Vignette 27: To Skate or Not to Skate

Dr. Logan Earthski works with adolescents and their families.  During the course of treating one adolescent male, the parents, Mr. and Mrs. Hawk, expressed frustration with their son Tony’s lack of involvement with sports.  The Hawks detailed how Tony enjoyed team sports in the past, but has not enjoyed participating due to anxiety and constantly comparing himself to others.

In order to bond and connect with the family, Dr. Earthski explained from his experience with teens, some male teens function better with individual sports.  Dr. Earthski disclosed that he grew up skateboarding and taught lessons for several years.  A few of the children and adolescents he taught fit the description of Tony.  In those cases, the adolescent tried soccer or baseball, but did not really like it because they felt too anxious and overly competitive. 

When it came to individual sports, like skateboarding, teens that became involved with individual sports usually showed a decrease in anxiety and an increase in self-confidence.  However, sometimes, when adolescents first show up at the skate park, they may experience a similar level of anxiety and heightened self-awareness that Dr. Earthski helped remediate during his coaching sessions. 

Dr. Earthski also revealed that he worked with one particular teenager who became very anxious and experienced episodes of panic related to going to the skate park.  That adolescent did not think he was good and was weary of other kids watching and judging him.  Dr. Earthski gave him some coaching on anxiety reduction techniques and worked through those negative, anxiety-provoking emotions.  Further, he did very well at skateboarding once he conquered his symptoms of anxiety and panic.  The teenager's self-confidence grew as he performed better at the skate park.  Based on Dr. Earthski's revelations, the parents seemed reassured.

Prior to the next session, Dr. Earthski received a voicemail message from Mrs. Hawk asking if he could coach Tony on skate boarding.

After thinking about this request, Dr. Earthski calls you for a consult.  Dr. Earthski puts forward the following concerns:

1.  Is coaching a teenager-patient on anxiety-related issues in context of a skate boarding lessons definitively a dual relationship?

2.  What if the coaching is time-limited, informed consent is given, and this activity is viewed as the exception rather than the rule?  (“Time-limited” means between one and six sessions, depending on his response to treatment.)

3.  Can time-limited skateboard coaching be incorporated as part of an in-vivo anxiety reduction technique and billed as therapy services?

4.  Would Dr. Earthski’s malpractice insurance likely cover this activity?

5.  What would happen if the teen-patient injured himself as part of coaching?

6.  Dr. Earthski asks about the use of self-disclosure.  What feedback might you give to Dr. Earthski about what he disclosed about himself?

7.  Given everything you know about the case, what is/are the final recommendation(s) about this scenario?

Guantanamo Bay: A Medical Ethics–free Zone?

George J. Annas, J.D., M.P.H., Sondra S. Crosby, M.D., and Leonard H. Glantz, J.D.
June 12, 2013
DOI: 10.1056/NEJMp1306065

American physicians have not widely criticized medical policies at the Guantanamo Bay detainment camp that violate medical ethics. We believe they should. Actions violating medical ethics, taken on behalf of the government, devalue medical ethics for all physicians. The ongoing hunger strike at Guantanamo by as many as 100 of the 166 remaining prisoners presents a stark challenge to the U.S. Department of Defense (DOD) to resist the temptation to use military physicians to “break” the strike through force-feeding.

President Barack Obama has publicly commented on the hunger strike twice. On April 26, he said, “I don't want these individuals [on hunger strike] to die.” In a May 23 speech on terrorism, the President said, “Look at our current situation, where we are force-feeding detainees who are . . . on a hunger strike. . . . Is this who we are? . . . Is that the America we want to leave our children? Our sense of justice is stronger than that.” How should physicians respond? That force-feeding of mentally competent hunger strikers violates basic medical ethics principles is not in serious dispute. Similarly, the Constitution Project's bipartisan Task Force on Detainee Treatment concluded in April that “forced feeding of detainees [at Guantanamo] is a form of abuse that must end” and urged the government to “adopt standards of care, policies, and procedures regarding detainees engaged in hunger strikes that are in keeping with established medical professional ethical and care standards.” Nevertheless, the DOD has sent about 40 additional medical personnel to help force-feed the hunger strikers.

The ethics standard regarding physician involvement in hunger strikes was probably best articulated by the World Medical Association (WMA) in its Declaration of Malta on Hunger Strikers. Created after World War II, the WMA comprises medical societies from almost 100 countries. Despite its checkered history, its process, transparency, and composition give it credibility regarding international medical ethics, and its statement on hunger strikers is widely considered authoritative.

The entire article is here.

Thanks to Gary Schoener for this lead.

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 25: A Questionable Letter

Dr. Betty Frances has been treating Peggy Olson for anxiety and depression related to job stress and intermittent spousal bullying.  During their course of treatment, Mr. Olson physically abused Mrs. Olson to the point where the police arrested him on charges of domestic violence and terroristic threats.  Because of the seriousness of his threats and prior criminal behavior, Mr. Olson’s family could not bail him out of prison.

After this event, Mrs. Olson became more forthcoming with Dr. Frances.  His behavioral history includes stalking, assault, battery, public disturbance, public intoxication, and other out of control behaviors.  Dr. Frances continues to treat Mrs. Olson for anxiety and depression on a weekly basis.

Dr. Frances arrived at her office one day and found a letter with the return address of Mr. Olson at the local detention facility.  Dr. Frances feels an anxiety reaction in her body.  Trying to calm down, Dr. Frances writes out a list of questions.

1.      Should I open the letter now (as it is addressed to me)?

2.      Should I tell the patient about the letter before I open it?

3.      What are the benefits of telling the patient about the letter?

4.      What are the drawbacks of telling the patient about the letter?

5.      If the letter contains threatening information toward Mrs. Olson, or me, am I able to turn the letter over to the District Attorney?

6.      Am I required to turn the letter over to the DA if there is threatening information in it?

7.      How much control does the patient have over the letter and its contents?

8.      Is the letter automatically part of the treatment record or does it depend on the contents of the letter?

9.      Do I need a self-care plan as I am stressed out about this situation?

Having calmed down and written out these questions, Dr. Frances calls you for an ethics consultation about the letter.

What are your responses to her questions about the letter?

Should I Report My Ex-Wife for Sleeping With Her Patient?

By Chuck Klosterman
The New York Times - The Ethicist
Originally published April 26, 2013

My ex-wife is a physician. We divorced when I found out she was having an affair with one of her H.I.V.-positive patients. I feel compelled to tell the state medical licensing board and the professional societies to which she belongs about her affair. My reasons for doing so are that I feel an intense urge to retaliate her breach of trust and that she potentially exposed me to H.I.V. (fortunately, I tested negative). I also know that, as a physician myself, I should report her to protect other patients, so that she may get increased supervision at her workplace and treatment if needed. Should I report her even though my main motivation is revenge?

The entire article is here.

Vignette 24: Institutional Conflict

Dr. Solomon, a psychologist on an inpatient psychiatric treatment team, is concerned about the pending discharge of a current inpatient. The patient admitted herself to the unit, with some persuasion by the local police, for making loud threats and menacing gestures in her neighbor’s driveway. Hence, the admission is voluntary.

Currently, the patient is denying the fact that she has made past threats toward her neighbor. However, the police report indicated she has made such verbal threats in the past but also, on several occasions, has damaged her neighbors property including scratching the paint on their car and throwing rocks at their house. Innuendos are that she allegedly killed her neighbors pet, but this has been unproven by the police.

During some individual time, the patient indicated to the psychologist that she has “had it” with her neighbor and has “something planned that will make you all finally understand” once she is discharged.

While the treatment team does not share Dr. Solomon’s concern and has started to make discharge plans, they have not spent as much individual time with the patient as Dr. Solomon. In fact, the patient has made no such comments to anyone else other than to Dr. Solomon and has been a model patient on the unit. The days allocated for her stay by her insurance are ending in two days. The attending psychiatrist concurs with the discharge plan and advised Dr. Solomon “not to worry about it.” In fact, the psychiatrist encouraged the psychologist to omit any reference to the patient’s comments about the neighbor in treatment summaries or clinical notes as “hysterical nonsense.”

What are the ethical issues involved?

If you were the psychologist, how would you feel about the situation?

What steps does the psychologist need to take?

How easy or how difficult would it be to take those steps?

Do We Need 'Thanaticians' for the Terminally Ill?

By Ronald W. Pies
Medscape - Ethics in Psychiatry
Originally published September 26, 2012

My 89-year-old mother had been losing ground for some years, experiencing what geriatricians sometimes call "the dwindles." Toward the end of her life, she was beset by a deteriorating heart; an inability to walk; and occasional, severe gastrointestinal pain. My family got her the best medical treatment available -- eventually including home hospice care -- and she generally maintained a positive attitude throughout her long downhill slide.

But one day, as I sat beside her bed, she seemed unusually subdued. "Honey," she said, "How do I get out of this mess?" I had a pretty good idea of what she was really asking me, but I deflected her question with another question: "Ma, what 'mess' do you mean?" I asked. "It's all right," she replied, smiling sadly, "I'll manage."

My mother was doing what she had always done: sparing her children from pain. In this case, it was the pain of dealing with the waning days of her life and the frustration of knowing there was no easy escape from the burdens of dying slowly. "Ma, I'll always make sure you are getting enough treatment for your pain," I added, taking her hand -- knowing that the prospect of unremitting pain is often an underlying fear of terminally ill persons.

Yet, unspoken in my mother's question was the issue of so-called physician-assisted dying, sometimes called "physician-assisted suicide" -- an enormously heated controversy both outside and within the medical profession. In my home state, Massachusetts, the issue has come to the fore, owing to a November ballot initiative for a measure that would allow terminally ill patients to be prescribed lethal drugs. A closely related bill (H.3884) has also come before the Massachusetts Legislature's Joint Committee on the Judiciary.

The entire ethical dilemma is here.

Drones, Ethics and the Armchair Soldier

By John Kaag
The New York Times - Opinionator
Originally published on March 17, 2013

Here are some excerpts:

Ten years later, I’m a philosopher writing a book about the ethics of drone warfare. Some days I fear that I will have either to give up the book or to give up philosophy. I worry that I can’t have both. Some of my colleagues would like me to provide decision procedures for military planners and soldiers, the type that could guide them, automatically, unthinkingly, mechanically, to the right decision about drone use. I try to tell them that this is not how ethics, or philosophy, or humans, work.

I try to tell them that the difference between humans and robots is precisely the ability to think and reflect, in Immanuel Kant’s words, to set and pursue ends for themselves. And these ends cannot be set beforehand in some hard and fast way — even if Kant sometimes thought they could.

What disturbs me is the idea that a book about the moral hazard of military technologies should be written as if it was going to be read by robots: input decision procedure, output decision and correlated action. I know that effective military operations have traditionally been based on the chain of command and that this looks a little like the command and control structure of robots. When someone is shooting at you, I can only imagine that you need to follow orders mechanically. The heat of battle is neither the time nor the place for cool ethical reflection.

Warfare, unlike philosophy, could never be conducted from an armchair. Until now. For the first time in history, some soldiers have this in common with philosophers: they can do their jobs sitting down. They now have what I’ve always enjoyed, namely “leisure,” in the Hobbesian sense of the word, meaning they are not constantly afraid of being killed. Hobbes thought that there are certain not-so-obvious perks to leisure (not being killed is the obvious one). For one, you get to think. This is what he means when he says that “leisure is the mother of philosophy.” I tend to agree with Hobbes: only those who enjoy a certain amount of leisure can be philosophers.

The entire article is here.

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 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?

Human Enhancements at Work Pose Ethical Dilemmas

By Kate Holland
Reuters Health Information
Originally published November 8, 2012


Retinal implants to help pilots see at night, stimulant drugs to keep surgeons alert and steady handed, cognitive enhancers to focus the minds of executives for a big speech or presentation.

Medical and scientific advances are bringing human enhancements into work but with them, according to a report by British experts, come not only the potential to help society and boost productivity, but also a range of ethical dilemmas.

"We're not talking science fiction here, we're talking about advances that could impact significantly on the way we work...in the near future," said Genevra Richardson, a professor of law at Kings College London and one of the authors of the report.

The report was published after a joint workshop involving four major British scientific institutions which looked at emerging technologies like cognitive enhancing drugs, bionic limbs and retinal implants that have the potential to change workplaces dramatically in future.

Richardson said while such developments may benefit society in important ways, such as by boosting workforce productivity, their use also had "significant policy implications" to be considered by governments, employers, workers and trades unions.

The entire article is here.

Vignette 19: A Missing Patient

A psychologist has been working individually with a 17-year-old male for issues related to depression and family dynamics. The psychologist and the young man have been engaged in psychotherapy for the past 2 years. The patient has trust issues with his parents, especially his father.

Ten minutes prior the scheduled appointment, the patient's mother calls the psychologist on the phone. The mother explains that the child has run away and the mother has reported the child missing to the police. The mother further reports that the patient's cousin has been driving the patient around town. She wants the psychologist to phone the police immediately when the patient arrives in order to arrest the cousin for unlawfully detaining the minor child or kidnapping and recover her minor child.

After the phone call, the psychologist checks the waiting room and sees the patient there.  He is talking with a young man, most likely his cousin.



What obligations does the psychologist have to the parent?

What obligations does the psychologist have to the patient?

What is the psychologist to do?

What are some likely emotional reactions would you have in this situation?

Vignette 17: Titles, Roles and Boundaries

Dr. Thomas is a psychologist who is a part owner of a private practice in which they offer Employee Assistance Program (EAP) services.  The EAP service provides a solution-focused, three-session benefit for companies within Pennsylvania.  Dr. Thomas normally does not handle EAP services. Several staff members were either ill or overbooked, so Dr. Thomas responds to EAP requests during the day.

When dealing with the EAP program, she thinks her title of “doctor” might put people off, so she announces herself as “Sue” when dealing with EAP clients.  When returning a call from Chuck who works for a company with the EAP benefit, the psychologist indicates that she is "Sue" from the EAP program.  Chuck is a 20-year old man who immediately expresses a great deal of agitation and anger. He complains loudly about his parents and his girlfriend. In the process of conversation, Dr. Thomas realizes that Chuck is the son of her next-door neighbors.  While Chuck now lives in an apartment in town, she remembers him well.  She actually attended his graduation party briefly and hired him to cut her lawn for two years.

Also during the course of the phone contact, Chuck expresses some homicidal rage toward his parents, particularly around financial issues and early childhood sexual abuse from his father. Dr. Thomas wants him to come in immediately for a more in-depth evaluation. Chuck hesitated to have a face-to-face interview at the practice, but agreed only if he can talk with Sue.  Sue schedules the appointment for early in the evening.

What are the ethical concerns in this scenario?

How would you advise Dr. Thomas to handle them?

If you were a co-owner of the business, how would you feel about this situation?

Genes Now Tell Doctors Secrets They Can’t Utter

By Gina Kolata
The New York Times
Originally 25, 2012

Dr. Arul Chinnaiyan stared at a printout of gene sequences from a man with cancer, a subject in one of his studies. There, along with the man’s cancer genes, was something unexpected — genes of the virus that causes AIDS.

It could have been a sign that the man was infected with H.I.V.; the only way to tell was further testing. But Dr. Chinnaiyan, who leads the Center for Translational Pathology at the University of Michigan, was not able to suggest that to the patient, who had donated his cells on the condition that he remain anonymous.

In laboratories around the world, genetic researchers using tools that are ever more sophisticated to peer into the DNA of cells are increasingly finding things they were not looking for, including information that could make a big difference to an anonymous donor.

The question of how, when and whether to return genetic results to study subjects or their families “is one of the thorniest current challenges in clinical research,” said Dr. Francis Collins, the director of the National Institutes of Health. “We are living in an awkward interval where our ability to capture the information often exceeds our ability to know what to do with it.”

(cut)

Such ethical quandaries grow more immediate year by year as genome sequencing gets cheaper and easier. More studies include gene sequencing and look at the entire genome instead of just one or two genes. Yet while some findings are clear-cut — a gene for colon cancer, for example, will greatly increase the disease risk in anyone who inherits it — more often the significance of a genetic change is not so clear. Or, even if it is, there is nothing to be done.

The entire story is here.

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?

Putting dignity to work

By Charles Foster
The Lancet
Originally published June 2, 2012

A profoundly brain-damaged teenage girl is brought to hospital. The nurses undress her and leave her, uncovered, on a trolley in front of some lascivious youths who are waiting in the Accident and Emergency Department. She seems to enjoy receiving their attention; they enjoy giving it. Is this wrong? Yes it is. But what language describes the wrongness? Certainly the four principles laid out by Tom Beauchamp and James Childress in their classic Principles of Biomedical Ethics (autonomy, beneficence, non-maleficence, and justice) can't really help, or can't help without straining uncomfortably. Autonomy isn't offended. Insofar as the girl is capable of exercising autonomous thought, she's all for it, and so are the boys. And there's no real harm here, as harm would conventionally be described. One might say that the maxim “Do good” has been violated, but what does “good” mean?

(cut)

In answering that question, and in saying what is meant by “good”, it is hard to avoid using words like dignity. And that, for many, is rather embarrassing. Dignity has a bad reputation among some philosophers. It tends to be thought of as feel-good philosophical window-dressing—the name you give to whatever principle gives you the answer you think is right; as a substitute for hard thinking; as impossibly amorphous or (because of its historical association with the notion of the Imago Dei), as incurably theological. Dignity-peddlers, it tends to be thought, are selling metaphysical snake oil.

(cut)

Beauchamp and Childress sometimes falter because their principles are second-order principles, derived ultimately from dignity. Sometimes, to get the right ethical answer, you've got to go to the source. Burrow down deep enough into any bioethical conundrum, and you'll eventually hit dignity.

The entire article is here.

Vignette 14: The Psychology of Advertising

Dr. Ron Popeil, a local psychologist, is upgrading his web site.  Along with a variety of upgrades, the web developer/consultant suggests that he add a testimonial page where former patients describe their positive experiences in therapy.  Since the web developer/consultant wants to get that page up and running, he suggests that they use some positive ratings and responses from Angie’s list and several other ratings sites that tell positive stories and experiences with Dr. Popeil.

Dr. Popeil thinks these ideas are good.  However, he researches the APA Ethics Code and believes that he may be acting inappropriately.  To discuss the matter in further detail,  Dr. Popeil calls you for an ethics consult.

What are the ethical issues involved in this situation?

Are there any other concerns about the web developer/consultant’s strategies?

What are some recommendations that you would make to the psychologist?

Vignette 13: Troubles in the ICU

You are a psychologist in a busy acute care hospital where you receive frequent consultation requests by the trauma service.  A physician requests a psychological evaluation of a 46-year-old man who attempted suicide via over dose of prescription medications along with alcohol. You arrive in the intensive care unit where the patient’s respiratory status is rapidly deteriorating. He is marginally coherent and unable to give any consistent responses.  However, upon his arrival in the emergency department, the medical record quotes the patient as saying, “This wasn’t supposed to have happened.”

The ICU nurse asks you to offer an opinion regarding the patient’s capacity to accept or refuse intubation.

While you are there, a family member arrives with a copy of a notarized advance directive, created within the last year, which specifically outlines the patient’s wishes not to be placed on a ventilator or any artificial life support. The ICU staff asks for your input.

What are the ethical issues involved?

What would you do in this situation?

Would your answer differ if the advanced directive was created 7 years ago or greater?

Would your answer differ if there were no advanced directives?

Vignette 11: An Unexpected Inheritance

A psychologist receives a letter from an attorney indicating that he inherited an old car from Frank Palmer.  Upon reflection, the psychologist recalls that he had treated Mr. Palmer a number of years ago.  Looking through his files, the psychologist cannot find his file, so it must have been more than five years ago.

The psychologist phones the attorney and discovers that Mr. Palmer left him a 1993 four-wheel drive Ford Explorer.  He asked the attorney if anyone is contesting the will.  Apparently, no one is.  The executor is Mr. Palmer’s brother, who lives in a different state.

The psychologist obtains the keys and title for the vehicle.  He drives the car to a local dealer who indicated that the Explorer is worth about $3,500.

The psychologist cannot remember many details about the patient.   He recalled that he was an older person with significant depression who eventually became better.  There is nothing unusual that stands out about their therapeutic relationship.

Feeling guilty, the psychologist calls you on the phone to discuss his feelings and any possible ethical concerns.

What are the potential ethical concerns about this scenario, if any?

What suggestions or options would you give the psychologist?

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

While a similar experience happened to a psychologist, for further discussion with students, supervisees, or colleagues, the educator or group leader may want to compare and contrast the ethics and options with different details.

Use the same scenario with an antique car worth $50,000 and a family member is contesting the psychologist’s portion of the will.

Would your opinions change about the ethical issues and options related to the situation.  If so, what is different that changes the opinions?

Ethical Questions Raised About Letters of Recommendation

By Trysh Travis

Inside Higher Ed

Originally Published February 27, 2012

Can I ethically say, "No, I will not write you a letter of recommendation"?

I'm not talking about saying no to a student who comes in the day before a deadline and asks you for a letter, or the cases where the student is unable to get you a transcript, waiver form, and all that stuff by the deadline. Those are easy calls. Nor am I talking about the — fairly frequent — occasions when a student who did not do particularly well in a class asks for a recommendation. At a huge public university like mine, students will often seek a letter from any instructor who knows their name. Since I teach relatively small general education classes, that is often me. In such cases, it’s easy to tell a student, "I'm happy to write for you, but you have to know my letter will say you earned a B- and were absent six times; are you sure you want a letter like that?" Sometimes they do, sometimes they don’t, but either way my conscience is clear.

No, what I'm talking about here is the ethically fraught situation where a student wants a letter for a program in which they are unlikely to succeed — and in which they may actually come to harm.  Since the economic downturn, I have found myself in this position a few times. One extreme example occurred last spring, when a student wanted a recommendation for an unpaid internship with an NGO in Africa. There was very little information about the organization on the website, and the student was not really sure what she would do as an intern there. She'd had an interview, but was reluctant to ask too many questions, she said, for fear she would seem "difficult" and not be offered the position. Despite knowing almost nothing about it, she'd decided the internship was necessary for her career goals. The issue of safety and of the cost of traveling and living near the placement, not to mention the substantive question of what kind of experience (if any) she’d gain from working in an organization that couldn’t even describe its expectations for employees — all this seemed, to her, irrelevant. Should I recommend a student into such a potentially useless, if not outright exploitative situation?

A less exotic version of this conundrum has come up several times in the last 18 months or so: the students who seek a recommendation for a graduate degree at a for-profit university, which they plan to finance through private loans or, worse, a credit card. The best undergraduates I teach get into top-flight graduate and professional schools and, even though law school placements of late have shaken my faith in the value of that degree, the insane costs of such programs make a kind of sense — at least for now.

The entire story is here.