“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.
The lady doth protest too much, methinks.
Hamlet, Act 3, Scene 2
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.
1Assume you are the psychology professor. What do you tell Dr. R about the ethics of “Googling” Ms. B?
A. Go ahead and Google; the Internet is public domain, and there is no ethical or legal problem with accessing the information.
B. Do not Google the patient; it is a violation of HIPAA, which protects the electronic exchange of individually identifiable information.
C. Don’t Google the patient; it is a breach of the patient’s trust in the therapeutic alliance.
D. 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.
A. 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.
B. 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.
C. Yes, ask her permission out of respect for her privacy.
D. Yes, ask her permission and suggest that you do the search together in your office during a session.
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?
A. Yes, Dr. R has a duty to overcome his own negative counter-transference toward the patient so that he can form a therapeutic relationship.
B. No, Dr. R does not have an ethical obligation to Google the patient because doing so is a breach of physician-patient confidentiality.
C. No, Dr. R has an obligation to work within the psychodynamic frame to empathically understand and effectively treat the patient.
D. 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?
A. 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.
B. 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.
C. 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.
D. 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.