Risk Management Considerations When Treating Violent Patients

Kristen Lambert
Psychiatric News
Originally posted September 4, 2018

Here is an excerpt:

When a patient has a history of expressing homicidal ideation or has been violent previously, you should document, in every subsequent session, whether the patient admits or denies homicidal ideation. When the patient expresses homicidal ideation, document what he/she expressed and the steps you did or did not take in response and why. Should an incident occur, your documentation will play an important role in defending your actions.

Despite taking precautions, your patient may still commit a violent act. The following are some strategies that may minimize your risk.

• Conduct complete timely/thorough risk assessments.

• Document, including the reasons for taking and not taking certain actions.

• Understand your state’s law on duty to warn. Be aware of the language in the law on whether you have a mandatory, permissive, or no duty to warn/protect.

• Understand your state’s laws regarding civil commitment.

• Understand your state’s laws regarding disclosure of confidential information and when you can do so.

• Understand your state’s laws regarding discussing firearms ownership and/or possession with patients.

• If you have questions, consult an attorney or risk management professional.

The info is here.

Medicine’s Financial Contamination

Editorial Board
The New York Times
Originally posted September 14, 2018

Here is an excerpt:

Sloan Kettering’s other leaders were well aware of these relationships. The hospital has said that it takes pains to wall off any employee involved with a given outside company from the hospital’s dealings with that company. But it’s difficult to believe that conflicts of this magnitude could have truly been worked around, given how many of them there were, and how high up on the organizational chart Dr. Baselga sat. It also strains credulity to suggest that he was the hospital’s only leader with such conflicts or with such apparent difficulty disclosing them. After the initial report, but before Dr. Baselga’s resignation, the hospital sent a letter to its entire 17,000-person staff acknowledging that the institution as a whole needed to do better. It remains to be seen what additional actions will be taken — and by whom — to repair the situation.

Financial conflicts are hardly confined to Sloan Kettering. A 2015 study in The BMJ found that a “substantial number” of academic leaders hold directorships that pay as much as or more than their clinical salaries. According to other surveys, nearly 70 percent of oncologists who speak at national meetings, nearly 70 percent of psychiatrists on the task force that ultimately decides what treatments should be recommended for what mental illnesses, and a significant number of doctors on Food and Drug Administration advisory committees have financial ties to the drug and medical device industries. As bioethicists have warned and as journal publishers have long acknowledged, not all of them report those ties when and where they are supposed to.

The info is here.

When You Fear Your Company Has Forgotten Its Principles

Sue Shellenbarger
The Wall Street Journal
Originally published September 17, 2018

Here is an excerpt:

People who object on principle to their employers’ conduct face many obstacles. One is the bystander effect—people’s reluctance to intervene against wrongdoing when others are present and witnessing it too, Dr. Grant says. Ask yourself in such cases, “If no one acted here, what would be the consequences?” he says. While most people think first about potential damage to their reputation and relationships, the long-term effects could be worse, he says.

Be careful not to argue too passionately for the changes you want, Dr. Grant says. Show respect for others’ viewpoint, and acknowledge the flaws in your argument to show you’ve thought it through carefully.

Be open about your concerns, says Jonah Sachs, an Oakland, Calif., speaker and author of “Unsafe Thinking,” a book on creative risk-taking. People who complain in secret are more likely to make enemies and be seen as disloyal, compared with those who resist in the open, research shows.

Successful change-makers tend to frame proposed changes as benefiting the entire company and its employees and customers, rather than just themselves, Mr. Sachs says. He cites a former executive at a retail drug chain who helped persuade top management to stop selling cigarettes in its stores. While the move tracked with the company’s health-focused mission, the executive strengthened her case by correctly predicting that it would attract more health-minded customers.

The info is here.

Huge price hikes by drug companies are immoral

Robert Klitzman
CNN.com
Originally posted September 18, 2018

Several pharmaceutical companies have been jacking up the prices of their drugs in unethical ways. Most recently, Nirmal Mulye, founder and president of Nostrum Pharmaceuticals, defended his decision to more than quadruple the price of nitrofurantoin, used to treat bladder infections, from about $500 to more than $2,300 a bottle. He said it was his "moral requirement to sell the product at the highest price."

Mulye argues that his only moral duty is to benefit his investors. As he said in defending Martin Shkreli, who in 2015 raised the price of an anti-parasite drug, daraprim, 5,000% from $13.50 to $750 per tablet, "When he raised the price of his drug he was within his rights because he had to reward his shareholders."

Mulye is wrong for many reasons. Drug companies deserve reasonable return on their investment in research and development, but some of these companies are abusing the system. The development of countless new drugs depends on taxpayer money and sacrifices that patients in studies make in good faith. Excessive price hikes harm many people, threaten public health and deplete huge amounts of taxpayer money that could be better used in other ways.

The US government pays more than 40% of all Americans' prescription costs, and this amount has been growing faster than inflation. In 2015, over 118 million Americans were on some form of government health insurance, including around 52 million on Medicare and 62 million on Medicaid. And these numbers have been increasing. Today, around 59 million Americans are on Medicare and 75 million on Medicaid.

The info is here.

Machine Ethics and Artificial Moral Agents

Francesco Corea
Medium.com
Originally posted July 6, 2017

Here is an excerpt:

However, let’s look at the problem from a different angle. I was educated as an economist, so allow me to start my argument with this statement: let’s assume we have the perfect dataset. It is not only omni-comprehensive but also clean, consistent and deep both longitudinally and temporally speaking.

Even in this case, we have no guarantee AI won’t learn the same bias autonomously as we did. In other words, removing biases by hand or by construction is not a guarantee of those biases to not come out again spontaneously.

This possibility also raises another (philosophical) question: we are building this argument from the assumption that biases are bad (mostly). So let’s say the machines come up with a result we see as biased, and therefore we reset them and start again the analysis with new data. But the machines come up with a similarly ‘biased result’. Would we then be open to accepting that as true and revision what we consider to be biased?

This is basically a cultural and philosophical clash between two different species.

In other words, I believe that two of the reasons why embedding ethics into machine designing is extremely hard is that i) we don’t really know unanimously what ethics is, and ii) we should be open to admit that our values or ethics might not be completely right and that what we consider to be biased is not the exception but rather the norm.

Developing a (general) AI is making us think about those problems and it will change (if it hasn’t already started) our values system. And perhaps, who knows, we will end up learning something from machines’ ethics as well.

The info is here.

Let's Talk About AI Ethics; We're On A Deadline

Tom Vander Ark
Forbes.com
Originally posted September 13, 2018

Here is an excerpt:

Creating Values-Aligned AI

“The project of creating value-aligned AI is perhaps one of the most important things we will ever do,” said the Future of Life Institute. It’s not just about useful intelligence but “the ends to which intelligence is aimed and the social/political context, rules, and policies in and through which this all happens.”

The Institute created a visual map of interdisciplinary issues to be addressed:

• Validation: ensuring that the right system specification is provided for the core of the agent given stakeholders' goals for the system.

• Security: applying cyber security paradigms and techniques to AI-specific challenges.

• Control: structural methods for operators to maintain control over advanced agents.

• Foundations: foundational mathematical or philosophical problems that have bearing on multiple facets of safety

• Verification: techniques that help prove a system was implemented correctly given a formal specification

• Ethics: effort to understand what we ought to do and what counts as moral or good.

• Governance: the norms and values held by society, which are structured through various formal and informal processes of decision-making to ensure accountability, stability, broad participation, and the rule of law.

The info is here.

Nudge or Grudge? Choice Architecture and Parental Decision‐Making

Jennifer Blumenthal‐Barby and Douglas J. Opel
The Hastings Center Report
Originally published March 28, 2018

Abstract

Richard Thaler and Cass Sunstein define a nudge as “any aspect of the choice architecture that alters people's behavior in a predictable way without forbidding any options or significantly changing their economic incentives.” Much has been written about the ethics of nudging competent adult patients. Less has been written about the ethics of nudging surrogates’ decision‐making and how the ethical considerations and arguments in that context might differ. Even less has been written about nudging surrogate decision‐making in the context of pediatrics, despite fundamental differences that exist between the pediatric and adult contexts. Yet, as the field of behavioral economics matures and its insights become more established and well‐known, nudges will become more crafted, sophisticated, intentional, and targeted. Thus, the time is now for reflection and ethical analysis regarding the appropriateness of nudges in pediatrics.

We argue that there is an even stronger ethical justification for nudging in parental decision‐making than with competent adult patients deciding for themselves. We give three main reasons in support of this: (1) child patients do not have autonomy that can be violated (a concern with some nudges), and nudging need not violate parental decision‐making authority; (2) nudging can help fulfill pediatric clinicians’ obligations to ensure parental decisions are in the child's interests, particularly in contexts where there is high certainty that a recommended intervention is low risk and of high benefit; and (3) nudging can relieve parents’ decisional burden regarding what is best for their child, particularly with decisions that have implications for public health.

The info is here.

ICP Ethics Code

Institute of Contemporary Psychoanalysis

Psychoanalysts strive to reduce suffering and promote self-understanding, while respecting human dignity. Above all, we take care to do no harm. Working in the uncertain realm of unconscious emotions and feelings, our exclusive focus must be on safeguarding and benefitting our patients as we try to help them understand their unconscious mental life. Our mandate requires us to err on the side of ethical caution. As clinicians who help people understand the meaning of their dreams and unconscious longings, we are aware of our power and sway. We acknowledge a special obligation to protect people from unintended harm resulting from our own human foibles.

In recognition of our professional mandate and our authority—and the private, subjective and influential nature of our work—we commit to upholding the highest ethical standards. These standards take the guesswork out of how best to create a safe container for psychoanalysis. These ethical principles inspire tolerant and respectful behaviors, which in turn facilitate the health and safety of our candidates, members and, most especially, our patients. Ultimately, ethical behavior protects us from ourselves, while preserving the integrity of our institute and profession.

Professional misconduct is not permitted, including, but not limited to dishonesty, discrimination and boundary violations. Members are asked to keep firmly in mind our core values of personal integrity, tolerance and respect for others. These values are critical to fulfilling our mission as practitioners and educators of psychoanalytic therapy. Prejudice is never tolerated whether on the basis of age, disability, ethnicity, gender, gender identity, race, religion, sexual orientation or social class. Institute decisions (candidate advancement, professional opportunities, etc.) are to be made exclusively on the basis of merit or seniority. Boundary violations, including, but not limited to sexual misconduct, undue influence, exploitation, harassment and the illegal breaking of confidentiality, are not permitted. Members are encouraged to seek consultation readily when grappling with any ethical or clinical concerns. Participatory democracy is a primary value of ICP. All members and candidates have the responsibility for knowing these guidelines, adhering to them and helping other members comply with them.

The ethics code is here.

Big Island considers adding honesty policy to ethics code

Associated Press
Originally posted September 14, 2018

Big Island officials are considering adding language to the county's ethics code requiring officers and employees to provide the public with information that is accurate and factual.

The county council voted last week in support of the measure, requiring county employees to provide honest information to "the best of each officer's or employee's abilities and knowledge," West Hawaii Today reported . It's set to go before council for final approval next week.

The current measure has changed from Puna Councilwoman Eileen O'Hara's original bill that simply stated "officers and employees should be truthful."

She introduced the measure in response to residents' concerns, but amended it to gain the support of her colleagues, she said.

The info is here.