May 1st, 2010

Networking sites raise ethical questions

Social networking Web sites like Facebook are ubiquitous especially among younger generations who’ve grown up with technology. But with these sites, medical professionals face many potential ethical questions about doctor-patient relationships.

David H. Brendel, M.D., Ph.D, chair of Harvard-affiliated McLean Hospital’s Institutional Review Board in Massachusetts, recently addressed these issues in a Journal of Medical Ethics article.

Does “friending” violate doctor-patient confidentiality? Should physicians, psychologists and other professionals include information from these sites in a patient’s medical record? Might accepting or rejecting an online friendship with a patient compromise treatment? And can a professional disclose too much personal information online?

Brendel, who teaches medical ethics and professionalism at Harvard Medical School, was inspired to author the article by his first-year medical students, many of whom saw nothing wrong with researching a patient on Facebook.

Brendel is also one of the authors of “Patient-Targeted Googling: The Ethics of Searching Online for Patient Information,” in the Harvard Review of Psychiatry, which delved into the ethics of doctors’ searching online (commonly called “Googling”) for patient information.

Because social networking is a relatively new phenomenon, Brendel wants to get a dialogue started about guidelines to help safeguard the patient-doctor relationship and prevent ethics breaches. “It’s very hard for medical students, residents and young physicians to get a lot of guidance and mentorship on this from more seasoned colleagues, because the more seasoned colleagues are not familiar with these ways of navigating on the Internet,” Brendel says.

Brendel discourages doctors from participating in social networking, but recognizes the reality that the majority of residents and young physicians are already active on such sites.

“So the deed is already done,” he says. “Now it’s a question of how to manage the information properly. If you don’t have a Facebook site, I would urge people to seriously think about whether they want to go down that road.”

Among safeguards he recommends to proceed with caution:

Do not initiate an invitation to a patient to become an online friend. If you receive one, address it immediately in person to avoid any damage to the therapeutic relationship. “People may be rejection-sensitive, be easily slighted or narcissistic. It can be seen as a slight or rejection,” he says. “I recommend that (medical professionals) don’t accept them but that they address them quickly.”

Do not enter information obtained on social networking sites into a patient’s medical record without his/her consent.

Use discretion when posting personal information.

Understand a site’s privacy settings and utilize them. Keep in mind that even “private” information can be vulnerable to security breaches, hackers or other vulnerabilities. “The idea that there are privacy settings is a little deceiving,” Brendel says. “They’re not foolproof in any way. So while you should be careful to set them, you can’t rely on them being airtight.”

Regarding “patient-targeted Googling,” Brendel says researchers have received a wide reaction from both ends of the spectrum. “I’ve spoken to some physicians who say absolutely it should never be done, it’s a privacy breach,” and that information should come directly from the patient or other collateral sources that the patient is aware of.

“But there are other physicians of all ages, clinical backgrounds and orientations who say the information is in a public domain, there’s an increasing presumption people are being searched by employers or potential dates or whomever and the physician in some cases may even be obligated to go online and get information if it’s clinically relevant,” he says.

“My own thinking on it is that there are some cases where it should be clearly forbidden,” such as for curiosity or voyeuristic reasons.

“But there are other cases where it may be ethically required to do it, like if you are giving emergency care and only have limited information about a patient,” such as finding the next of kin. In an emergency situation, “you are probably obligated, ethically.

The vast majority of cases fall in the gray area,” he says.

He suggests clinicians be thoughtful and ask themselves six questions before “Googling” a patient: Why do I want to conduct this search? Will it advance or compromise the treatment? Should I obtain informed consent from the patient prior to searching? Should I share the results with the patient? Should I document the findings in the medical records? How do I monitor my motivations and the ongoing risk-benefit profile of searching?

Brendel says he is unaware of any legal case or precedence yet concerning this issue, but he expects there will be in the future. “I think there are questions about whether physicians are opening themselves up to any liability, by engaging in these searches,” he says. For example, if a suicidal or self-injurying patient has a blog that you’ve read, are you obligated to monitor it for signs of trouble?

Brendel suggests professionals use their clinical judgment about telling a patient about information obtained online. “The upside is that you may get more clinical information, the downside is that you may have information that you really didn’t want,” he says. “And in order to maintain a trusting relationship with your patient, you’re going to have to do some fairly fancy footwork. In some cases, the relationship may be deepened. But you can easily imagine patients feeling their privacy was violated. So there’s no question it’s risky.”

By Pamela Berard

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