Conflict of Interest: Why Does It Matter?

Harvey V. Fineberg
JAMA. 2017;317(17):1717-1718.

Preservation of trust is the essential purpose of policies about conflict of interest. Physicians have many important roles including caring for individual patients, protecting the public’s health, engaging in research, reporting scientific and clinical discoveries, crafting professional guidelines, and advising policy makers and regulatory bodies. Success in all these functions depends on others—laypersons, professional peers, and policy leaders—believing and acting on the word of physicians. Therefore, the confidence of others in physician judgment is of paramount importance. When trust in physician judgment is impaired, the role of physicians is diminished.

Physicians should make informed, disinterested judgments. To be disinterested means being free of personal advantage. The type of advantage that is typically of concern in most situations involving physicians is financial. When referring to conflict of interest, the term generally means a financial interest that relates to the issue at hand. More specifically, a conflict of interest can be discerned by using a reasonable person standard; ie, a conflict of interest exists when a reasonable person would interpret the financial circumstances pertaining to a situation as potentially sufficient to influence the judgment of the physician in question.

The article is here.

Doctors Behaving Badly

By Roni Caryn Rabin
The New York Times - Well
Originally published

Here is an excerpt:

Nancy Berlinger, a scholar at The Hastings Center who writes about ethical challenges in health care as well as issues of power between junior and senior clinicians, disagrees. “Doctors must be respectful even if a patient is sedated,” she said. And in these cases, she said, the supervising physicians also did harm to the medical students they were responsible for training and mentoring.

“This is the worst thing a role model can do: to suggest that wrong behavior is acceptable, to nudge junior people to be callous and to misuse power,” Dr. Berlinger said. In both cases, the senior doctors made a trainee student complicit in their abuse and “made them feel dirty at an early stage of their careers.”

The entire article is here.

Weird Minds Might Destabilize Human Ethics

By Eric Schwitzgebel
The Splintered Mind Blog
Originally published August 13, 2015

Here is an excerpt:

For physics and biology, we have pretty good scientific theories by which to correct our intuitive judgments, so it's no problem if we leave ordinary judgment behind in such matters. However, it's not clear that we have, or will have, such a replacement in ethics. There are, of course, ambitious ethical theories -- "maximize happiness", "act on that maxim that you can at the same time will to be a universal law" -- but the development and adjudication of such theories depends, and might inevitably depend, on our intuitive judgments about such cases. It's because we intuitively or pre-theoretically think we shouldn't give all our cookies to the utility monster or kill ourselves to tile the solar system with hedonium that we reject the straightforward extension of utilitarian happiness-maximizing theory to such cases and reach for a different solution. But if our commonplace ethical judgments about such cases are not to be trusted, because these cases are too far beyond what we can reasonably expect human moral intuition to handle well, what then? Maybe we should kill ourselves to tile the solar system with hedonium (the minimal collection of atoms capable of feeling pleasure), and we're just unable to appreciate this fact with moral theories shaped for our limited ancestral environments?

The entire blog post is here.

Ethical Judgments of Counselors: Results From a Turkish Sample

By Rahsan Sivis-Cetinkaya
Ethics & Behavior
DOI:10.1080/10508422.2014.941981

Abstract

The present study examined the ethical judgements of Turkish counselors (N = 767) using a translation of the Gibson and Pope (1993) ethical judgements survey. Items predominantly judged as ethical and unethical, and group differences regarding gender, taking ethics as a course, professional affiliation, and level of academic degree, were investigated. Chi-square analysis, Fishers’s exact test, and Fisher–Freeman–Halton tests were used in statistical analysis. Results revealed that participants predominantly judged breach of confidentiality in cases of child abuse and potential harm toward oneself or others as ethical. Items concerning sexual dual relationships were predominantly perceived as unethical, and male participants were more likely to judge items regarding sexual and nonsexual dual relationships as ethical. Implications for future research and practice are discussed.

The entire article is here.

Are we journalists first?

The longstanding debate about whether and when a reporter can intervene in a story is rekindled in the age of inequality

By Alexis Fitts and Nicola Pring
Columbia Journal Review
Originally published July 1, l2014

Here are a few excerpts:

She watched children beg their way into play dates for the promise of a meal. She watched a teacher handing out apples be thronged by more hungry students than he could feed.

She never offered help. When a photographer she was working with gave a bag of groceries to one family, Nazario felt he had crossed an ethical line. “I think what was beaten into me early as a reporter was you don’t intervene or change a story that you’re writing about,” says Nazario. As she would patiently explain to each subject at the beginning of her reporting, she was there to observe, to tell a story that alerts the public to problems and hopefully motivates others to address those problems. It is a traditional notion of objectivity that has been American journalism’s defining ideal for more than a century.

(cut)

The irony is that Nazario’s story had real impact: Within 24 hours of its publication, child-abuse reports in Los Angeles County increased by 20 percent, and eventually rose 45 percent. The county ordered an audit of the Child Welfare Agency and reorganized its reporting hotlines. More federal and state funds were allocated to programs for addicted mothers. The story also improved the lives of the families she’d profiled: The county placed Tamika Triggs in a foster home; her mother was admitted to a choice rehabilitation program.

The entire story is here.

Thanks to Dr. Deborah Derrickson Kossmann for this story.

Editor's note: Clearly, psychologists face issues related to poverty, inequality, and emotional suffering. An ethical dilemma may emerge when a psychologist struggles with boundary issues while in their professional role.  These issues typically involve compassion overriding professional judgment and role.

Research: We Should Speak Up About Ethical Violations More Often

by Joseph Grenny
Harvard Business Review
Originally published on January 8, 2014

Whistle-blowing reveals not just acute misdeeds, but chronic and longstanding patterns of misconduct. For example, Edward Snowden’s bombshell release of more than 200,000 documents revealed questionable government surveillance programs that existed for years. Miami Dolphins player Jonathan Martin withdrew from play, alleging more than a year of emotional abuse from teammate Richie Incognito. These high-profile cases are just a few examples of what happens in organizations large and small every day.

And yet, many leaders wrongly believe the path to consistent, proper conduct is special methods to reward whistle-blowing — offering incentives to truth-tellers who report major lapses. The SEC, for example, offers up to 30 percent of recovered funds as payment to those whose testimony aids in prosecution of corporate wrongdoing. One payment recently topped $14 million. Is a multimillion-dollar payday the key to corporate ethics?

The entire article is here.

Blind ethics: Closing one’s eyes polarizes moral judgments and discourages dishonest behavior

AUTHORS: E. M. Caruso and F. Gino
PUBLICATION: Cognition (forthcoming)

ABSTRACT

Four experiments demonstrate that closing one's eyes affects ethical judgment and behavior because it induces people to mentally simulate events more extensively. People who considered situations with their eyes closed rather than open judged immoral behaviors as more unethical and moral behaviors as more ethical. In addition, considering potential decisions with closed eyes decreased stated intentions to behave ethically and actual self-interested behavior. This relationship was mediated by the more extensive mental simulation that occurred with eyes closed rather than open, which, in turn, intensified emotional reactions to the ethical situation. We discuss the implications of these findings for moral psychology and ethical decision making.

The entire article is here.

Girls Talk: The Sexualization of Girls

By the American Psychological Association

APA's Public Interest directorate invited six middle school girls to sit down and share their thoughts about the images of girls they see all around them and how they feel about the way girls today are portrayed.




The Executive Summary of this report can be found here.

Empathy Plays a Key Role in Moral Judgments

Science Daily
Originally published May 22, 2013

Is it permissible to harm one to save many? Those who tend to say "yes" when faced with this classic dilemma are likely to be deficient in a specific kind of empathy, according to a report published in the scientific journal PLOS ONE.

Philosophers and psychologists have long argued about whether there is one "right" answer to such moral questions, be it utilitarian ethics, which advocates saving as many as possible, even if it requires personally harming an individual, or non-utilitarian principles, which mandate strict adherence to rules like "don't kill" that are rooted in the value of human life and dignity.

In their new report, co-authors Liane Young, an assistant professor of psychology at Boston College, and Ezequiel Gleichgerrcht of the Institute of Cognitive Neurology and Favaloro University in Argentina, address two key questions related to moral decision-making: First, what specific aspect of emotional responding is relevant for these judgments? Second, is this aspect of emotional responding selectively reduced in utilitarian respondents or enhanced in non-utilitarians?

The entire story is here.

The entire article is here.

Abstract

Is it permissible to harm one to save many? Classic moral dilemmas are often defined by the conflict between a putatively rational response to maximize aggregate welfare (i.e., the utilitarian judgment) and an emotional aversion to harm (i.e., the non-utilitarian judgment). Here, we address two questions. First, what specific aspect of emotional responding is relevant for these judgments? Second, is this aspect of emotional responding selectively reduced in utilitarians or enhanced in non-utilitarians? The results reveal a key relationship between moral judgment and empathic concern in particular (i.e., feelings of warmth and compassion in response to someone in distress). Utilitarian participants showed significantly reduced empathic concern on an independent empathy measure. These findings therefore reveal diminished empathic concern in utilitarian moral judges.

Citation: Gleichgerrcht E, Young L (2013) Low Levels of Empathic Concern Predict Utilitarian Moral Judgment. PLoS ONE 8(4): e60418. doi:10.1371/journal.pone.0060418

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?

Of Medical Giants, Accolades and Feet of Clay

By LAWRENCE K. ALTMAN, M.D.
The New York Times
Published: April 1, 2013

Medicine honors its heroes in many ways. But sometimes high accolades can turn out to be highly embarrassing.

Consider the annual award for lifetime achievement in preventing and controlling sexual infections, given since 1972 by the American Sexually Transmitted Diseases Association. The prize is named for an authentic giant of medicine: Dr. Thomas Parran Jr., the nation’s sixth surgeon general (from 1936 to 1948), who used what was then a supremely powerful position to lift American public health to the front ranks.

At a time when “venereal diseases” were spoken of in whispers, Dr. Parran influenced Congress to finance rapid-treatment centers to control and prevent syphilis, gonorrhea and chancroid.

(cut)

The debate over the Parran Award throws a spotlight on the issue of changing standards in medicine. What are scientists to do when they name their most prestigious award for an icon linked years later to unethical research?

The two medical scandals revolved around experiments that are now universally regarded as shocking. Dr. Parran did not perform either study. Though national experts approved them both, he presided over them, strongly supported them and followed their progress in medical journals.

One, the Tuskegee study, observed the course of untreated syphilis among hundreds of men who were infected naturally in Alabama. The study began in 1932, and it was not halted by the United States Public Health Service until 1972, after a whistle-blower complained that infected patients in the study were not given penicillin, the standard therapy after World War II.  Some participants died of the disease, some of their sexual partners contracted it, and some children were born infected.

The entire story is here.

Physicians' Top Ethical Dilemmas: Medscape 2012 Survey Results

Physicians' Top Ethical Dilemmas

Would you fight with a family that wanted to withdraw care from a viable patient? Would you follow the family's directive to continue treatment if you thought it was futile? Would you date a patient? More than 24,000 physicians told us how they feel about this and other ethical dilemmas.

The entire survey is here.

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.

When Is It Okay to Date a Patient?

By Shelly Reese
Medscape Ethics Report 2012
Originally published November 15, 2012


Introduction

To the besotted poet, love is intoxicating, exasperating, invigorating. To the doctor -- if the would-be paramour is a patient -- it's also unethical.

But physician responses to Medscape's 2012 ethics survey clearly indicate that many physicians aren't willing to condemn every romance. When asked, "Is it ever acceptable to become involved a romantic or sexual relationship with a patient?" more than two thirds (68%) of the 24,000 doctors who responded resoundingly say "no."

In contrast, nearly one third are more nuanced in their view. Only a tiny minority (1%) give romance with current patients a green light, but a sizable share (22%) say that a romantic relationship with a former patient may be acceptable, as long as at least 6 months have passed since the professional relationship was terminated. Another 9% say the ethics depend on the situation.

Whereas the American Medical Association (AMA) clearly states that sexual contact that is concurrent with the doctor/patient relationship constitutes sexual misconduct, it takes a fuzzier position on relationships that might develop later. The AMA notes that the prior doctor/patient relationship may unduly influence the patient and that such a relationship is unethical if the doctor "uses or exploits trust, knowledge, emotions or influence derived from the previous professional relationship."

Ethicists, such as Dr. Richard Martinez, director of forensic psychiatry services at Denver Health Medical Center and the author of several articles on ethical decision-making and the patient/physician relationship, says the AMA was wise to leave a little wiggle room in its opinion.

"Relationships are complicated," he says. "Every ethical dilemma has to be evaluated and considered on a case-by-case basis."

The entire story is here.

Thanks to Gary Schoener for this information.

Studies Find More Students Cheating, With High Achievers No Exception

By Richard Perez-Pena
The New York Times
Originally published September 7, 2012

Large-scale cheating has been uncovered over the last year at some of the nation’s most competitive schools, like Stuyvesant High School in Manhattan, the Air Force Academy and, most recently, Harvard.

Studies of student behavior and attitudes show that a majority of students violate standards of academic integrity to some degree, and that high achievers are just as likely to do it as others. Moreover, there is evidence that the problem has worsened over the last few decades.

Experts say the reasons are relatively simple: Cheating has become easier and more widely tolerated, and both schools and parents have failed to give students strong, repetitive messages about what is allowed and what is prohibited.

“I don’t think there’s any question that students have become more competitive, under more pressure, and, as a result, tend to excuse more from themselves and other students, and that’s abetted by the adults around them,” said Donald L. McCabe, a professor at the Rutgers University Business School, and a leading researcher on cheating.

The entire story is here.

NH psychologist's sex charges reinstated

Hollenbeck’s sex charges reinstated

By Danielle Rivard
Sentinel Source.com
Originally published September 6, 2012

The case of a psychologist with a practice in Keene who was accused of having sex with a former patient is headed back to court.

Burton G. Hollenbeck Jr., 58, of Richmond faced 30 counts of aggravated felonious sexual assault before a Cheshire County Superior Court judge dismissed the charges.

Prosecutors appealed to the N.H. Supreme Court, which reversed the decision in a ruling released Wednesday.

Hollenbeck was accused of engaging in sexual conduct with the woman less than a year after her therapy with him ended, which violates state law, according to court documents.

(cut)

In its 3-1 decision Wednesday, the N.H. Supreme Court said the state has a legitimate interest in protecting people whose ability to consent to sexual contact may be compromised by the inherent nature of the treatment relationship, and in maintaining the integrity of mental health professionals.

The entire story is here.

An Academic Ghostwriter, the 'Shadow Scholar,' Comes Clean

By Dan Berrett

The Chronicle of Higher Education

Originally published on August 21, 2012

When The Chronicle published a confessional essay two years ago by a writer for a student-paper mill who had spent nearly a decade helping college students cheat on their assignments, it provoked anger, astonishment, and weary resignation.

The writer, under the pseudonym Ed Dante, said he had completed scores of papers for students who were too lazy or simply unprepared for their work at the undergraduate, master's, and doctoral levels.

The academic ghostwriter has retired, and in his new memoir, he reveals his true identity: Dave Tomar, 32, a graduate of the bachelor's program in communications at Rutgers University's New Brunswick campus and, now, a freelance writer in Philadelphia.

In The Shadow Scholar: How I Made a Living Helping College Kids Cheat, which is due out next month from Bloomsbury, Mr. Tomar seeks to cast himself as a millennial antihero while scolding colleges for placing the pursuit of money and status above student learning.

The entire article is here.

Psychologist Has License Suspended

By Robert Cook
PortsmouthPatch - Public Safety
Originally published August 14, 2012

An Exeter psychologist charged with running a prostitution operation out of his Portsmouth apartment has had his license temporarily suspended by the New Hampshire Board of Mental Health.

Alexander Marino, 38, of 565 Sagamore Ave., in Portsmouth is currently free on bail following his arrest for allowing his apartment in Sagamore Court to be used for prostitution. But until Monday, he was free to keep treating patients.

Peggy Lynch, the board's administrative assistant, said the board has scheduled a review hearing with Marino at Merrimack County Superior Court in Concord on Aug. 27 to determine if his license to practice psychiatry in New Hampshire will remain suspended or be re-instated as his criminal case proceeds through the court system.

The entire article 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?