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Thursday, 1 April 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 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!


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