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

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

Tuesday, June 18, 2024

Medical-Targeted Ransomware Is Breaking Records After Change Healthcare’s $22M Payout

Andy Greenberg
wired.com
Originally posted 12 June 24

When Change Healthcare paid $22 million in March to a ransomware gang that had crippled the company along with hundreds of hospitals, medical practices, and pharmacies across the US, the cybersecurity industry warned that Change's extortion payment would only fuel a vicious cycle: Rewarding hackers who had carried out a ruthless act of sabotage against the US health care system nationwide with one of the largest ransomware payments in history, it seemed, was bound to incentivize a new wave of attacks on similarly sensitive victims. Now that wave has arrived.

In April, cybersecurity firm Recorded Future tracked 44 cases of cybercriminal groups targeting health care organizations with ransomware attacks, stealing their data, encrypting their systems, and demanding payments from the companies while holding their networks hostage. That's more health care victims of ransomware than in any month Recorded Future has seen in its four years of collecting that data, says Allan Liska, a threat intelligence analyst at the company. Comparing that number to the 30 incidents in March, it's also the second biggest month-to-month jump in incidents the company has ever tracked.

While Liska notes that he can't be sure of the reason for that spike, he argues it's unlikely to be a coincidence that it follows in the wake of Change Healthcare's eight-figure payout to the hacker group known as AlphV or BlackCat that was tormenting the company.


Here are some thoughts:

The recent record-breaking ransom payment by a healthcare giant raises a troubling question: are profits being prioritized over patient well-being? This approach creates an ethical dilemma and poses serious psychological and public health risks.

Imagine needing urgent medical attention, only to find your records inaccessible due to a cyberattack. Ransomware disrupts services, causing immense anxiety for patients. Disrupted access to data can delay diagnoses, hinder treatment, and even threaten public health initiatives. Furthermore, these attacks essentially blackmail healthcare providers, potentially eroding trust in the medical system.

To combat this growing threat, we need a multi-pronged approach. Healthcare institutions must prioritize robust cybersecurity. International law enforcement collaboration is crucial to hold cybercriminals accountable. Finally, open communication with patients during and after an attack is essential to rebuild trust and minimize stress. By working together, we can build a more resilient healthcare system that safeguards patient data and well-being.

Monday, May 13, 2024

Ethical Considerations When Confronted by Racist Patients

Charles Dike
Psychiatric News
Originally published 26 Feb 24

Here is an excerpt:

Abuse of psychiatrists, mostly verbal but sometimes physical, is common in psychiatric treatment, especially on inpatient units. For psychiatrists trained decades ago, experiencing verbal abuse and name calling from patients—and even senior colleagues and teachers—was the norm. The abuse began in medical school, with unconscionable work hours followed by callous disregard of students’ concerns and disparaging statements suggesting the students were too weak or unfit to be doctors.

This abuse continued into specialty training and practice. It was largely seen as a necessary evil of attaining the privilege of becoming a doctor and treating patients whose uncivil behaviors can be excused on account of their ill health. Doctors were supposed to rise above those indignities, focus on the task at hand, and get the patients better in line with our core ethical principles that place caring for the patient above all else. There was no room for discussion or acknowledgement of the doctors’ underlying life experiences, including past trauma, and how patients’ behavior would affect doctors.

Moreover, even in recent times, racial slurs or attacks against physicians of color were not recognized as abuse by the dominant group of doctors; the affected physicians who complained were dismissed as being too sensitive or worse. Some physicians, often not of color, have explained a manic patient’s racist comments as understandable in the context of disinhibition and poor judgment, which are cardinal symptoms of mania, and they are surprised that physicians of color are not so understanding.


Here is a summary:

This article explores the ethical dilemma healthcare providers face when treating patients who express racist views. It acknowledges the provider's obligation to care for the patient's medical needs, while also considering the emotional toll of racist remarks on both the provider and other staff members.

The article discusses the importance of assessing the urgency of the patient's medical condition and their mental capacity. It explores the option of setting boundaries or termination of treatment in extreme cases, while also acknowledging the potential benefits of attempting a dialogue about the impact of prejudice.

Sunday, April 21, 2024

An Expert Who Has Testified in Foster Care Cases Across Colorado Admits Her Evaluations Are Unscientific

Eli Hager
Originally posted 18 March 24

Diane Baird had spent four decades evaluating the relationships of poor families with their children. But last May, in a downtown Denver conference room, with lawyers surrounding her and a court reporter transcribing, she was the one under the microscope.

Baird, a social worker and professional expert witness, has routinely advocated in juvenile court cases across Colorado that foster children be adopted by or remain in the custody of their foster parents rather than being reunified with their typically lower-income birth parents or other family members.

In the conference room, Baird was questioned for nine hours by a lawyer representing a birth family in a case out of rural Huerfano County, according to a recently released transcript of the deposition obtained by ProPublica.

Was Baird’s method for evaluating these foster and birth families empirically tested? No, Baird answered: Her method is unpublished and unstandardized, and has remained “pretty much unchanged” since the 1980s. It doesn’t have those “standard validity and reliability things,” she admitted. “It’s not a scientific instrument.”

Who hired and was paying her in the case that she was being deposed about? The foster parents, she answered. They wanted to adopt, she said, and had heard about her from other foster parents.

Had she considered or was she even aware of the cultural background of the birth family and child whom she was recommending permanently separating? (The case involved a baby girl of multiracial heritage.) Baird answered that babies have “never possessed” a cultural identity, and therefore are “not losing anything,” at their age, by being adopted. Although when such children grow up, she acknowledged, they might say to their now-adoptive parents, “Oh, I didn’t know we were related to the, you know, Pima tribe in northern California, or whatever the circumstances are.”

The Pima tribe is located in the Phoenix metropolitan area.


Here is my summary:

The article discusses Diane Baird, an expert who has testified in foster care cases across Colorado, admitting that her evaluations are unscientific. Baird, who has spent four decades evaluating the relationships of poor families with their children, labeled her method for assessing families as the "Kempe Protocol." This revelation raises concerns about the validity of her evaluations in foster care cases and highlights the need for more rigorous and scientific approaches in such critical assessments.

Monday, February 5, 2024

Should Patients Be Allowed to Die From Anorexia? Is a 'Palliative' Approach to Mental Illness Ethical?

Katie Engelhart
New York Times Magazine
Originally posted 3 Jan 24

Here is an excerpt:

He came to think that he had been impelled by a kind of professional hubris — a hubris particular to psychiatrists, who never seemed to acknowledge that some patients just could not get better. That psychiatry had actual therapeutic limits. Yager wanted to find a different path. In academic journals, he came across a small body of literature, mostly theoretical, on the idea of palliative psychiatry. The approach offered a way for him to be with patients without trying to make them better: to not abandon the people who couldn’t seem to be fixed. “I developed this phrase of ‘compassionate witnessing,’” he told me. “That’s what priests did. That’s what physicians did 150 years ago when they didn’t have any tools. They would just sit at the bedside and be with somebody.”

Yager believed that a certain kind of patient — maybe 1 or 2 percent of them — would benefit from entirely letting go of standard recovery-oriented care. Yager would want to know that such a patient had insight into her condition and her options. He would want to know that she had been in treatment in the past, not just once but several times. Still, he would not require her to have tried anything and everything before he brought her into palliative care. Even a very mentally ill person, he thought, was allowed to have ideas about what she could and could not tolerate.

If the patient had a comorbidity, like depression, Yager would want to know that it was being treated. Maybe, for some patients, treating their depression would be enough to let them keep fighting. But he wouldn’t insist that a person be depression-free before she left standard treatment. Not all depression can be cured, and many people are depressed and make decisions for themselves every day. It would be Yager’s job to tease out whether what the patient said she wanted was what she authentically desired, or was instead an expression of pathological despair. Or more: a suicidal yearning. Or something different: a cry for help. That was always part of the job: to root around for authenticity in the morass of a disease.


Some thoughts:

The question of whether patients with anorexia nervosa should be allowed to die from their illness or receive palliative care is a complex and emotionally charged one, lacking easy answers. It delves into the profound depths of autonomy, mental health, and the very meaning of life itself.

The Anorexic's Dilemma:

Anorexia nervosa is a severe eating disorder characterized by a relentless pursuit of thinness and an intense fear of weight gain. It often manifests in severe food restriction, excessive exercise, and distorted body image. This relentless control, however, comes at a devastating cost. Organ failure, malnutrition, and even death can be the tragic consequences of the disease's progression.

Palliative Care: Comfort Not Cure:

Palliative care focuses on symptom management and improving quality of life for individuals with life-threatening illnesses. In the context of anorexia, it would involve addressing physical discomfort, emotional distress, and spiritual concerns, but without actively aiming for weight gain or cure. This raises numerous ethical and practical questions:
  • Respecting Autonomy: Does respecting a patient's autonomy mean allowing them to choose a path that may lead to death, even if their decision is influenced by a mental illness?
  • The Line Between Choice and Coercion: How do we differentiate between a genuine desire for death and succumbing to the distorted thinking patterns of anorexia?
  • Futility vs. Hope: When is treatment considered futile, and when should hope for recovery, however slim, be prioritized?
Finding the Middle Ground:

There's no one-size-fits-all answer to this intricate dilemma. Each case demands individual consideration, taking into account the patient's mental capacity, level of understanding, and potential for recovery. Open communication, involving the patient, their family, and a multidisciplinary team of healthcare professionals, is crucial in navigating this sensitive terrain.

Potential Approaches:
  • Enhanced Supportive Care: Focusing on improving the patient's quality of life through pain management, emotional support, and addressing underlying psychological issues.
  • Conditional Palliative Care: Providing palliative care while continuing to offer and encourage life-sustaining treatment, with the possibility of transitioning back to active recovery if the patient shows signs of willingness.
  • Advance Directives: Encouraging patients to discuss their wishes and preferences beforehand, allowing for informed decision-making when faced with difficult choices.

Tuesday, January 23, 2024

What Is It That You Want Me To Do? Guidance for Ethics Consultants in Complex Discharge Cases

Omelianchuk, A., Ansari, A.A. & Parsi, K.
HEC Forum (2023).

Abstract

Some of the most difficult consultations for an ethics consultant to resolve are those in which the patient is ready to leave the acute-care setting, but the patient or family refuses the plan, or the plan is impeded by deficiencies in the healthcare system. Either way, the patient is “stuck” in the hospital and the ethics consultant is called to help get the patient “unstuck.” These encounters, which we call “complex discharges,” are beset with tensions between the interests of the institution and the interests of the patient as well as tensions within the ethics consultant whose commitments are shaped both by the values of the organization and the values of their own profession. The clinical ethics literature on this topic is limited and provides little guidance. What is needed is guidance for consultants operating at the bedside and for those participating at a higher organizational level. To fill this gap, we offer guidance for facilitating a fair process designed to resolve the conflict without resorting to coercive legal measures. We reflect on three cases to argue that the approach of the consultant is generally one of mediation in these types of disputes. For patients who lack decision making capacity and lack a surrogate decision maker, we recommend the creation of a complex discharge committee within the organization so that ethics consultants can properly discharge their duties to assist patients who are unable to advocate for themselves through a fair and transparent process.

The article is paywalled.  Please contact the author for full copy.

Here is my summary:
  • Ethics consultants face diverse patient situations, including lack of desire to leave, potential mental health issues, and financial/space constraints.
  • Fair discharge processes are crucial, through mediation or multidisciplinary committees, balancing patient needs with system limitations.
  • "Conveyor belt" healthcare can strain trust and create discharge complexities.
  • The ethics consultant role is valuable but limited, suggesting standing "complex case committees" with diverse expertise for effective, creative solutions.
In essence, this summary highlights the need for a more nuanced and collaborative approach to complex discharges, prioritizing patient well-being while recognizing systemic constraints.

Thursday, January 18, 2024

Biden administration rescinds much of Trump ‘conscience’ rule for health workers

Nathan Weixel
The Hill
Originally published 9 Jan 24

The Biden administration will largely undo a Trump-era rule that boosted the rights of medical workers to refuse to perform abortions or other services that conflicted with their religious or moral beliefs.

The final rule released Tuesday partially rescinds the Trump administration’s 2019 policy that would have stripped federal funding from health facilities that required workers to provide any service they objected to, such as abortions, contraception, gender-affirming care and sterilization.

The health care conscience protection statutes represent Congress’s attempt to strike a balance between maintaining access to health care and honoring religious beliefs and moral convictions, the Department of Health and Human Services said in the rule.

“Some doctors, nurses, and hospitals, for example, object for religious or moral reasons to providing or referring for abortions or assisted suicide, among other procedures. Respecting such objections honors liberty and human dignity,” the department said.

But at the same time, Health and Human Services said “patients also have rights and health needs, sometimes urgent ones. The Department will continue to respect the balance Congress struck, work to ensure individuals understand their conscience rights, and enforce the law.”


Summary from Healthcare Dive

The HHS Office of Civil Rights has again updated guidance on providers’ conscience rights. The latest iteration, announced on Tuesday, aims to strike a balance between honoring providers’ religious and moral beliefs and ensuring access to healthcare, according to the agency.

President George W. Bush created conscience rules in 2008, which codify the rights of healthcare workers to refuse to perform medical services that conflict with their religious or moral beliefs. Since then, subsequent administrations have rewritten the rules, with Democrats limiting the scope and Republicans expanding conscience protections. 

The most recent revision largely undoes a 2019 Trump-era policy — which never took effect — that sought to expand the rights of healthcare workers broadly to refuse to perform medical services, such as abortions, on religious or moral grounds.

Saturday, December 9, 2023

Physicians’ Refusal to Wear Masks to Protect Vulnerable Patients—An Ethical Dilemma for the Medical Profession

Dorfman D, Raz M, Berger Z.
JAMA Health Forum. 2023;4(11):e233780.
doi:10.1001/jamahealthforum.2023.3780

Here is an excerpt:

In theory, the solution to the problem should be simple: patients who wear masks to protect themselves, as recommended by the CDC, can ask the staff and clinicians to wear a mask as well when seeing them, and the clinicians would oblige given the efficacy masks have shown in reducing the spread of respiratory illnesses. However, disabled patients report physicians and other clinical staff having refused to wear a mask when caring for them. Although it is hard to know how prevalent this phenomenon is, what recourse do patients have? How should health care systems approach clinicians and staff who refuse to mask when treating a disabled patient?

Physicians have a history of antagonism to the idea that they themselves might present a health risk to their patients. Famously, when Hungarian physician Ignaz Semmelweis originally proposed handwashing as a measure to reduce purpureal fever, he was met with ridicule and ostracized from the profession.

Physicians were also historically reluctant to adopt new practices to protect not only patients but also physicians themselves against infection in the midst of the AIDS epidemic. In 1985, the CDC presented its guidance on workplace transmission, instructing physicians to provide care, “regardless of whether HCWs [health care workers] or patients are known to be infected with HTLV-III/LAV [human T-lymphotropic virus type III/lymphadenopathy-associated virus] or HBV [hepatitis B virus].” These CDC guidelines offered universal precautions, common-sense, nonstigmatizing, standardized methods to reduce infection. Yet, some physicians bristled at the idea that they need to take simple, universal public health steps to prevent transmission, even in cases in which infectivity is unknown, and instead advocated for a medicalized approach: testing or masking only in cases when a patient is known to be infected. Such an individualized medicalized approach fails to meet the public health needs of the moment.

Patients are the ones who pay the price for physicians’ objections to changes in practices, whether it is handwashing or the denial of care as an unwarranted HIV precaution. Yet today, with the enactment of disability antidiscrimination law, patients are protected, at least on the books.

As we have written elsewhere, federal law supports the right of a disabled individual to request masking as a reasonable disability accommodation in the workplace and at schools.


Here is my summary:

This article explores the ethical dilemma arising from physicians refusing to wear masks, potentially jeopardizing the protection of vulnerable patients. The author delves into the conflict between personal beliefs and professional responsibilities, questioning the ethical implications of such refusals within the medical profession. The analysis emphasizes the importance of prioritizing patient well-being and public health over individual preferences, calling for a balance between personal freedoms and ethical obligations in healthcare settings.

Wednesday, August 9, 2023

The Moral Crisis of America’s Doctors

Wendy Dean & Elisabeth Rosenthal
The New York Times
Orignally posted 15 July 23

Here is an excerpt:

Some doctors acknowledged that the pressures of the system had occasionally led them to betray the oaths they took to their patients. Among the physicians I spoke to about this, a 45-year-old critical-care specialist named Keith Corl stood out. Raised in a working-class town in upstate New York, Corl was an idealist who quit a lucrative job in finance in his early 20s because he wanted to do something that would benefit people. During medical school, he felt inspired watching doctors in the E.R. and I.C.U. stretch themselves to the breaking point to treat whoever happened to pass through the doors on a given night. “I want to do that,” he decided instantly. And he did, spending nearly two decades working long shifts as an emergency physician in an array of hospitals, in cities from Providence to Las Vegas to Sacramento, where he now lives. Like many E.R. physicians, Corl viewed his job as a calling. But over time, his idealism gave way to disillusionment, as he struggled to provide patients with the type of care he’d been trained to deliver. “Every day, you deal with somebody who couldn’t get some test or some treatment they needed because they didn’t have insurance,” he said. “Every day, you’re reminded how savage the system is.”

Corl was particularly haunted by something that happened in his late 30s, when he was working in the emergency room of a hospital in Pawtucket, R.I. It was a frigid winter night, so cold you could see your breath. The hospital was busy. When Corl arrived for his shift, all of the facility’s E.R. beds were filled. Corl was especially concerned about an elderly woman with pneumonia who he feared might be slipping into sepsis, an extreme, potentially fatal immune response to infection. As Corl was monitoring her, a call came in from an ambulance, informing the E.R. staff that another patient would soon be arriving, a woman with severe mental health problems. The patient was familiar to Corl — she was a frequent presence in the emergency room. He knew that she had bipolar disorder. He also knew that she could be a handful. On a previous visit to the hospital, she detached the bed rails on her stretcher and fell to the floor, injuring a nurse.

In a hospital that was adequately staffed, managing such a situation while keeping tabs on all the other patients might not have been a problem. But Corl was the sole doctor in the emergency room that night; he understood this to be in part a result of cost-cutting measures (the hospital has since closed). After the ambulance arrived, he and a nurse began talking with the incoming patient to gauge whether she was suicidal. They determined she was not. But she was combative, arguing with the nurse in an increasingly aggressive tone. As the argument grew more heated, Corl began to fear that if he and the nurse focused too much of their attention on her, other patients would suffer needlessly and that the woman at risk of septic shock might die.

Corl decided he could not let that happen. Exchanging glances, he and the nurse unplugged the patient from the monitor, wheeled her stretcher down the hall, and pushed it out of the hospital. The blast of cold air when the door swung open caused Corl to shudder. A nurse called the police to come pick the patient up. (It turned out that she had an outstanding warrant and was arrested.) Later, after he returned to the E.R., Corl could not stop thinking about what he’d done, imagining how the medical-school version of himself would have judged his conduct. “He would have been horrified.”


Summary: The article explores the moral distress that many doctors are experiencing in the United States healthcare system. Doctors are feeling increasingly pressured to make decisions based on financial considerations rather than what is best for their patients. This is leading to a number of problems, including:
  • Decreased quality of care: Doctors are being forced to cut corners on care, which is leading to worse outcomes for patients.
  • Increased burnout: Doctors are feeling increasingly stressed and burned out, which is making it difficult for them to provide quality care.
  • Loss of moral compass: Doctors are feeling like they are losing their moral compass, as they are being forced to make decisions that they know are not in the best interests of their patients.
The article concludes by calling for a number of reforms to the healthcare system, including:
  • Paying doctors based on quality of care, not volume of services: This would incentivize doctors to provide the best possible care, rather than just the most profitable care.
  • Giving doctors more control over their practice:This would allow doctors to make decisions based on what is best for their patients, rather than what is best for their employers.
  • Supporting doctors' mental health: Doctors need to be supported through the challenges of providing care in the current healthcare system.

Saturday, May 13, 2023

Doctors are drowning in paperwork. Some companies claim AI can help

Geoff Brumfiel
NPR.org - Health Shots
Originally posted 5 APR 23

Here are two excerpts:

But Paul kept getting pinged from younger doctors and medical students. They were using ChatGPT, and saying it was pretty good at answering clinical questions. Then the users of his software started asking about it.

In general, doctors should not be using ChatGPT by itself to practice medicine, warns Marc Succi, a doctor at Massachusetts General Hospital who has conducted evaluations of how the chatbot performs at diagnosing patients. When presented with hypothetical cases, he says, ChatGPT could produce a correct diagnosis accurately at close to the level of a third- or fourth-year medical student. Still, he adds, the program can also hallucinate findings and fabricate sources.

"I would express considerable caution using this in a clinical scenario for any reason, at the current stage," he says.

But Paul believed the underlying technology can be turned into a powerful engine for medicine. Paul and his colleagues have created a program called "Glass AI" based off of ChatGPT. A doctor tells the Glass AI chatbot about a patient, and it can suggest a list of possible diagnoses and a treatment plan. Rather than working from the raw ChatGPT information base, the Glass AI system uses a virtual medical textbook written by humans as its main source of facts – something Paul says makes the system safer and more reliable.

(cut)

Nabla, which he co-founded, is now testing a system that can, in real time, listen to a conversation between a doctor and a patient and provide a summary of what the two said to one another. Doctors inform their patients that the system is being used in advance, and as a privacy measure, it doesn't actually record the conversation.

"It shows a report, and then the doctor will validate with one click, and 99% of the time it's right and it works," he says.

The summary can be uploaded to a hospital records system, saving the doctor valuable time.

Other companies are pursuing a similar approach. In late March, Nuance Communications, a subsidiary of Microsoft, announced that it would be rolling out its own AI service designed to streamline note-taking using the latest version of ChatGPT, GPT-4. The company says it will showcase its software later this month.

Sunday, November 20, 2022

Telehealth is here to stay. Psychologists should equip themselves to offer it.

Hannah Calkins
The Monitor On Psychology
Vol. 53 No. 7, Print version: page 30

Telehealth continues to play a significant role in the health care industry. However, psychologists who offer both in-person and virtual services are poised to meet increased demand for flexible, accessible mental health care.

In 2020, psychologists responded to the onset of the COVID-19 pandemic by making a nearly universal pivot to telehealth. This rapid and widespread adoption was largely enabled by the federal government’s declaration of a public health emergency (PHE), which prompted several significant policy changes that made telehealth more feasible for both patients and providers.

Yet in the following year, an APA survey found that 50% of psychologists had moved to offering both in-person and virtual services to their patients, up from 30% in 2020. Additionally, Pew Research Center data showed that 25% of adults with ­low incomes do not own smartphones, and 40% of this group do not have broadband internet or computers at home, signaling significant concerns about telehealth equity.

This means that psychologists should prepare for a hybrid future in which they deliver services via both modalities.

“Telehealth is here to stay. In-person isn’t going away,” said Robin McLeod, PhD, a licensed psychologist and president and chief business development officer at Natalis Psychology in St. Paul, Minnesota. “I believe it is vital for most psychologists to be able and willing to provide both options for patients. It just makes good business sense.”

Meeting demand for telehealth

Like many other providers, those at McLeod’s large practice made a quick pivot to virtual care during the pandemic and now offer hybrid options.

“[Our] providers have returned to providing in-person care, which many of our patients welcomed,” said McLeod. “However, most every provider in our organization continues to provide telehealth services for those clients who prefer that.”

Similarly, Zixuan Wang, PsyD, of Encounter Psychotherapy in Gaithersburg, Maryland, also has a robust hybrid practice. However, prior to spring 2020, she had never seriously considered offering telehealth.

“I am so appreciative that technology has enabled us to provide telehealth services, as they have been proven to be effective and beneficial for so many people who need care,” she said.

Wang and McLeod’s stories are scaled-down versions of the broader narrative of telehealth during the pandemic: Rapid and sustained implementation out of necessity has led to a permanent change.

Friday, November 18, 2022

When Patients Become Colleagues

Charles C. Dike
Psychiatric News
Published Online:27 Oct 2022

Dr. Jones, a psychiatrist in private practice, described to me a conundrum she was trying to resolve. A patient she has been treating for eight years with psychotherapy and medication was recently certified as a therapist. The patient intends to terminate treatment with her and set up a private practice in the same district as the psychiatrist. The new therapist is asking for a collaborative relationship with the psychiatrist in which he would refer patients to the psychiatrist for medication management. The psychiatrist is not comfortable with the proposal and worries that her deep knowledge of her ex-patient’s flaws would negatively influence her view of the patient as a therapist. Most importantly, however, she is concerned about the risks of boundary violations and a breach in confidentiality, for example, when patients ask about the relationship between the psychiatrist and their referring therapist, as often happens.

The APA Ethics Committee has received questions about similar situations. One such question involved a patient who had received psychiatric treatment at an institution for years and was now applying to work as a clinician at the same institution a decade later. In this case, the Ethics Committee affirmed the need for psychiatrists “to support the concept that treatment matters and that people can recover and live full lives by addressing the challenges of mental illness. Psychiatrists should model that seeking treatment is a healthful and positive behavior and not a stigmatized act that will forever preclude a person, once a patient, from joining a team of respected mental health professionals. A history of mental health treatment should not be used to ban employment; a history of appropriate qualifications and pursuit of necessary medical treatment should be positive indicators for employment.”

Nonetheless, every such situation requires deep reflection to avoid potential ethics breaches. In some cases, the guidance is clear. For example, it is unethical for a psychiatrist in a solo private practice to employ a former patient because the pre-existing doctor-patient relationship is likely to influence the working relationship on both sides with potential negative consequences. In Dr. Jones’s case, however, the situation has ethics considerations that need to be addressed. Here is the advice that I gave to Dr. Jones: After celebrating her patient’s success, she should schedule a private meeting to discuss the contours of their new professional relationship. She should clarify that it would be a challenge to be his psychiatrist in the future should he suffer a relapse and need care. Further, Dr. Jones should point out that a personal relationship with a former patient could be unethical, especially if intimate, and therefore, all social interactions should be avoided as much as possible. When it is not possible to avoid them, they should carefully manage their interactions, social or professional, making sure boundaries are not breached. Dr. Jones should also discuss possible circumstances that could insinuate to others that she and the therapist had a prior treatment relationship as any such acknowledgment on her part would be a breach of her patient’s confidentiality. The fact that her former patient discloses their relationship to others does not absolve the psychiatrist of this ethical injunction. Such a discussion would prevent future problems and set the stage for the next chapter of their relationship.

Monday, October 10, 2022

7 tell-tale red flags of medical gaslighting

Ashley Laderer
Insider.com
Originally published 29 AUG 2022

Here is an except:

"Medical gaslighting is a term recently used to describe when health care providers dismiss a patient's concerns, feelings, or complaints," says Faith Fletcher, an assistant professor in the Center for Medical Ethics and Health Policy at Baylor College of Medicine and a senior advisor to the Hastings Center, a bioethics research institute. 

Numerous studies over the years have found examples of medical gaslighting, whether it's interrupting a patient or misdiagnosing them based on unconscious biases about race or gender. Gaslighting in the medical field tends to affect marginalized groups the most.

"These interactions don't take place in a vacuum and are rooted in long-standing structural and social injustices such as racism, sexism, and class oppression in the US healthcare system," Fletcher says. 

Here are seven signs your doctor may be gaslighting you and the consequences it can have on your health.

1. They interrupt you
2. They rush you 
3. They won't discuss your symptoms with you
4. They let underlying biases affect diagnosis 
5. They say it's all in your head
6. They question the legitimacy of your medical history 
7. They're uncollaborative on treatment options

Thursday, October 6, 2022

Defining Their Own Ethics, Online Creators Are De Facto Therapists for Millions—Explosive Demand & Few Safeguards

Tantum Hunter
The Washington Post
Originally posted 29 AUG 22

Here are two excerpts:

In real life, mental health information and care are sparse. In the United States, 1 in 3 counties do not have a single licensed psychologist, according to the American Psychological Association, and Americans say cost is a top barrier to seeking mental health help. On the internet, however, mental health tips are everywhere: TikTok videos with #mentalhealth in the caption have earned more than 43.9 billion views, according to the analytics company Sprout Social, and mentions of mental health on social media are increasing year by year.

The growing popularity of the subject means that creators of mental health content are filling a health-care gap. But social media apps are not designed to prioritize accurate, helpful information, critics say, just whatever content draws the biggest reaction. Young people could see their deepest struggles become fodder for advertisers and self-promoters. With no road map even for licensed professionals, mental health creators are defining their own ethics.

“I don’t want to give anyone the wrong advice,” Moloney says. “I’ve met some [followers] who’ve just started crying and saying ‘thank you’ and stuff like that. Even though it seems small, to someone else, it can have a really big impact.”

As rates of depression and anxiety spiked during the pandemic and options for accessible care dwindled, creators shared an array of content including first-person accounts of life with mental illness and videos listing symptoms of bipolar disorder. In many cases, their follower counts ballooned.

(cut)

Ideally, social media apps should be one item in a collection of mental health resources, said Jodi Miller, a researcher at Johns Hopkins University School of Education who studies the relationships among young people, technology and stress.

“Young people need evidence-based sources of information outside the internet, from parents and schools,” Miller said.

Often, those resources are unavailable. So it’s up to consumers to decide what mental health advice they put stock in, Fisher-Quann said. For her, condescending health-care providers and the warped incentives of social media platforms haven’t made that easy. But she thinks she can get better — and that her followers can, too.

“It all has to come from a place of self-awareness and desire to get better. Communities can be extremely helpful for that, but they can also be extremely harmful for that,” she said.

Wednesday, October 5, 2022

Making psychiatry moral again: the role of psychiatry in patient moral development

McConnell D, Broome M, Savulescu, J.
Journal of Medical Ethics 
Published Online First: 19 August 2022.
doi: 10.1136/jme-2022-108442

Abstract

Psychiatric involvement in patient morality is controversial. If psychiatrists are tasked with shaping patient morality, the coercive potential of psychiatry is increased, treatment may be unfairly administered on the basis of patients’ moral beliefs rather than medical need, moral disputes could damage the therapeutic relationship and, in any case, we are often uncertain or conflicted about what is morally right. Yet, there is also a strong case for the view that psychiatry often works through improving patient morality and, therefore, should aim to do so. Our goal is to offer a practical and ethical path through this conflict. We argue that the default psychiatric approach to patient morality should be procedural, whereby patients are helped to express their own moral beliefs. Such a procedural approach avoids the brunt of objections to psychiatric involvement in patient morality. However, in a small subset of cases where patients’ moral beliefs are sufficiently distorted or underdeveloped, we claim that psychiatrists should move to a substantive approach and shape the content of those beliefs when they are relevant to psychiatric outcomes. The substantive approach is prone to the above objections but we argue it is nevertheless justified in this subset of cases.

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Helping people elaborate a conception of morality has little risk of coercion and damage to the therapeutic relationship because the patient is requesting that content and is not committed to a conflicting moral position. Of course, it would be wrong to simply indoctrinate the patient so, to avoid that, the process of moral development should be patient-led as much as possible. However, if the moral views the patient gravitates towards in this process are clearly unreasonable, then the psychiatrist has an obligation to guide the patient’s views back within the bounds of reasonableness.

Psychiatrists are well placed to affect substantive moral growth. Their skill for helping people understand and elaborate their subjective worlds can reveal where the moral growth required to treat mental illness and support flourishing might be most easily achieved. We suggest a pluralist approach where the psychiatrist draws on any moral reasons, arguments or insights that help the patient achieve moral growth. In order to tailor moral reasons to the patient, psychiatrists would benefit not only from training in normative moral theories (eg, contractualism, deontology, consequentialism) but also from familiarity with a diverse range of autobiographical or fictional narratives that illustrate how different moral views are experienced and put into practice. The latter would also provide material that the psychiatrist could draw on to help the patient develop moral aspects of their own self-narrative. In the near future, the substantive approach could also benefit from pharmacotherapies, such as psychedelics, which might help patients who consent to such treatment become more receptive to new moral reasons, beliefs and emotions.

Thursday, June 30, 2022

Ernst & Young to Pay $100 Million Penalty for Employees Cheating on CPA Ethics Exams and Misleading Investigation

Largest Penalty Ever Imposed by SEC Against an Audit Firm

FOR IMMEDIATE RELEASE
2022-114

Washington D.C., June 28, 2022 —

The Securities and Exchange Commission today charged Ernst & Young LLP (EY) for cheating by its audit professionals on exams required to obtain and maintain Certified Public Accountant (CPA) licenses, and for withholding evidence of this misconduct from the SEC’s Enforcement Division during the Division’s investigation of the matter. EY admits the facts underlying the SEC’s charges and agrees to pay a $100 million penalty and undertake extensive remedial measures to fix the firm’s ethical issues.

“This action involves breaches of trust by gatekeepers within the gatekeeper entrusted to audit many of our Nation’s public companies. It’s simply outrageous that the very professionals responsible for catching cheating by clients cheated on ethics exams of all things,” said Gurbir S. Grewal, Director of the SEC’s Enforcement Division. “And it’s equally shocking that Ernst & Young hindered our investigation of this misconduct. This action should serve as a clear message that the SEC will not tolerate integrity failures by independent auditors who choose the easier wrong over the harder right.”

EY admits that, over multiple years, a significant number of EY audit professionals cheated on the ethics component of CPA exams and various continuing professional education courses required to maintain CPA licenses, including ones designed to ensure that accountants can properly evaluate whether clients’ financial statements comply with Generally Accepted Accounting Principles.

EY further admits that during the Enforcement Division’s investigation of potential cheating at the firm, EY made a submission conveying to the Division that EY did not have current issues with cheating when, in fact, the firm had been informed of potential cheating on a CPA ethics exam. EY also admits that it did not correct its submission even after it launched an internal investigation into cheating on CPA ethics and other exams and confirmed there had been cheating, and even after its senior lawyers discussed the matter with members of the firm’s senior management. And as the Order finds, EY did not cooperate in the SEC’s investigation regarding its materially misleading submission.

Wednesday, June 29, 2022

Abuse case reveals therapist’s dark past, raises ethical concerns

Associated Press
Originally posted 11 JUN 22

Here is an excerpt:

Dushame held a valid driver’s license despite five previous drunken driving convictions, and it was his third fatal crash — though the others didn’t involve alcohol. The Boston Globe called him “the most notorious drunk driver in New England history.”

But over time, he dedicated himself to helping people recovering from addiction, earning a master’s degree in counseling psychology and leading treatment programs from behind bars.

Two years later, he legally changed his name to Peter Stone. He was released from prison in 2002 and eventually set up shop as a licensed drug and alcohol counselor.

Last July, he was charged with five counts of aggravated felonious sexual assault under a law that criminalizes any sexual contact between patients and their therapists or health care providers. Such behavior also is prohibited by the American Psychological Association’s ethical code of conduct.

In a recent interview, the 61-year-old woman said she developed romantic feelings for Stone about six months after he began treating her for anxiety, depression and alcohol abuse in June 2013. Though he told her a relationship would be unethical, he initiated sexual contact in February 2016, she said.

“‘That crossed the line,’” the woman remembers him saying after he pulled up his pants. “‘When am I seeing you again?’”

While about half the states have no restrictions on name changes after felony convictions, 15 have bans or temporary waiting periods for those convicted of certain crimes, according to the ACLU in Illinois, which has one of the most restrictive laws.

Stone appropriately disclosed his criminal record on licensing applications and other documents, according to a review of records obtained by the AP. Disclosure to clients isn’t mandatory, said Gary Goodnough, who teaches counseling ethics at Plymouth State University. But he believes clients have a right to know about some convictions, including vehicular homicide.

Monday, May 9, 2022

C.I.A. Captive Was Too Small for Waterboard, Interrogator Testifies

Carol Rosenberg
The New York Times
Originally posted 3 MAY 22

The psychologist who for the C.I.A. waterboarded a prisoner accused of plotting the U.S.S. Cole bombing testified this week that the Saudi man broke quickly and became so compliant that he would crawl into a cramped crate even before guards ordered him inside.

The psychologist, James E. Mitchell, also told a military judge that the prisoner, Abd al-Rahim al-Nashiri, was so scrawny that Dr. Mitchell and his interrogation partner, [psychologist] John Bruce Jessen, stopped waterboarding him after the third session at a secret site in Thailand in 2002 because they feared he might be hurt.

In that instance, they put him in a neck brace and strapped him to a gurney that served as the board. But when they tilted the board up to let him breathe after a “40-second pour,” the 5-foot-5, 120-pound prisoner nearly slid out of the straps to the floor, Dr. Mitchell said.

“He was snorting and blowing water out of his nose,” Dr. Mitchell testified. 

A former career military psychologist..., Dr. Mitchell said the waterboarding episodes were so long ago that he could not recall whether the prisoner actually cried.

Defense lawyers for Mr. Nashiri questioned Dr. Mitchell on Monday and Tuesday about what went on for several weeks in the black site in November 2002. 

His testimony was meant to offer an account of what may have been on videotapes that senior C.I.A. leaders destroyed at a time when the Senate Intelligence Committee was investigating the black site activities.

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For Mr. Nashiri, it was the fourth stop on what would become a four-year odyssey of C.I.A. detention through 10 secret overseas sites.

The episodes Dr. Mitchell described included:
  • A member of an interrogation team used a belt to strap Mr. Nashiri’s arms behind his back and lift him up from behind to “his tiptoes,” Dr. Mitchell said. The prisoner howled, and Dr. Mitchell said he protested, fearing Mr. Nashiri’s shoulders would be dislocated. The treatment continued.
  • Guards forced a shackled Mr. Nashiri onto his knees then bent him backward, with a broomstick placed behind the prisoner’s knees.
  • The chief interrogator, ostensibly seeking to train Mr. Nashiri to address him as “sir,” used a stiff bristle brush to give Mr. Nashiri a cold-water bath, then scraped the brush from the prisoner’s anus to his face and mouth.
Dr. Mitchell said he learned only in recent days — from case prosecutors — that Mr. Nashiri had been subjected to “rectal feeding,” a procedure he said was mostly handled by C.I.A. doctors for medical reasons, except when the chief interrogator in Afghanistan chose to use it.

Wednesday, February 23, 2022

I See Color

Khama Ennis
On The Flip Side
Original date: February 13, 2020

9 minutes worth watching: Patient biases versus professional obligations

Monday, July 26, 2021

Do doctors engaging in advocacy speak for themselves or their profession?

Elizabeth Lanphier
Journal of Medical Ethics Blog
Originally posted 17 June 21

Here is an excerpt:

My concern is not the claim that expertise should be shared. (It should!) Nor do I think there is any neat distinction between physician responsibilities for individual health and public health. But I worry that when Strous and Karni alternately frame physician duties to “speak out” as individual duties and collective ones, they collapse necessary distinctions between the risks, benefits, and demands of these two types of obligations.

Many of us have various role-based individual responsibilities. We can have obligations as a parent, as a citizen, or as a professional. Having an individual responsibility as a physician involves duties to your patients, but also general duties to care in the event you are in a situation in which your expertise is needed (the “is there a doctor on this flight?” scenario).

Collective responsibility, on the other hand, is when a group has a responsibility as a group. The philosophical literature debates hard to resolve questions about what it means to be a “group,” and how groups come to have or discharge responsibilities. Collective responsibility raises complicated questions like: If physicians have a collective responsibility to speak out during the COVID-19 pandemic, does every physician has such an obligation? Does any individual physician?

Because individual obligations attribute duties to specific persons responsible for carrying them out in ways collective duties tend not to, I why individual physician obligations are attractive. But this comes with risks. One risk is that a physician speaks out as an individual, appealing to the authority of their medical credentials, but not in alignment with their profession.

In my essay I describe a family physician inviting his extended family for a holiday meal during a peak period of SARS-CoV-2 transmission because he didn’t think COVID-19 was a “big deal.”

More infamously, Dr. Scott Atlas served as Donald J. Trump’s coronavirus advisor, and although he is a physician, he did not have experience in public health, infectious disease, or critical care medicine applicable to COVID-19. Atlas was a physician speaking as a physician, but he routinely promoted views starkly different than those of physicians with expertise relevant to the pandemic, and the guidance coming from scientific and medical communities.

Tuesday, April 13, 2021

Can Clinical Empathy Survive? Distress, Burnout, and Malignant Duty in the Age of Covid‐19

A. Anzaldua & J. Halpern
Hastings Report
Jan-Feb 2021 22-27.

Abstract

The Covid‐19 crisis has accelerated a trend toward burnout in health care workers, making starkly clear that burnout is especially likely when providing health care is not only stressful and sad but emotionally alienating; in such situations, there is no mental space for clinicians to experience authentic clinical empathy. Engaged curiosity toward each patient is a source of meaning and connection for health care providers, and it protects against sympathetic distress and burnout. In a prolonged crisis like Covid‐19, clinicians provide care out of a sense of duty, especially the duty of nonabandonment. We argue that when duty alone is relied on too heavily, with fear and frustration continually suppressed, the risk of burnout is dramatically increased. Even before Covid‐19, clinicians often worked under dehumanizing and unjust conditions, and rates of burnout were 50 percent for physicians and 33 percent for nurses. The Covid‐19 intensification of burnout can serve as a wake‐up call that the structure of health care needs to be improved if we are to prevent the loss of a whole generation of empathic clinicians.

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The Dynamics of Clinical Empathy

Clinical empathy, a specific form of empathy that has therapeutic impact in the medical setting and is professionally sustainable, was first conceptualized by one of us, Jodi Halpern, as emotionally engaged curiosity. Her work challenged the expectation that physicians should limit themselves to detached cognitive empathy, showing how affective resonance, when redirected into curiosity about the patient, is essential for therapeutic impact. Halpern's interactive model of affective and cognitive empathy has been supported by empirical research, including findings regarding improved diagnosis, treatment adherence, and coping as well as studies of specific diseases (for example, about improved diabetes outcomes), though more research is needed to precisely identify the specific ways that affective resonance and cognitive curiosity contribute to meeting specific clinical needs. This model is also supported by neuroscientific findings showing how affective attunement improves cognitive empathy.

Models of compassion in medical care add valuable practices of mindfulness but do not emphasize an individualized appreciation of each patient's predicament. We thus work with Halpern's model, which emphasizes using emotional resonance to inform imagining the world from each patient's perspective. Halpern defines the cognitive aim of imagining each patient's perspective as “curiosity” because the practice of clinical empathy as engaged curiosity is founded on the recognition that each patient brings their own distinct world, with a unique set of values and needs that the physician cannot presume to know. This is a subtle but vital point.