Cynthia M.A. Geppert, MD, MA, MPH, MSBE, DPS

On December 11, 2020, the US Food and Drug Administration (FDA) announced it issued an 

 (EUA) for the Pfizer-BioNTech coronavirus disease 2019 (COVID-19) vaccine

 it had granted an EUA for the Moderna vaccine.

 overcame unprecedented scientific obstacles to develop these 2 vaccines and reach governmental authorization.

 Yet the ethical challenges of vaccine allocation may be even more daunting.

Since at least 1962, when the FDA first grappled with the conundrum of who should get access to the novel dialysis machine,

 health care professionals, bioethicists, and public health leaders have wrestled with how to justly distribute the angel of life-saving resources when the devil is in the details precisely because the resource is scarce. Sadly, not everyone who needs and could benefit from life-saving care can receive it. Allocation decisions for COVID-19 vaccines are especially weighty, given that the virus has thwarted most other therapeutics, besieged the health care system, collapsed the economy, and caused widespread 

 surrounding COVID-19 vaccine allocation. Fortunately, we are not alone in navigating this moral labyrinth. In the past few months, several of the most respected public health institutions in the world have published reports that provide ethical frameworks for allocating the COVID-19 vaccine (

). Any ethical framework must consider those with serious mental illness, and the hundreds of members of our specialty who are on the front line delivering COVID-19 care. (Note: future 

 articles will consider exactly where individuals with mental health illness should fall in the vaccine prioritization queue.)

Table. Ethical Frameworks for Vaccine Allocation

Several observations about the ethics of COVID-19 vaccine allocation in the United States can be drawn from these summaries. First, the 3 American frameworks summarized in the 

 contain principles of distributive and procedural justice.

 In the context of allocating scarce resources, “distributive justice” concerns the outcomes that are sought when competing ethical values, principles, and interests must be balanced. For example, ethical vaccine prioritization must balance utility in maximizing the reduction of severe disease and mortality from COVID-19, ensuring groups with health disparities have fair access to the vaccine and promoting respect for the dignity of vulnerable populations, such as those with disabilities.

“Procedural justice” concerns the process of specifying and weighing these many values, principles, and interests. For vaccine allocation planning and execution, an ethical process requires wide stakeholder input, transparent decision-making, and a clear mechanism for adjusting criteria in response to new scientific data and logistic developments.

 also illustrates the critical difference between the clinical ethics most of us practice, in which the preferences and needs of the individual patient are the locus of decision-making, and public health ethics, in which the common good is the focus.

 Another key distinction between the clinical and public health ethics is that legal, social, and even political factors wield much more powerful and pervasive influence in public health deliberations.

 The distinguishing pathophysiology and unique epidemiology of the 

, stressing the nation at one of the most divisive times in US history, has revealed as never before the fault lines in American health care. The legacy of health disparities and structural racism have enabled the COVID-19 pandemic to savagely afflict communities of color.

 This made it morally incumbent upon the expert multidisciplinary panels who crafted these frameworks to incorporate not only traditional principles of utility and beneficence, but also the democratic values of equity and the dignity of all individuals.

The importance of remedying racial health inequities is one of the most difficult issues related to COVID-19 vaccine allocation. Some thought-leaders argue race should be directly addressed, as in prioritizing race as a health factor, while others recommend prioritizing the comorbidities that are more common among disadvantaged groups.

 Each of these and many other questions require ethical trade-offs, which are measured in human lives and economic disruption so long as there is not an adequate supply of vaccine and functional distribution plan and infrastructure.

As can be seen from the 3 primary American ethical frameworks for vaccine distribution, there is a general agreement that health care workers and other first responders on the front line of health care should also be among the first to receive the vaccine. There are multiple rationales to support the primacy of health care workers: they are among the populations at highest risk for exposure; they are a scarce resource, without which the health care system collapses, leading to more disease and death; and they are owed reciprocity for putting their professional obligation to care for the sick above their personal interests. The critical role of health care workers has led some in the public health field to contend that vaccination should be mandatory for employment. Although it has gained legal traction, this proposition violates the 

 that has been the hallmark of American professionalism.

Similarly, all but the most utilitarian among us will support vaccinating older, sicker Americans before younger ones, especially those in congregate living situations, along with the staff who care for these vulnerable patients. Data have consistently shown a higher risk of morbidity and mortality from COVID-19 with age and comorbidities such as diabetes and hypertension.

 Individuals in nursing homes, group homes, and residential programs, many of whom are patients with mental health disorders, often have overlapping comorbidities that reduce their ability to protect themselves from infection.

 Similarly, there is an over-representation of ethnic and social groups with greater health disparities in lower-paying caregiver jobs.

 That being said, there is an alternative position arguing that it is those in the prime of life who should preferentially receive scarce resources, as their investment in society has not yet been returned, and they have the best chance of recovery when stricken with the virus.

m these perspectives the thrust of our efforts should be on vaccinating younger cohorts in whom vaccination

 is likely to be more effective in reducing transmission.

For ethical guidance to be flexible enough to respond to the rapidly evolving scientific knowledge and dynamic nature of conditions on the ground, it cannot be overly prescriptive or rigid. This leaves latitude for interpretation, especially among the states where the actual implementation occurs and, hence, room for disagreement, especially as we move down the levels of the framework. A clear example of this phenomenon was when the federal government encouraged states to begin vaccinating all those 65 years and older. But when the nationwide immunization effort lagged the schedule, the Department of Health & Human Services modified prior US Centers for Disease Control and Prevention guidance, ruling that 75 years of age should be the cutoff for 1b 

Among the most problematic questions is “Who is an essential worker?” For a single mother, it is essential that her school-age child’s teacher be vaccinated so schools can open, so the mom can return to work. On the other hand, mass transit and social services workers may be necessary for survival for an urban family whose breadwinner has lost their job due to the pandemic. Even reasoned efforts to choose the most crucial groups raise the specter of social worth criteria, by which some individuals are deemed more valuable than others.

A careful review of these frameworks suggests that they overlook patients with mental illness and mental health care professionals. Patients with mental illness and those who care for them are often sidelined during major health care initiatives; that other struggle for parity and equity extends to vaccine allocation in this pandemic.

Mental health has been discounted in a range of health care scenarios, from representation on the expert panels that produced the reports to inclusion of psychiatrists in essential health care worker categories to specific attention to the needs and challenges of vaccinating patients with mental illness. An ethical analysis of how our profession and patients should fit into vaccine allocation frameworks, and practical recommendations for promoting immunity in our community, remain to be done.

is professor, Department of Psychiatry and Internal Medicine, and director of Ethics Education, University of New Mexico School of Medicine in Albuquerque, New Mexico; she is also health care ethicist, Ethics Consultation Service, VA National Center for Ethics in Health Care and adjunct professor of bioethics, Alden March Bioethics Institute Albany Medical College.

1. United States Food and Drug Administration. FDA takes key action in fight against COVID-19 by issuing emergency use authorization for first COVID-19 vaccine. Press release December 11, 2020. Accessed January 26, 2021. 

https://www.fda.gov/news-events/press-announcements/fda-takes-key-action-fight-against-covid-19-issuing-emergency-use-authorization-first-covid-19

2. United States Food and Drug Administration. FDA takes additional action in fight against COVID-19 by issuing emergency use authorization for second COVID-19 vaccine. Press release December 18, 2020. Accessed January 26, 2021.


https://www.fda.gov/news-events/press-announcements/fda-takes-additional-action-fight-against-covid-19-issuing-emergency-use-authorization-second-covid

3. Hennessy M. How pharmaceutical innovation is saving the world. 

https://www.psychiatrictimes.com/view/how-pharmaceutical-innovation-saving-world

Medical Ethics: Accounts of Ground-Breaking Cases

5. Foege, WH, Gayle, HD, Brandeau, ML, ed. Framework For Equitable Allocation of COVID-19 Vaccine. National Academies of Sciences, Engineering, and Medicine. October 2, 2020. Accessed January 26, 2021. 

Interim Framework for COVID-19 Vaccine Allocation and Distribution in the United States

. Johns Hopkins Center for Health Security; 2020.

7. Foglia MB, Pearlman RA, Bottrell MM, Altemose JA, Fox E. Priority setting and the ethics of resource allocation within VA healthcare facilities: results of a survey. 

9. Jennings B. A strategy for discussing ethical issues in public health. In: Jennings B, Kahn JP, Mastroianni A, Parker LS, eds. 

Ethics and Public Health: Model Curriculum

. Association of Schools of Public Health;2003:1-12.

10. Lee IJ, Ahmed NU. The devastating cost of racial and ethnic health inequity in the COVID-19 pandemic. 

11. Schmidt H, Gostin LO, Williams MA. Is it lawful and ethical to prioritize racial minorities for COVID-19 vaccines? 

12. Vestal C. Health care workers can decline a COVID-19 shot—for now. 

. December 8, 2020. Accessed January 26, 2021. 

https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2020/12/08/health-care-workers-can-decline-a-covid-19-shot-for-now

13. Imam Z, Odish F, Gill I, et al. Older age and comorbidity are independent mortality predictors in a large cohort of 1305 COVID-19 patients in Michigan, United States. 

14. Bagchi S, Mak J, Li Q, et al. Rates of COVID-19 among residents and staff members in nursing homes - United States, May 25-November 22, 2020. 

15. Emanuel EJ, Persad G, Upshur R, et al. Fair allocation of scarce medical resources in the time of Covid-19. 

16. Matrajt L, Eaton J, Leung T, Brown R. Vaccine optimization for COVID-19, who to vaccinate first? 

. Preprint. Published online August 15, 2020:2020.08.14.20175257. 

https://pubmed.ncbi.nlm.nih.gov/32817963/

17. Simmons-Duffin, S. Trump Administration Urges States to Open COVID-19 Vaccination to Everyone over 65. National Public Radio. January 12, 2021. 

https://www.npr.org/sections/health-shots/2021/01/12/956017635/trump-administration-to-change-covid-19-vaccination-guidance-to-speed-up-rollout

Articles

Leaders are struggling to justly distribute the coveted vaccine, as their are many vexing ethical issues surrounding COVID-19.

Whose Turn Should It Be? The Ethics of COVID-19 Vaccine Allocation

Imagine there's no heaven
It's easy if you try
No hell below us
Above us only sky
Imagine all the people living for today

This iconic song inspired Geppert, Professor of Psychiatry and Director of Ethics Education at the 

University of New Mexico School of Medicine

, to share her thoughts on moral imagination. Dr Geppert is also the Ethics Chair for 

Although many believe these are utopian lyrics, she explains, she sees it as having faith in humanism and an expression of the idealistic belief that the world can be better. Lennon hopes for things—for ideals—that we may or may not agree with and may or may not be possible. Yet, if every person uses this moral imagination to explore a better world, maybe we can make it happen, Geppert notes.

Leveraging cognitive science, Mark Johnson shared introduced the idea of moral imagination in the 

. Here, Geppert challenges us to discern the various possibilities on how we can act, despite the challenges faced by the pandemic—or any hardship. The goal, she explains, is not to retreat into fantasy or escape, but rather to face the terrible realities and set ourselves free through our imaginations. Doing so, she explains, allows us to leverage renewal and empathy as we move forward.

Geppert points to the examples of the good we have seen as a result of the pandemic, and ponders how we might bring those positives forward with us as we re-open and re-emerge into the post-lockdown and quarantine world. For instance, animals have returned to their habitats and exploring areas they had long abandoned in national parks worldwide. Perhaps, she muses, as we move forward, we can find ways to enjoy our natural surroundings without disturbing these animals’ homes. Animal shelters quickly emptied with lockdown. She ponders, is there a way to encourage adoptions and fostering in the future? Pollution has subsided in many areas. Can we can continue to forgo some car and plane trips to minimize the damage to our environment? Recovered patients donated plasma, health care workers put their own well-being aside to care for others, and people have offered to shop for the elderly and the sick. Can we continue to value and foster the acts of 

Geppert reminds us of what a fellow dreamer shared, as he helped eradicate polio, which was once considered impossible: “There is hope in dreams, imagination, and in the courage of those who wish to make those dreams a reality.” And she invites listeners to have the courage to use their imagination to rebuild a better and kinder world with 

You may say I'm a dreamer
But I'm not the only one
I hope some day you'll join us
And the world will be as one.

Videos

Dr Cynthia Geppert invites listeners to have the courage to use their imagination to rebuild a better and kinder world

It’s Time to Use Our Moral Imagination

Slideshows

In psychiatry, hot debates abound if you just look around-and if this Special Report collection is any indication, the result is a balance of opinion and civility made richer by virtue of opposing views.

Psychiatric Questions, Queries, and Quarrels

Perhaps no branch of medicine has been the subject of so much controversy as psychiatry. Almost everything about our profession has been doubted and debated: our assumptions about the nature of psychiatric disorders from psychoanalysis to neuropsychiatry, and our interventions from ECT to CBT. Those who query and quarrel are often from outside the fold of the profession, albeit at times with help from insiders like the late great Thomas Szasz.

 Recently, the most impassioned polemic has frequently come from other mental health disciplines-those closest to us always know our weaknesses best. The intrinsic division within our own house has also been the subject of T. M. Luhrmann’s ethnography of psychiatry.

As of March 2, 28 states and the District of Columbia have approved medical marijuana, and there is an ever-burgeoning list of psychiatric conditions that meet the criteria for state programs-despite the concerns of many psychiatrists about the increased risk of psychosis, especially for those individuals with a diathesis.

 Yet this is also regrettably a topic on which there has been rhetoric that too often obfuscates reason on both sides. Christopher Fichtner, MD, and Howard Moss, MD, may prolong the controversy by providing more of a 

. Medical marijuana as a phenomenon in the culture of medicine has been driven far more by the public and politicians than by practitioners and professionals. Except perhaps for our colleagues with expertise in complementary and alternative medicines, many mainstream psychiatrists are playing scientific catch-up.

No issue in psychiatry has been as contentious and protracted as the arguments and counterarguments over the DSM diagnostic system. In our own social life, most of us have learned that there are subjects where the disagreement is so intense we have to change the subject. This is exactly what we have in the article by Bruce Cuthbert, PhD, on the National Institutes of Mental Health Research Domain Criteria (RDoC). Cuthbert discusses this research-based diagnostic system and offers instructive comparisons and contrasts with DSM. The acronym RDoC is the latest chapter in psychiatry’s ongoing story of the search for a holy grail of biological etiology. Those who think this a quixotic or futile quest may take some solace in that any criteria still leave ample room for the judgment and experience of the practicing clinician.

 redux hones in on one of the most popular targets of the media: that psychiatric disorders are overdiagnosed in an effort to medicalize and medicate normal variants in human behavior. Psychiatric detractors give a variety of rationales-some suggestive of conspiracy theories-for this tendency. Rahil R. Jummami, MD, Emily Hirsch, and Glenn Hirsch, MD, take on one of the most heated topics-the diagnosis and treatment of 

. Mining the epidemiological data field, they draw interesting, and at times opposing, conclusions as befits a Special Report dedicated to dissension. Readers can decide after reading the article whether ADHD is really over-or perhaps even under-diagnosed as well as parse out the logical fallacy that a diagnosis leads ineluctably to medication management.

 is arguably on a subject that is the most oriented toward future debates-physician-assisted suicide (PAS) for patients with mental illness. PAS has been legal and ethical not only in Europe for years but more contemporaneously in our neighbor to the north-Canada. No other issue in our series has aroused such polarized and powerfully held opinions, and this is not surprising given that PAS or PAD (

), depending on your view, goes to the heart of the ethical commitment of psychiatry as a profession of healers of the mind.

 We urge readers to seriously consider the positives and negatives of this momentous change in our evaluation and balancing of the age-old tension in mental health care between compassion and suffering and begin to formulate their own position and justifications for a question that urgently confronts us all.

 ProCon.org. The Leading Source for Pros and Cons of Controversial Issues. 

http://medicalmarijuana.procon.org/view.resource.php?resourceID=000881

 Pies R, Geppert CM. Not just a matter of semantics. 

An overview of the DSM diagnostic system, the medicalization of normal variants of human behavior, and physician-assisted suicide.

Introduction: More Dives and Intellectual Jujitsu

, to controvert “is to oppose with logical reasoning, to dispute or contradict”; even more literally in the Latin it means, “turned against.” Hence came the disputations of medieval theologians and the point-counterpoint of the 

 of Thomas Aquinas. In this 2-part Special Report on Controversies in Psychiatry, we offer our modern version of such point-counterpoint.

But first a bit of a clarification. Cable television and social media have taken the academic shine off of controversy and sullied it with scandal. True controversies, such as those we will examine in this Report, are substantive clinical issues about which there is real and serious disagreement among experts. Political controversy, as we have sadly seen these past few months, can be a sign that the social body is ailing. But respectful debates about substantive topics are signs of curiosity and imagination signaling health of mind-or in this case the community of minds that is psychiatry.

Gauged by this measure, psychiatry is very well indeed, for the most difficult part of chairing this Special Report was how to choose from the dozens of controversies our outstanding editorial staff developed.

The articles in part I examine some of the most intriguing questions. Strong evidence supports sound arguments on each side of each topic.

The first set of articles addresses assisted outpatient treatment (AOT), a topic that may not seem like a controversy to many of our readers. The authors of the 2 articles suggest that there are salient counter-claims about AOT that strike the fundamental chord of mental health ethics: the conflict between beneficence and autonomy, and between paternalism and liberty that deserves a hearing and thoughtful response.

The second issue addressed is the debate over the use of antidepressants in pregnancy-another contemporary clinical dilemma in which practitioners often fear they have no viable options. Lauren Osborne, MD, Katherine McEvoy, MB ChB, and Jennifer Payne, MD, show that empirical data and shared decision-making offer a number of reasonable strategies.

Neuroscience has more than proved that engaging in challenging mental exercise is key to the longevity and vitality of the life of the mind. So we invite readers to join us in this age-old intellectual jujitsu, which has been an essential part of the training of rabbis and lawyers, philosophers, and-yes-physicians.

Dr. Geppert is Professor of Psychiatry and Director of Ethics Education, University of New Mexico School of Medicine; and Chief, Consultation Psychiatry and Ethics, New Mexico VA Health Care System, Albuquerque, NM.

This special report on controversies in psychiatry examines the pros and cons of assisted outpatient treatment and also antidepressant use in pregnancy.

Introduction: Deep Dives and Intellectual Jujitsu

If we were to conduct a survey of readers’ responses to the quiz that follows, we would likely find a marked generational divide between those who believe that “patient-targeted Googling” is just another form of collateral information and those who think that Googling is just a new type of boundary crossing.

 The etiquette and ethics of the electronic revolution have been styled “digital professionalism,” and it is a field in flux as we see when we analyze the 

The case presented a mid-career psychiatrist, Dr. R, with a predominantly psychotherapy practice who is treating Ms B, a woman in her thirties who purports to have been a famous academic musician until she unjustly lost her career after a student accused her of sexual misconduct. Initially, the psychiatrist believes the patient is suffering from an adjustment disorder, but as the sessions proceed he begins to doubt the patient’s narrative. His best efforts to engage Ms B in more critical reflection on the events, or even offer up more factual details, fail. He entertains the idea of Googling Ms B to find out what really happened-ostensibly to move the stalled therapy forward. But first he seeks advice from his former psychology professor, who assures him that there is nothing unethical about the practice.

The quiz asks you to think about whether you agree with the professor’s advice and how in your own practice you would handle information about a patient obtained from an Internet search.

1. Assume you are the psychology professor. What do you tell Dr. R about the ethics of “Googling” Ms B?

Go ahead and Google; the Internet is public domain.

 This is one of the most common reasons or rationalizations-depending on your perspective-in favor of Googling a patient. It is technically true that the Internet is mostly public domain, but this assumes that the person conducting the search is “the public” with the prevailing mores and morals of their society and not a mental health professional who many ethicists believe should be held to a higher standard of conduct.

 Don’t Google the patient; it’s a violation of HIPAA. 

This is often used to mechanistically intimidate practitioners into not Googling, although the psychiatrist is technically not “exchanging information” in that he is not disclosing any protected health information about the patient. But this reflexive turn to HIPAA shows the ambivalence of many who contemplate Googling, yet who instinctively believe it is intruding on a patient’s privacy or who fear the legal consequences of a violation.

Don’t Google the patient; it is a breach of the patient’s trust in the therapeutic alliance.

 This is the answer of many older psychiatrists as well as those who have strong psychoanalytic training or orientation. How and when the patient reveals her psyche in the therapeutic relationship is at least as significant as what is revealed, and taking such a shortcut betrays not only the patient’s trust but the integrity of the process.

Don’t Google the patient; instead search the major newspapers from the city where Ms B purports the events occurred.

 This raises a fascinating question. How is Googling ethically better or worse than searching the newspapers, the latter inarguably being public domain? Ask yourself if you picked up the morning 

 and found a story about one of your long-term patients: would you read it, or would you first ask the patient for her permission? A survey published this year found that nearly 40% of psychotherapists had searched online for information about a patient, especially when-as in the case of Ms B-they felt they had been deceived. About the same percentage knew or supervised someone who had engaged in patient-targeted Googling.3 Earlier surveys that focused on psychiatrists found similar percentages.

 One study found that 60% of psychiatrists questioned in New York believed that patient-targeted Googling could be constructively utilized in psychiatry.

2. The professor tells Dr. R there is no ethical reason he cannot Google the patient. Dr. R then asks if he should obtain informed consent from the patient to conduct the search.

In question 2, Dr. R is still struggling with the question of confidentiality and so brings up the equally fundamental ethical concept of informed consent and whether he should obtain it before searching.

No, don’t tell her. This undermines the entire psychological purpose of the activity and its ethical justification to find out the truth, so you could help her in therapy.

 This is an odd mixture of motives that are key in determining whether a search is ethical. The professor seems to be saying that the goal of Googling is not just to obtain the information but to use it psychologically to facilitate the therapy. It is this basis in beneficence that could provide the ethical counterweight to the breach of confidentiality.

No, don’t ask her permission, but you can tell Ms B later that you conducted a search to be better able to understand and work with her in therapy. 

This bends the beneficence toward soft paternalism and assumes that the patient will accept that the psychiatrist acted for her “good.” It is easy to see how this strategy, especially for this already embittered patient, might unwittingly have the opposite effect of reinforcing her immature defenses-she will continue to believe that all that has befallen her is the result of undeserved perfidy.

Yes, ask her permission out of respect for her privacy. 

This is a prudent choice and may be what Ms B desires with her insistence that she was such a renowned figure that her reversal of fortune was headline news. The only catch is that the truth the papers printed is far less glamorous than Ms B’s fantasy, and a stark confrontation of this discrepancy would expose the false self she is desperately holding onto in therapy. More simplistically, if she says no, Dr. R will have no information and must also deal with the unpredictable reaction of his patient.

Yes, ask her permission and suggest that you do the search together in your office during a session.

 This best respects the patient’s autonomy and privacy and probably also has the most therapeutic potential to enable Ms B to face the truth of her past. However, like option C, she can obviously refuse the suggestion, leaving the course of therapy even more impeded. Should Dr. R decide to Google Ms B, it is hard to see how he could constructively use the information or preserve the alliance given the way the information was obtained.

3. The professor tells you not only is it ethically permissible to Google Ms B but that you actually have an ethical obligation to conduct the search in order to provide appropriate care. Does Dr. R really have an ethical duty to Google Ms B, and if so, what is its nature?

Question 3 emphasizes the spectrum of ethical views on the subject, even among leading psychiatric ethicists.

Yes, Dr. R has a duty to overcome his own negative counter-transference toward the patient.

 This locates the warrant for Dr. R to work through his own negative emotions toward Ms B to regain the position of therapeutic neutrality he needs to be effective in treating his patient.

No, Dr. R does not have an ethical obligation to Google the patient because doing so is a breach of physician-patient confidentiality.

 This is the most traditional answer at the other end of the continuum: Googling cannot be a professional duty because it directly contravenes the more fundamental obligation to respect patient confidentiality.

No, Dr. R has an obligation to work within the psychodynamic frame to empathically understand and effectively treat the patient.

 This offers a more sophisticated variant of the previous option. It locates the psychiatrist’s primary duty to maintain the boundaries of the therapeutic relationship, within which compassionate listening may enable the patient to find healing.

Yes, if Dr. R does not review information that could potentially prevent harm to the patient, and if she attempts suicide, he will not have done his duty to protect her and could be held legally liable.

 This is the even more extreme version of C and once again emphasizes the diversity of opinion on the practice. A psychiatrist who did not obtain clinically indicated collateral information such as previous treatment records or reports of significant others-with consent outside an emergency situation-would not have met the standard of care.

Since by analogy the Internet is a source of information about the patient, do we not also have a duty to consult it? One thing almost every practitioner along the Googling continuum agrees on is the need for more definitive ethical and legal guidance, and several organizations and experts have proposed professional recommendations.

4. Now that Dr. R has this information, what should he do with it?

In the final question, Dr. R’s clinical reality intrudes on the professor’s pontifications. Dr. R searched the Internet for information about Ms B-and now how does he handle it in therapy? Sound clinical advice is found in a review article by Clinton and colleagues.

Dr. R should tell Ms B that he Googled her and would like to discuss what he found, so they can engage in more productive work about her real problems.

Dr. R should tell Ms B that he Googled her and that she has a right to know what he learned, so she can make an informed decision about whether to continue in therapy.

Both options assume Dr. R did not seek Ms B’s consent before his virtual detective work, and each is an attempt to restore some measure of ethical equilibrium. Option A pleads that he did not seek her consent for her own good, while option B gives Ms B a chance to exercise her own self-determination even if the search is a faitaccompli.

Dr. R should not tell Ms B that he Googled her but should begin shifting the therapeutic approach from adjustment disorder to narcissistic personality disorder.

 Options B and C add a breach of truth-telling to the lack of consent. Most psychiatrists would scrutinize a clinician who changed his diagnostic impressions on the basis of news stories.

Dr. R should not tell Ms B that he Googled her; instead he should say that he had read about her in a newspaper at the time of the incident but recalled the details differently.

 This is prevarication, and the worthwhile therapeutic objective could be more honestly accomplished through Dr. R disclosing his search.

Working through the case scenario, the wisdom of the deontological stance of the American Psychiatric Association (APA) Ethics Committee becomes apparent.

 In its commentary on the Principles of Medical Ethics, the APA opines that what renders a decision to Google a patient ethically justifiable is the motive of the psychiatrist. To Google for the good of the patient may be acceptable, to Google to circumvent the hard work of interviewing, or for voyeuristic breaching of boundaries, or in the case of Dr. R frustration over a thwarted therapy, may well not be ethical. You decide.

Googling a patient is not, in and of itself, unethical. First and foremost, the Googling of a patient should be done only in the interests of promoting patient care and well-being and never to satisfy the curiosity or other needs of the psychiatrist. Also important to consider is how such information will influence treatment, and how the clinician will ultimately use this information. The psychiatrist should ask himself or herself these questions before resorting to a Google search.

Dr. Geppert is Professor of Psychiatry and Director of Ethics Education, University of New Mexico School of Medicine; and Chief, Consultation Psychiatry and Ethics, New Mexico VA Health Care System, Albuquerque, NM. She reports no conflicts of interest concerning the subject matter of this article.

 John NJ, Shelton PG, Lang MC, Ingersoll J. Training psychiatry residents in professionalism in the digital world. 

 Geppert C. To google or not to google? This is the question. 

 Eichenberg C, Herzberg PY. Do therapists google their patients? A survey among psychotherapists.

 Koh S, Cattell GM, Cochran DM, et al. Psychiatrists’ use of electronic communication and social media and a proposed framework for future guidelines.

 Deen SR, Withers A, Hellerstein DJ. Mental health practitioners’ use and attitudes regarding the Internet and social media. 

 Genes N, Appel J. The ethics of physicians’ web searches for patients’ information. 

 Clinton BK, Silverman BC, Brendel DH. Patient-targeted googling: the ethics of searching online for patient information. 

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Opinions of the Ethics Committee on the Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry.

 Arlington, VA: American Psychiatric Association; 2016.

How would you handle information about a patient obtained from an Internet search? Take the quiz.  

To Google or Not to Google? Is “Patient-Targeted” Googling Ethical?

The lady doth protest too much, methinks.

Dr. R is a psychiatrist who has been in private practice for 15 years in a large urban city in the Northeast.

 His practice consists mostly of psychodynamic psychotherapy with some minor medication management. The majority of his patients are self-pay.

Ms. B is an attractive, very intelligent 36-year-old single woman whom Dr. R has been treating for about 6 months for what initially appeared to be an adjustment disorder with depressed mood resulting from an unfortunate career reversal. Most of the sessions have revolved around Ms. B’s feelings of betrayal and embitterment regarding the loss of her academic post in the music department of a large university in the Midwest, where she previously lived. Ms. B insists that a student had falsely accused her of improper sexual advances and that because of department politics, she was forced to resign a year ago. At the time Ms. B says she was a promising concert violinist and music scholar.

Ms. B is distraught that after having graduated from a famous conservatory the only job she has been able to obtain is directing the music program at a local private school. She is enraged that circumstances have reduced her to such a lowly position. Dr. R is well aware of the literature on adjustment disorder and that these patients have an elevated risk of suicide.

The central theme that has emerged in therapy is Ms. B’s loss of reputation and honor and her extreme resentment regarding the unfairness of academia. She vehemently blames the Chair of the department for not defending her against what she perceives as ridiculous allegations from a student who did not get the grade he wanted in her music theory class. She voices revenge fantasies but states that she “would never act on them as I am beyond such primitive reactions; that is why I am in therapy.” As the therapy proceeds, the psychiatrist begins to doubt Ms. B’s account of her recent events and even questions her history as a musician. His psychodynamic formulation is now moving toward a narcissistic personality disorder or even, at times, delusions of grandeur suggesting a bipolar diagnosis.

Repeated efforts using a variety of psychotherapeutic techniques to explore Ms. B’s family of origin or to enable her to describe the emotional effects of the professional upheaval are met with accusations that Dr. R is calling her a liar and a renewed preoccupation-even obsession-with her stolen fame. Ms. B rebuffs any reinterpretation of her experience with the response that “you must have read all about this when I was humiliated in the newspapers; of course it happened exactly as I told you.”

Dr. R is becoming increasingly skeptical of Ms. B’s personal narrative and frustrated with her resistance. He is a regular reader of several major newspapers and a music aficionado yet cannot recall ever reading anything about Ms. B. After much struggling with his own sense of psychoanalytic boundaries, Dr. R finally decides to try to substantiate at least the basic details of Ms. B’s story. He fears that unless he can obtain some reliable independent report about her past he will be unable to constructively help her build a future.

Dr. R believes that the most efficient means of accessing such information would be through the Internet, where he can run a targeted search using the facts as he knows them from the therapy. Dr. R has not kept up much with digital professionalism. He is aware of colleagues who are on Facebook and some who advertise their services on the Internet. He knows that a few even regularly provide psychiatric commentary in blogs. “Googling” a patient does not seem much different from the old-fashioned obtaining of collateral information, but he is unsure of the legal or even ethical ramifications of using the Internet to gather such information. He calls an old friend who was his psychology professor in college and who now teaches ethics at a local college for advice.

Assume you are the psychology professor. What do you tell Dr. R about the ethics of “Googling” Ms. B?

 Go ahead and Google; the Internet is public domain, and there is no ethical or legal problem with accessing the information.

 Do not Google the patient; it is a violation of HIPAA, which protects the electronic exchange of individually identifiable information.

 Don’t Google the patient; it is a breach of the patient’s trust in the therapeutic alliance.

 Don’t Google the patient; instead go to the public library and search the major newspapers from the city where Ms. B purports the events occurred.

2 The professor tells Dr. R there is no ethical reason he cannot Google the patient. Dr. R then asks if he should obtain informed consent from the patient to conduct the search.

 No, don’t tell her. This undermines the entire psychological purpose of the activity and its ethical justification to find out the truth, so you could help her in therapy.

 No, don’t ask her permission, but you can tell Ms. B later that you conducted a search to be better able to understand and work with her in therapy.

 Yes, ask her permission out of respect for her privacy.

3 The professor tells you not only is it ethically permissible to Google Ms. B but that you actually have an ethical obligation to conduct the search in order to provide appropriate care. Does Dr. R really have an ethical duty to Google Ms. B, and if so, what is its nature?

Yes, Dr. R has a duty to overcome his own negative counter-transference toward the patient so that he can form a therapeutic relationship.

 No, Dr. R does not have an ethical obligation to Google the patient because doing so is a breach of physician-patient confidentiality.

 No, Dr. R has an obligation to work within the psychodynamic frame to empathically understand and effectively treat the patient.

 Yes, if Dr. R does not review information accessible to him that could potentially prevent harm to the patient, and if she attempts suicide, he will not have done his duty to protect her and could be held legally liable.

Dr. R decides to Google Ms. B because he fears that unless he knows what really happened to her, her enraged desperation may result in her harming herself or someone else. He finds a few stories in the city newspaper as well as a brief statement from the university about the incident. From these communications, Dr. R learns that Ms. B was not only charged with allegations of sexual impropriety with a student, but the charges were actually substantiated and she was given a choice to resign or to be terminated. She is described as an instructor in the department and a substitute violinist in the local symphony-hardly the irreproachable luminary of classical music she portrayed herself to be in therapy.

4 Now that Dr. R has this information, what should he do with it?

 At the next session, Dr. R should tell Ms. B that he Googled her and would like to discuss what he found so that they can engage in more productive work about her real problems.

 At the next session, Dr. R should tell Ms. B that he Googled her and that she has a right to know what he learned, so she can make an informed decision about whether to continue in therapy.

 At the next session, Dr. R should not tell Ms. B that he Googled her but should begin shifting the therapeutic approach from adjustment disorder to narcissistic personality disorder.

 At the next session, Dr. R should not tell Ms. B that he Googled her; instead he should say that he had read about her in a newspaper at the time of the incident but recalled the details differently and could they discuss the discrepancies as a means of moving her toward insight.

Ethics consultations often involve a number of different and often conflicting ethical concerns and questions. Please vote for your choices-and post your comments below. I’ll offer a discussion of your comments and commentary about the ethical concerns and questions this case raises in a coming issue of Psychiatric Times.

Dr. Geppert is Professor of Psychiatry and Director of Ethics Education, University of New Mexico School of Medicine; and Chief, Consultation Psychiatry and Ethics, New Mexico VA Health Care System, Albuquerque, NM. She reports no conflicts of interest concerning the subject matter of this article. 

“Googling” a patient does not seem much different from the old-fashioned obtaining of collateral information, but the ramifications may be far more than you bargain for.

Cynthia M.A. Geppert, MD, MA, MPH, MSBE, DPS

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