Thursday, April 1, 2010

Google, Facebook, and a Suicidal Patient

A recent Washington Post article posed a fascinating ethical question about psychotherapists and the web:
As his patient lay unconscious in an emergency room from an overdose of sedatives, psychiatrist Damir Huremovic was faced with a moral dilemma: A friend of the patient had forwarded to Huremovic a suicidal e-mail from the patient that included a link to a Web site and blog he wrote. Should Huremovic go online and check it out, even without his patient's consent?

Huremovic decided yes; after all, the Web site was in the public domain and it might contain some potentially important information for treatment. When Huremovic clicked on the blog, he found quotations such as this: "Death makes angels of us all and gives us wings." A final blog post read: "I wish I didn't wake up." Yet as Huremovic continued scanning the patient's personal photographs and writings, he began to feel uncomfortable, that perhaps he'd crossed some line he shouldn't have.

Across the country, therapists are facing similar situations and conflicted feelings. When Huremovic, director of psychosomatic medicine services at Nassau University Medical Center in New York, recounted his vignette last year at an American Psychiatric Association meeting and asked whether others would have read the suicidal man's blog, his audience responded with resounding calls -- of both "yes!" and "no!" One thing was clear: How and when a therapist should use the Internet -- and even whether he or she should -- are questions subject to vigorous debate.
In my view, Dr. Huremovic got the ethical challenge exactly right. With his patient in the midst of treatment for an overdose, the information might have life and death implications. Perhaps his patient wrote about what substances he intended to ingest. That could be important for the emergency medical treatment itself. Or perhaps the blog would suggest a stronger suicidal drive than Dr. Huremovic was aware of. That could guide psychiatric treatment after recovery from the overdose.

But what about confidentiality?

From the perspective of the patient, the clinician's responsibility to do what he can to save his patient's life and health clearly trumps confidentiality concerns. The patient had been speaking to the public through his blog. The patient's friend knew about the blog and about the treatment with Dr. Huremovic. If, in the future, the patient accused Dr. Huremovic of "violating my privacy - you went to my website without my permission," Dr. Huremovic would rightly respond - "I'd rather risk disturbing your concern with privacy than attending your otherwise avoidable funeral!"

If the patient was a philosopher familiar with rule utilitarianism he might respond - "the issue isn't just the impact on me - your actions will reduce overall trust in therapists...in the future patients who are suicidal may avoid therapy out of privacy concerns...what you did increased the risk that people will die from suicide!" Here Dr. Huremovic could make a two part response. First, he might challenge the empirical claim - "I think it's just the opposite - how could potential patients trust therapists who would let theoretical concerns outweigh commitment to their patient's lives?" But beyond the competing hypotheticals Dr. Huremovic could say "In theory you could be right about the impact on others - but given the uncertainty, combined with the emergency, I felt - and continue to feel - that my primary duty was to your safety."

In the course of looking to see whether therapists have expressed opinions about situations like this I came upon Dr. Keely Kolmes' social media policy (see here):
It is NOT a regular part of my practice to search for clients on Google or Facebook or other search engines. Extremely rare exceptions may be made during times of crisis. If I have a reason to suspect that you are in danger and you have not been in touch with me via our usual means (coming to appointments, phone, or email) there might be an instance in which using a search engine (to find you, find someone close to you, or to check on your recent status updates) becomes necessary as part of ensuring your welfare. These are unusual situations and if I ever resort to such means, I will fully document it and discuss it with you when we next meet.
I sent Dr. Kolmes a fan letter for this model of ethical analysis and clear communication with patients.

The web continues to pose new, important and fascinating ethical questions. It's heartening to see colleagues like Drs. Huremovic and Kolmes identifying the issues and dealing with them so thoughtfully!

8 comments:

Hamid said...

Thanks!
Great food for thought.
I wonder what would the doctor decide if the patient happens to need a ventilator as a means of life support. Would it be ethical to withhold, on the grounds of his posts on his blog? Is that a "living will"?

Myron Pulier said...

There may be less of an ethical conflict than the patient is hypothesized to describe. The physician's main duty is nearly always to the individual patient rather than to society (e.g., public health), to the medical profession or to the economic welfare of the hospital. People hope for this attitude in their physicians and seeing it instantiated can strengthen, not weaken confidence.

Ethics aside, acquiring information about a patient "behind his back" will likely weaken the therapeutic relationship. If information falls into a psychiatrist's hands, such as when a family member calls up or sends email, it is best to disclose this to the patient immediately, and never to agree with an informant, never to conspire, to conceal the source. If someone has something important to say that the patient can't or won't talk about, this is grist for discussion and perhaps a reason to agree with the patient to conduct a joint session.

Jim Sabin said...

Hello Myron

Thank you for your thoughtful comment!

I agree with your view of the physician's "main duty," and with the way you discuss how to handle information that "falls into a psychiatrist's hands."

I see three additional features in the Huremovic case - the patient was in a potentially life and death emergency situation, the information was on a public website, and the information might have a material impact on the patient's survival.

You might be interested in a post I wrote last year about therapists' non-emergency "snooping" on a patient's Facebook site. I think the position I took accords with yours.

Best

Jim

Jim Sabin said...

Hi Hamid -

What a great question! I'm currently teaching the required medical ethics course to first year Harvard Medical students, and I'm going to send them the post and your question to see how the students answer it.

I would not see the web comments as an advance directive that should be followed by taking the patient off the ventilator. Presumably the patient was being treated for depression, and depression can alter cognitive process in ways that undermine decisional capacity. I can't imagine that Dr. Hurevomic would see the web statements as reflection of what in legal terms would be called a "competent" decision.

The question you raise is of great practical import for terminally ill patients who may well feel ready for "God to take me." I've seen situations in which patients and families have had (a) advance directives along with (b) letters from their physicians (c) taped to the refrigerator, so that (d) if EMTs were called in an emergency they would be empowered to provide comfort care only.

Best

Jim

Hamid said...

Thanks Jim for the response. I would be really interested to know how the students analyze this issue.

While reading your comment, I was thinking about Terry Schiavo case. If in Terry's case, life support could finally be withdrawn based on her expressed prior oral will, why couldn't it be in this case?

The only answer--as you mentioned--might be that the patient has not had the capacity at the time to decide, and that statement seems too general to be applicable to all patients with depression, even when under anti-depression treatments. Wouldn't it mean depriving them of their autonomy, and pave the path for a paternalistic/fiduciary relationship?

All the best,
Hamid

Jim Sabin said...

Hi Hamid -

Thanks for your followup comments!

I didn't mean to be making a generalization about depression and capacity to make legally "competent" decisions. You're right that the situation of each patient would need to be considered. If the depressed person is utterly hopeless about the future and says "I want to be dead because I know my life will never be any different than it is now" when prior to the episode of depression he was happy and enjoyed life, it is easy to say that the wish to be dead is not a rational autonomous choice. If someone with a terminal illness expresses the same wish it may be equally easy to reach the opposite conclusion. In between the extremes there's a gray zone in which different clinicians might reach different conclusions about competence and autonomy.

No psychiatric diagnosis per se entails the conclusion that a person is not competent to decide about declining withdrawing life prolonging treatment.

If I get enough responses from the medical students and the primary care residents I sent your initial question to I'll present what I hear from them in another post.

Best

Jim

Hamid said...

That was a great joy for me to have a chance to exchange ideas on such an important issue. I thank you very much for your feedback and thoughtful responses.

Regards,
Hamid

Jim Sabin said...

Hi Hamid

I also find thoughtful exchange of ideas a source of joy! I hope you'll "visit" the blog again in the future.

I haven't heard back from the students or residents yet about the initial question you raised. I'll let you know via a blog post when and if I do hear enough to report on.

Best

Jim