES: This research describes uninsurance rates over time among nonelderly adults in the United States with or without frequent physical and mental distress and provides estimates of uninsurance by frequent mental distress status and sociodemographic characteristics nationally and by state.

METHODS: Data from the 1993 through 2009 Behavioral Risk Factor Surveillance System, a telephone survey that uses random-digit dialing, were used to examine the prevalence of uninsurance among nearly 3 million respondents by self-report of frequent physical and frequent mental distress and sociodemographic characteristics, response year, and state of residence.

RESULTS: After adjustment for sociodemographic characteristics, uninsurance among adults aged 18 to 64 years was markedly higher among those with frequent mental distress only (22.6%) and those with both frequent mental and frequent physical distress (21.8%) than among those with frequent physical distress only (17.7%). The prevalence of uninsurance did not differ markedly between those with only frequent mental distress and those with both frequent mental distress and frequent physical distress. The prevalence of uninsurance among those with frequent mental distress only and those with neither frequent mental distress nor frequent physical distress increased significantly over time.

CONCLUSIONS: Uninsurance rates among nonelderly adults with frequent mental distress were disproportionately high. The results of this analysis can be used as baseline data to assess whether implementation of the Affordable Care Act is accompanied by changes in health care access, utilization, and self-reported measures of health, particularly among those with mental illness. (Psychiatric Services 62:1131–1137, 2011)

Link to full article is here.

Friday, October 28, 2011

VA reports records breach

By Howard Altman
The Tampa Tribune

The Department of Veterans Affairs is investigating the "inappropriate removal" from the James A. Haley Veterans' Hospital of records that contain personal information about hundreds of veterans who had received treatment there.

"This is an active, open investigation," said Haley spokeswoman Carolyn Clark, who would not say where the records were taken from, who took them, or why.

Someone used the information taken from Haley to open at least one debit card account in the name of one of the hospital's patients, according to Tampa police records.

The security breach was reported to the hospital by the VA's Office of Inspector General, said Clark, who would not say when the records were discovered missing. The VA's Office of Inspector General declined comment, referring questions to the Tampa Police Department.

Veterans whose information was compromised say they are livid.

"This is unacceptable," said Navy veteran John Toborg, who found out about the security breach at Haley last week when he received a letter from the hospital stating his records, which contained his name and Social Security number, were "inappropriately removed" from the hospital.

The entire story can be found here.

Thursday, October 27, 2011

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

Wednesday, October 26, 2011

Many on Medical Guideline Panels Have Conflicts of Interest

By Amanda Gardner
HealthDay Reporter

More than half of panel members who gather to write clinical practice guidelines on diabetes and high cholesterol have conflicts of interest, new research suggests.

"The concern is that compensation by industry on some of these panels can pose a potential risk of industry influence on the guideline recommendations," said Dr. Jennifer Neuman, lead author of a paper published online Oct. 11 in the BMJ.

Clinical practice guidelines are meant to direct health care professionals on how to best care for patients.

In the United States and Canada, most organizations (including nonprofit and governmental bodies) have their own protocol for divulging conflicts of interest.

And recently, the Institute of Medicine (IOM) published recommendations on how organizations should manage conflicts of interest when drawing up guidelines. Among other things, the institute advocated excluding individuals with financial ties to the drug industry.

The rest of the story can be read here.

Tuesday, October 25, 2011

Would You Like to See a Christian Psychologist?

By Sam Knapp, Ed.D., ABPP
Director of Professional Affairs

Some patients will request a psychologist of a particular gender, and psychologists will usually try to accommodate those concerns. For example, a female patient with sensitive sexual or gender-related issues might not feel comfortable raising them with a male psychologist, and an effort will be made to find a woman psychologist. However, is it possible to implicitly accept or endorse discriminatory practices by agreeing to other similar requests? For example, should psychologists respect the preferences of prospective patients who want to have Christian psychologists?

Some conservative Christians fear that psychologists will mock their religious beliefs or try to blame their problems on their religion. Consequently, having a Christian psychologist may be very important for them. Most non-Christian psychologists I have spoken to have received phone calls from prospective patients who ask them if they are Christian. One psychologist commonly responds, “no, but I am very respectful of Christian beliefs and will help you formulate goals consistent with your beliefs.” So far, no prospective Christian patient has ever failed to make an appointment after that conversation.

How should a psychologist respond if asked to provide a referral for a Christian psychologist? Perhaps one response would be to anticipate the concern of the patients, which is to have someone who respects their beliefs, without necessarily restricting the referrals to a psychologist who happens to be a Christian. It could be possible to respond by saying, “Psychologists are expected to respect the religious beliefs of their patients. I don’t have a list of Christian psychologists, but here are psychologists whom I know to be respectful of Christian beliefs.”

Should race, ethnicity, or sexual orientation be a factor in making a referral? On the one hand, it seems reasonable that some patients may want assurance that the psychologist they have will understand their racial or cultural background or respect their sexual orientation. It is possible to imagine a prospective patient who has not had a history of positive experiences with European Americans, or who has had a background with issues or struggles that even a sensitive European American would have difficulty understanding. Or, consider the case of a European American family who adopted an African American child who generally did well in school and at home. However, as a teenager he struggled to consolidate his racial identity and asked to speak to an African American psychologist.  It appears that race would be a relevant factor in making that referral.

On the other hand, psychologists who defer to patient preferences for race may inadvertently reinforce racist attitudes. So, the perception of the clinical relevance of the request appears important. Psychologists can decide how to respond to these requests by looking to three overarching ethical principles. First, we generally want to respect patient autonomy, including respecting their preferences in a health care professional. Second, we typically want to give patients a referral based on beneficence and nonmaleficence; that is, we want to provide a referral based on who we think can help the prospective patient. Finally, we are also guided by the overarching ethical principle of justice wherein we refuse to engage in unfair discrimination based on race, religion, gender, national origin, or other factors. Often justice is sufficiently important to trump other ethical principles.

I once had a patient who wanted a referral to a different psychiatrist because he said the one I had sent him to was not a “real American” (the psychiatrist was an American citizen of Filipino descent and highly competent). I refused to give him a new referral, and he stayed with the Filipino American psychiatrist, who was of benefit to him. In this case, the overarching ethical principle of justice trumped the other ethical principles. However, I might have responded differently if this patient were highly suicidal or homicidal. Then I would have made inquiries about his concerns, but ultimately deferred to his wish if doing so substantially reduced the risk of death.

Please feel free to contact me with your thoughts on this issue.

Monday, October 24, 2011

Subtle and Stunning Slights

By Sara Martin
Monitor Staff
October 2011, Vol. 42, No. 9
As an Asian-American, Derald Wing Sue, PhD, says he often gets compliments for speaking good English. Such "praise," he says, is a typical example of a "microagression," the brief and pervasive verbal, behavioral or environmental slights that—intentionally or not—communicate hostility.

"The hidden message is that I am a perpetual alien in my own country," said Sue, who researches microaggressions as a psychology professor at Columbia University's Teachers College.

At an APA 2011 Annual Convention session, Sue and other psychologists discussed their work in the area and their frustration that many people don't recognize microaggressions' detrimental psychological consequences.

More on ethics and diversity can be found here.

Attention students and ECPs: Self-care is an 'ethical imperative'

The Monitor on Psychology
October 2011, Vol 42, No. 9

Graduate students and early career psychologists have a lot to juggle. Huge debt. Academic demands. Working to launch their careers. Possibly starting a family. Yet too few students and new psychologists recognize the stress they are under and fail to make self-care a priority, said speakers at the APA Annual Convention symposium "When Self-Care and Real World Collide for Students and Early Career Psychologists."

Additional information can be found here.

Sunday, October 23, 2011

Concussions on the Rise for Young Athletes

By Denise Mann
WebMD Health News

There was about a 60% increase in the estimated number of concussions and other traumatic brain injuries (TBI) seen among young athletes during the past decade, according to the CDC.

In 2001, there were an estimated 153,375 traumatic brain injuries among people from birth to age 19. This number rose to 248,418 in 2009.

Many of these injuries occurred among bicyclers, football players, and children in playgrounds. Basketball and soccer players are also at risk for TBI, according to a new report in the CDC's Morbidity and Mortality Weekly Report.

Exactly why we are seeing this uptick is not known, but "I believe this is, at least, in part due to increased awareness," says study researcher Julie Gilchrist, MD. She is a pediatrician with the CDC's Division of Unintentional Injury Prevention in the National Center for Injury Prevention and Control in Atlanta.

"We are hoping that awareness has gotten up to the point that parents, teachers, and coaches recognize the signs and symptoms of concussion and make sure that children are evaluated," she says.

The entire story can be read here.

The Pennsylvania Psychological Association helped to pass concussion management legislation.  Through active advocacy efforts, one of our aspirational ethics, psychologists are independent professionals able to assess and determine return to play for teenagers who suffered a head injury.

N.F.L. Plans Broader Concussion Research

By Sam Borden
The New York Times

The N.F.L’s first attempt at a long-range study on the effects of concussions was riddled with problems from the manner in which data was collected to conflicts of interest for those overseeing it. After criticism from outside experts and even members of Congress, the study was shut down by the league in late 2009.

Nearly two years later, however, the N.F.L.’s committee on concussion research is planning a considerably broader study — an effort that could begin gathering data as soon as next season, according to one of the doctors involved.

The doctor, Mitchel S. Berger, the chairman of the neurological surgery department at the University of California San Francisco, said Monday that he and the N.F.L.’s subcommittee on former players and long-term effects of brain and spine injury had been holding conference calls regarding the study every two weeks with representatives from the players’ union. He added that he hoped to make a final presentation to the union and Commissioner Roger Goodell “in the near future.”

Berger said he was aware of the issues surrounding the previous study, and said the latest model was completely different.

“There was no science in that,” Berger said in reference to the study coordinated by Dr. Ira Casson, who was also the league’s primary voice in discrediting outside research on concussions. Asked if he might use any of the data from Casson’s work, Berger shook his head.

The entire story can be read here.

An Ordinary Football Game, Then a Player Dies

By Jorge Castillo
The New York Times

Football coaches and school administrators at John C. Birdlebough High School congregated in a small room off the library Monday, huddling around a computer for a most painful and unusual review of game video. They examined every play that one student was involved in, assuming the role of medical examiners.

They were trying to discern which collision of the hundreds in a football game at Homer High School on Friday night might have caused Ridge Barden, a 16-year-old defensive tackle, to fall to the turf in the third quarter and die within a few hours. The coroner attributed Barden’s death to a subdural hematoma, or a brain bleed.

“There’s nothing here; there’s still nothing there; there’s nothing there; there’s nothing there — and now he’s laying on his stomach,” Jeff Charles, the head coach, said while watching the sequence frame by frame.
As those who play and coach football learn new ways to improve safety — through training, medical response and equipment — sometimes they are left to contemplate this: brains remain vulnerable, and even the most ordinary collisions on the field can kill.


Barden’s father, Jody, said he had no objection to the sport in the wake of his son’s death.

“I just don’t want a negative spin on this,” Mr. Barden said Sunday. “There is no blame in this. I don’t want to scare kids from playing the game. Ridge loved playing the game, and I know he wouldn’t want it to get a bad name.”

The entire story can be read here.

Saturday, October 22, 2011

Stanford Hospital & Clinics vows to fight $20M class action

By Jason Green

Stanford Hospital & Clinics vowed Monday to "vigorously defend" itself against a $20-million class-action complaint filed in the wake of a data breach that saw the medical records of 20,000 patients posted on a commercial website for nearly a year.

Shana Springer filed the complaint on Sept. 28 in Los Angeles County Superior Court, on behalf of fellow patients treated in Stanford's emergency room between March 1, 2009, and Aug. 31, 2009. She is seeking $1,000 per patient, as well as other penalties, damages and attorneys fees.

The nine-page complaint alleges the hospital violated the Confidentiality of Medical Information Act, a state law that requires medical providers to safeguard patient information and prohibits its disclosure without written consent.

"On its website, Stanford claims that its patients' 'health care experience is [its] highest priority.' Thus, it should be no surprise that when patients are treated at Stanford's facilities, they expect that their private medical information will be kept confidential and will not be disclosed to anyone without their authorization," the complaint states.

In a brief statement released Monday, Stanford placed the blame on complaint codefendant Multi-Specialty Collection Services LLC, saying it was the subcontractor that mishandled the data. The hospital has since cut ties with the Woodland Hills-based company, which provided collection and billing services.

The entire story can be read here.

Friday, October 21, 2011

Third-party cases pose liability risks to doctors

By Alicia Gallgos
amdnews.com staff

The Utah Supreme Court is reviewing whether the children of a patient can sue their father's physician for medication mismanagement after the patient shot his wife to death. In a similar case, the Supreme Court of Georgia has ruled that a psychiatrist can be sued for medication negligence after a patient fatally attacked his mother.

The cases raise concerns about doctors' potential liability for criminal actions committed by their patients and what duty, if any, physicians owe to nonpatients. Experts say the cases remind doctors to take note of circumstances that could increase their liability risk to third parties.

In the Georgia case, the father of Victor Bruscato filed a lawsuit on behalf of Victor against psychiatrist Derek O'Brien, MD. He alleged that the doctor's discontinuation of Bruscato's two antipsychotic medications aggravated his son's violent tendencies. After the drugs were stopped, Bruscato, a mentally ill patient with a history of violence, stabbed his mother to death.

Dr. O'Brien had ordered two of Bruscato's medications stopped for six weeks to rule out the possibility that Bruscato was developing neuroleptic malignancy syndrome, according to court documents. A trial court dismissed the case in favor of Dr. O'Brien, ruling that public policy does not allow the Bruscatos to benefit from any wrongdoing, namely the killing of Lillian Bruscato. The appeals court reversed the decision.

In its Sept. 12 opinion, the Supreme Court affirmed, allowing the lawsuit to proceed. Though public policy prevents profiting from a wrongdoing in court, an exception exists if a mentally ill patient isn't aware of what he is doing, the court said. Bruscato was never found guilty of a crime; instead, he was ruled incompetent to stand trial and committed to a state mental hospital.

The rest of the story can be found here.

Judge says Prozac factor in teen murder

Winnipeg Free Press
Sympatico.ca News

WINNIPEG - A Manitoba judge says a Winnipeg teen was driven to fatally stab another teen due to the adverse effects of an anti-depressant drug.

Provincial court Judge Robert Heinrichs agreed to keep the case in youth court, where the male youth now faces a maximum sentence of just four more years behind bars on the charge of second-degree murder.

Heinrichs said Friday the use of Prozac resulted in “unique circumstances” which he was forced to consider.

He described how the youth, who was 16 at the time of the stabbing in 2009, went from a loving, happy-go-lucky kid to a dark, depressed drug abuser who began to act out violently and even tried to harm himself on several occasions.

Heinrichs said it’s clear the youth's parents did the right thing in bringing their concerns to his various doctors, but they were largely ignored and the drug's dosage was increased.

Since his arrest, the youth is now clean of all drugs, has expressed remorse for his actions and greatly reduced his risk to the public.

“His basic normalcy now further confirms he no longer poses a risk of violence to anyone and that his mental deterioration and resulting violence would not have taken place without exposure to Prozac,” Heinrichs said in a written decision.

The entire story can be read here.

Thursday, October 20, 2011

The Best Treatment Of Anxiety May Not Involve The Drugs That Recent Literature Suggests

Medical News Today

A recent data analysis that was published in the British Medical Journal (BMJ) suggested that antidepressant drugs may offer the best treatment for generalized anxiety disorder. This new data analysis that is published in the recent issue of Psychotherapy and Psychosomatics suggests that BMJ is faulty and biased by conflict of interest.

Generalized anxiety disorder, the constant and fearful worry and fearful anticipation of events, is a common disturbance. A recent data analysis that was published in the British Medical Journal (BMJ) suggested that antidepressant drugs may offer the best treatment for generalized anxiety disorder. A new data analysis that is published in the recent issue of Psychotherapy and Psychosomatics suggests that BMJ is faulty and biased by conflict of interest.


Although the study was allegedly independent, all authors had financial ties with Lundbeck and other pharmaceutical companies which manufactured the drugs that were included and discussed in the meta-analysis. The meta-analysis performed by Baldwin and colleagues is likely to yield misleading conclusions, particularly for the busy clinician who has no time to check its faulty procedures and the lack of appropriate clinical integration. The publication of this paper calls for a reassessment of journals' policies concerned with reviews, editorials and meta-analyses.

The entire article can be found here.

Wednesday, October 19, 2011

Barriers High in Mental Health Care

By Nancy Walsh
Staff Writer, MedPage Today

For mental health care, how bad are things, really?

That was the question posed by a group of physicians in Boston who had found difficulties in providing psychiatric referrals for their patients.

So they undertook a "simulated patient" study, telephoning all 64 Blue Cross Blue Shield in-network psychiatric facilities within 10 miles of the center of Boston, according to Rachel Nardin, MD, of the Cambridge Health Alliance in Cambridge, and colleagues.

This summary article can be found here.

The original article in the Annals of Emergency Medicine can be found here.

The article concludes:

"Although there are many contributors to the inadequacy of our mental health system, managed care has hit psychiatric services hard. Private insurers aggressively constrain patients' access to services by stringently limiting provider networks. As our study shows, this is often covert; insurers provide lists of in-network providers, but most are unavailable. Reimbursements for psychiatric services are far lower than for other types of care, so institutions frequently restrict access as stringently as possible, often, as in our study, by requiring that a patient have an in-system primary care provider (even though the insurer requires no referral). Many private practitioners refuse to accept insurance payments altogether. Improved reimbursements for psychiatric care will be an important step in reducing the barriers to care experienced by patients with severe depression."

Suspended Nova Scotia doctor may get licence back

CBC News.
Former patient blames doctor for suicide

A Nova Scotia doctor who used a patient to get a narcotic drug for her personal use will be allowed to return to the practice of medicine if she fulfils several conditions imposed by the College of Physicians and Surgeons of Nova Scotia.

Dr. Violet Hawes of Middle Musquodoboit had her licence suspended in November 2009 after the allegations surfaced.

The following month, one of her former patients committed suicide and left a note blaming her.
Doug Carpenter, 49, took his life in the parking lot of the Musquodoboit Valley Memorial Hospital in December 2009.

He left a note for his family saying "Dr. Hawes did this to me."

According to Carpenter's medical records, Hawes prescribed him Hydromorph Contin — a narcotic — for the first time in January 2008.

Carpenter's mother, Phyllis, said her son had described an arrangement with his doctor when she prescribed the drug.

"She would have a prescription ready for him when he went in there for his drug. He would fill it and give it to her," Carpenter told CBC News last December.

The entire CBCNews-Canada story can be here.

There was a similar case in central Pennsylvania in which a physician used numerous patients to obtain narcotics for himself.  In the Pennsylvania case, the physician's patient did not commit suicide, but he apparently told patients the drugs were for a dying parent.  Physicians using patient to obtain narcotics occurs.

Some of that information can be found here.
Petitioner was charged with five misdemeanor counts of unlawful procurement of prescription drugs in violation of 63 P.S. � 390-8(13) - however, the misdemeanor conviction is not at issue in this proceeding. Both the felony and misdemeanor charges involved Hydrocodone (Lortab) a Schedule III controlled substance. I.G. Ex. 8, at 1.

Tuesday, October 18, 2011

Antisocial Personality Traits Predict Utilitarian Responses To Moral Dilemmas

By Daniel M. Bartels and David A. Pizarro

The Mismeaure of Morals:
Anitsocial Personality Traint Predict Utilitarian Responses to Moral Dilemmas
Cognition, Volume 121, Issue 1, October 2011, pages 154-161

Researchers have recently argued that utilitarianism is the appropriate framework by which to evaluate moral judgment, and that individuals who endorse non-utilitarian solutions to moral dilemmas (involving active vs. passive harm) are committing an error. We report a study in which participants responded to a battery of personality assessments and a set of dilemmas that pit utilitarian and non-utilitarian options against each other. Participants who indicated greater endorsement of utilitarian solutions had higher scores on measures of Psychopathy, machiavellianism, and life meaninglessness. These results question the widely-used methods by which lay moral judgments are evaluated, as these approaches lead to the counterintuitive conclusion that those individuals who are least prone to moral errors also possess a set of psychological characteristics that many would consider prototypically immoral.

The first two pages of the article can be found here

Bartels, Pizarro

Facebook refuses to shut rape page run by schoolboy

By Philip Sherwell in New York

Nobody knows better than MJ Stephens that rape is no laughing matter. So as the victim of a sexual assault, she was horrified when she encountered the contents of a Facebook page full of jokes about rape and violence towards women.

But worse was to come when the young American tried to argue with people who had attached comments to a page called: "You know shes [sic] playing hard to get when your [sic] chasing her down an alleyway" - most of them teenagers and young adults from Australia and Britain.

In sickeningly explicit terms, several of them threatened her and expressed the wish that she be raped again.

Such pages, full of ugliness, aggression and pornographic language are multiplying on Facebook, drawing lucrative user traffic to the social networking site.

Now it has emerged that one of the "administrators" of the page - users with the right to edit its content - is believed to be a British schoolboy linked to a network of hackers in Australia, Britain and America who have set up Facebook pages featuring offensive sexual and violent content.

Micheal O'Brien, a Canadian computer systems engineer who co-founded the Rape Is No Joke (RINJ) campaign to pressure Facebook to delete "rape pages" via petitions and boycotts, has tracked the activity on several such pages and contacted participants online.

He told London's The Sunday Telegraph that associates of 4chan, a loose-knit collection of international "cyber-anarchists" who champion absolute online freedom, including the right to share pornography, have founded and administer several of the pages.
The entire story can be found here.

Thanks to Gary Schoener for the link to this article.

Monday, October 17, 2011

Apple FaceTime May Be HIPAA Secure

The FaceTime video chat feature of Apple's iPhone 4 and iPad 2 has the potential to be a game changer for doctor-patient communications, health IT experts tell InformationWeek Healthcare, but only if it's secure enough to satisfy federal privacy regulations.

InformationWeek asked Apple about reports that FaceTime can be configured so that it meets the requirements of Health Insurance Portability and Accountability Act (HIPAA). In response, Apple said that only HIPAA-covered entities, not software applications, can be HIPAA-compliant. But the company also stated, "Our [iPad 2 and iPhone 4] products can be used by HIPAA-compliant organizations."

For FaceTime communications to be highly secure, Apple told a contributor to ZDnet, an iPad2 user would have to configure the device's security settings so that it uses WPA2 Enterprise to access an enterprise wireless network. WPA2 Enterprise has 128-bit AES encryption. Moreover, each video chat is encrypted with unique session keys, and each participant receives a unique ID number, Apple said.

The entire article can be found here.

Sunday, October 16, 2011

W.Va. board withdraws autism rule after lawsuit

By Lawrence Messina
Associated Press
Published September 27, 2011

The West Virginia board that regulates psychologists voted Tuesday to withdraw an emergency rule that claimed jurisdiction over specialists who treat children with autism, after the new policy spurred a lawsuit and an outcry among parents of these children and their supporters.

The rule issued in July by the state Board of Examiners of Psychologists has been misinterpreted and misunderstood, board Executive Director Jeffrey Harlow said in a statement emailed to the media late Tuesday.

"The parents are calling the board and expressing fear and anger," the statement said, adding that "The last thing the Board would want to do is obstruct the provision of vitally needed services to these vulnerable children."

The rule had barred applied behavioral analysis, a therapy considered crucial for many children diagnosed with an autism spectrum disorder, unless a licensed psychologist supervised the ABA analyst. When it applied for the rule, the board called the providing of this therapy outside its jurisdiction "an immediate threat to public safety."

"There is a relatively small, but most likely soon to increase, group of individuals engaging in the practice of psychology who are not licensed and who do not meet the minimum education and training requirements for licensure," the board wrote when it sought the rule. "They are not prepared to practice independently, lack oversight and constitute a serious and immediate concern to public safety."

A certified ABA analyst, Jill Scarbro-McLaury, sued the board last week, asking a judge to scuttle the rule. Her Kanawha Circuit lawsuit alleged that ABA therapy is separate and distinct from psychology, and has been practiced in West Virginia for years without the board's interference.

"We are encouraged that the board recognized that the rule should be pulled since it was in violation of the law, and we hope no more road blocks are placed in front of our families who just want to help their children," Scarbro-McLaury said in an email.

The board pursued the rule over a new law that will eventually require both public and private insurers to cover ABA therapy. Parents of children with these neurological ailments and their supporters had lobbied the Legislature for several years for the measure. Acting Gov. Earl Ray Tomblin signed the regular session bill into law in April.

The entire story can be read here.

Saturday, October 15, 2011

The Ethics Of Gallows Humor In Medicine

By Katie Watson
The Hastings Center

Medical professionals regularly joke about their patients’ problems. Some of these jokes are clearly wrong, but are all jokes wrong?

It was 3:00 am and three tired emergency room residents were wondering why the pizza they’d ordered hadn’t come yet. A nurse interrupted their pizza complaints with a shout: “GSW Trauma One—no pulse, no blood pressure.”

The residents rushed to meet the gurney and immediately recognized the unconscious shooting victim: he was the teenage delivery boy from their favorite all-night restaurant, and he’d been mugged bringing their dinner.

That made them work even harder. A surgeon cracked the kid’s rib cage and exposed his heart, but the bullet had torn it open and they couldn’t even stabilize him for the OR. After forty minutes of resuscitation they called it: time of death, 4:00 a.m.

The young doctors shuffled into the temporarily empty waiting area. They sat in silence. Then David said what all three were thinking.

“What happened to our pizza?”

Joe found their pizza box where the delivery boy dropped it before he ran from his attackers. It was face up, a few steps away from the ER’s sliding doors. Joe set it on the table. They stared at it. Then one of the residents made a joke.

“How much you think we ought to tip him?”

The residents laughed. Then they ate the pizza.

Gallows humor is humor that treats serious, frightening, or painful subject matter in a light or satirical way. Joking about death fits the term most literally, but making fun of life-threatening, disastrous, or terrifying situations fits the category as well. There is a fair amount of literature on humor in medicine generally, most of which is focused on humor in clinician-patient interactions or humor’s benefit to patients. There is relatively little specifically addressing the topic of this article: gallows humor in medicine, which usually occurs in interactions between health care providers.

Gallows humor is not a feel-good, Patch Adams kind of humor, but it is not synonymous with all cruel humor, either. As one physician put it, the difference between gallows humor and derogatory humor is like “the difference between whistling as you go through the graveyard and kicking over the gravestones.” Many health care providers witness or participate in gallows humor at some point. After reviewing over forty medical memoirs, Suzanne Poirier reports that “Anger and gallows humor are generally accepted forms of expression among undergraduate and graduate medical students . . . but expressions of serious self-doubt or grief are usually kept private or shared with only a trusted few.”

David’s question intrigued me as a bioethicist because it is about moral distress, power imbalances between doctors and patients, and good people making surprising choices. But it also piqued my interest as someone who enjoys joking around—when not teaching bioethics, I teach improv and sketch writing at Second City, where I’m an adjunct faculty member. But David didn’t ask me if the tip joke was funny. He asked about it in ethics’ normative terms of right and wrong.

David told me this story fifteen years after he finished his residency, but the urgency with which he told it made it seem like it happened last night. “You’re the ethicist,” he said. “Was it wrong to make a joke?”

The rest of the story can be read here.  In order to access the entire article, you may have to register with The Hastings Center.

Confidentiality, Seinfeld Style

If you are a Seinfeld fan, then you likely remember this scene.

If you are not a Seinfeld fan, then you need to know the following.

George is in bed with Susan, his fiance.  George has been experiencing "cold feet" about their upcoming nuptuals.  He confides some of his ambivalence to Elaine.  Elaine and George have a prickly social relationship.

Enjoy the scene.

Friday, October 14, 2011

Richard F. Small: PPA's 2011 Ethics Educator of the Year

Richard F. Small, PhD ABPP
Ethics Educator of the Year

Pennsylvania is fortunate to have Dr. Richard F. Small as a practicing psychologist and ethics educator.

A survey by Ken Pope showed that psychologists were more often likely to turn to peers as a source of ethical information than published articles, ethics codes, or other sources. Here at PPA, we are pleased that the ethics educators’ award not only goes to academic psychologists but also goes to practicing psychologists (such as Don Jennings, Don McAleer, and Eve Orlowe) who have a substantial impact and credibility in supporting their professional colleagues.

Part of Dr. Small’s success as a thinker or presenter on ethical issues stems from  real life experience, as a psychotherapist, a marriage therapist, a practice owner, a supervisor, an evaluator, and a teacher.  This wide ranging experience gives him credibility and familiarity with the ethical issues that psychologists face on an average, everyday basis.

In everything he does, whether as a practicing psychologist, a consultant on insurance and practice issues, or a volunteer for PPA, Rick is guided by overarching ethical principles. For example, his writings on insurance and practice management always kept patient well-being at the forefront. He gave special attention to multiculturalism and diversity while PPA President, and, through the Pennsylvania Psychological Foundation, he has focused on developing book awards for graduate students in psychology.

Dr. Small presented on ethics for a number of organizations, including the American Psychological Association, the Pennsylvania Psychological Association, various private organizations (such as The American Health Care Institute), and non-profits.  In fact, Rick and Sam Knapp first used the term “positive ethics” in a workshop they gave 15 years ago entitled, “Ethics is more than a code.”  Dr. Small has also authored or co-authored a number of articles for The Pennsylvania Psychologist.  He has been a member of our Ethics Committee for years.  He remains committed to multiculturalism and diversity as well.

As you will see this afternoon, Rick is an excellent presenter.  Using the Acculturation model as a guide, Dr. Small balances the legal aspects of ethics with the personal values and emotional qualities of a seasoned psychologist to provide a truly integrated approach to teaching ethics.

For all his work with ethics education at the state and national level, I am pleased to present Dr. Richard F. Small as this year’s the Ethics Educator of the Year.