David H. Brendel

Medical professionalism in the age of online social networking

The rapid emergence and exploding usage of online social networking forums, which are frequented by millions, present clinicians with new ethical and professional challenges. Particularly among a younger generation of physicians and patients, the use of online social networking forums has become widespread. In this article, we discuss ethical challenges facing the patient–doctor relationship as a result of the growing use of online social networking forums. We draw upon one heavily used and highly trafficked forum, Facebook, to illustrate the elements of these online environments and the ethical challenges peculiar to their novel form of exchange. Finally, we present guidelines for clinicians to negotiate responsibly and professionally their possible uses of these social forums.

Patient-Targeted Googling: The Ethics of Searching Online for Patient Information

&NA; With the growth of the Internet, psychiatrists can now search online for a wide range of information about patients. Psychiatrists face challenges of maintaining professional boundaries with patients in many circumstances, but little consideration has been given to the practice of searching online for information about patients, an act we refer to as patient‐targeted Googling (PTG). Psychiatrists are not the only health care providers who can investigate their patients online, but they may be especially likely to engage in PTG because of the unique relationships involved in their clinical practice. Before searching online for a patient, psychiatrists should consider such factors as the intention of searching, the anticipated effect of gaining information online, and its potential value or risk for the treatment. The psychiatrist is obligated to act in a way that respects the patients best interests and that adheres to professional ethics. In this article, we propose a pragmatic model for considering PTG that focuses on practical results of searches and that aims to minimize the risk of exploiting patients. We describe three cases of PTG, highlighting important ethical dilemmas in multiple practice settings. Each case is discussed from the standpoint of the pragmatic model.

The Use of Palliative Sedation for Existential Distress: A Psychiatric Perspective

&NA; This article introduces a structure for standardization in the ongoing debate about the application of palliative sedation for psychological and existential suffering at the end of life. We differentiate the phenomenon of existential distress from the more general one of existential suffering, defining existential distress as a special case of existential suffering that applies to persons with terminal illness. We introduce both a clinical classification system of existential distress based on proximity to expected death and a decision‐making process for considering palliative sedation (represented by the mnemonic, TIRED). Neuropsychiatric clinical cases will be used to demonstrate some of the concepts and ethical arguments.

A Plea for Pragmatism in Clinical Research Ethics

Pragmatism is a distinctive approach to clinical research ethics that can guide bioethicists and members of institutional review boards (IRBs) as they struggle to balance the competing values of promoting medical research and protecting human subjects participating in it. After defining our understanding of pragmatism in the setting of clinical research ethics, we show how a pragmatic approach can provide guidance not only for the day-to-day functioning of the IRB, but also for evaluation of policy standards, such as the one that addresses acceptable risks for healthy children in clinical research trials. We also show how pragmatic considerations might influence the debate about the use of deception in clinical research. Finally, we show how a pragmatic approach, by regarding the promotion of human research and the protection of human subjects as equally important values, helps to break down the false dichotomy between science and ethics in clinical research.

Philosophy of Mind in the Clinic: The Relation between Causal and Meaningful Explanation in Psychiatry

&NA; Conceptual dichotomies between mind and brain, psychology and neuroscience, meaning and causation, and fact and value confound thinking in philosophy of mind, clinical psychiatry, and psychiatric ethics. Paul Churchlands theory of eliminative materialism highlights these dichotomies, stating that advances in neuroscience have restricted, and eventually will eliminate, any need for psychology. The core principles of this theory are questionable, because psychiatrists still need psychology and perhaps always will. The main argument in this essay is that even in cases of well‐defined brain pathology (where eliminative materialism seems most plausible), psychological concepts remain critical. Thus, philosophers and psychiatrists should generate conceptual models that lead not to eliminativism but to explanatory pluralism, which is the pragmatic integration of diverse concepts toward the end of better handling clinical challenges. The contributions of Karl Jaspers in opposition to eliminative materialism and in support of pluralism are discussed. Jaspers delineated the role of meaningful psychological explanation in a psychiatry rooted in neuroscientific explanation. However, his notion that meaningful states do not have causal power is disputable and has come under fire in recent philosophy of mind and cognitive neuroscience, which highlight the possibility that meaningful psychological states can be causally significant. This idea has implications for psychiatric ethics and the fact/value debate.

Healing Psychiatry: A Pragmatic Approach to Bridging the Science/Humanism Divide

&NA; Competing urges to think of human mental suffering as comprehensible and susceptible to scientific formulation, or as deeply complex and beyond the reach of scientific analysis, have torn at the fabric of psychiatry for many years and have left the field conceptually divided between science and humanism. Conceptual reparation of psychiatry is now a core mission of a field that is trying to heal itself so that it is equipped to heal the patients it serves. To formulate their cases comprehensively and provide patients with cutting‐edge care, psychiatrists must heal the conceptual wounds that have resulted from dividing the human individual into an object of scientific scrutiny and a subject of personal experience. They must synthesize science and humanism in order to generate new understanding of mental disorders and to train future clinicians and researchers. Principles of classical American pragmatism, I argue in this article, can help to transcend the science/humanism divide in psychiatry. Clinical pragmatism focuses on favorable treatment outcomes by respecting the practical, pluralistic, participatory, and provisional aspects of psychiatric care. It demands that psychiatrists have the skill and flexibility to use multiple explanatory concepts in a collaborative, open‐ended process with their patients. These themes are explored from the perspectives of contemporary psychiatric treatment, training, and research.

Ethics Consultation to PACT Teams: Balancing Client Autonomy and Clinical Necessity

&NA; The Program for Assertive Community Treatment (PACT) is a community‐based treatment program for people with severe and persistent mental illness, who have been underserved by traditional levels of care and are thought to be at high risk for rehospitalization. Within this model can be found a number of nontraditional treatment practices, some of which challenge the balance between client autonomy and paternalism, and can lead to clinical impasses. In this article we present three clinical cases (with discussions) to illustrate the most common ethical dilemmas that our PACT team has faced in assisting clients with their finances, legal terms of probation, and personal safety. We describe our use of professional ethics consultation to help us manage these dilemmas, enhance client informed consent, and promote collaborative care within the PACT model. Such ethics consultation may be useful to other PACT teams struggling to resolve clinical and ethical dilemmas by respecting both the autonomy and best interests of their clients.

Avatars, cybercoaches, and search engines: Internet technology's value in modern psychiatry.

Patient: Well, my boyfriend made me come here. Computer: YOUR BOYFRIEND MADE YOU COME HERE Patient: He says I’m depressed much of the time. Computer: I AM SORRY TO HEAR YOU ARE DEPRESSED Patient: It’s true. I am unhappy Computer: DO YOU THINK COMING HERE WILL HELP YOU NOT TO BE UNHAPPY Patient: I need some help, that much seems certain. Computer: WHAT WOULD IT MEAN TO YOU IF YOU GOT SOME HELP Patient: Perhaps I could learn to get along with my mother.

Introduction: The Complex Mosaic of Psychotherapy in the Twenty-First Century

Psychotherapy plays a central role in the treatment of psychiatric disorders. For over a century, patients have sought the “talking cure,” and therapists have sought to provide it. Yet in recent decades the field of psychotherapy has undergone a gradual, but profound, transformation. The hegemony of psychoanalysis in the mid-twentieth-century United States stands in marked contrast to the heterogeneity of perspectives characterizing the field today. A proliferation of therapeutic orientations, techniques, and practices has resulted in a dizzying array of choices for clinicians and patients. Currently, the evolving psychotherapy landscape comprises a complex mosaic of complementary, but often competing, therapeutic approaches. This growing multiplicity of perspectives has been paralleled by a trend toward attempted integration of theoretical and clinical paradigms. Pluralism, eclecticism, and integrationism have arisen as highly developed theoretical movements1−4 and as overarching principles of therapeutic practice. Some psychotherapists favoring such approaches have constructed theoretical models that draw on the traditional schools of psychotherapy (e.g., psychodynamic and cognitive-behavioral therapies). Others have advocated for clinical integration of whatever distinct theoretical framework might be helpful to a given patient at a particular time. This pragmatic approach seems justified, as the modes of action of psychotherapy remain poorly understood, despite growing efforts to identify the underlying mechanisms at play. In this regard, the field of psychotherapy stands alongside other areas of clinical psychiatry and general medicine where, despite demonstrable efficacy, explicit knowledge of the modes of therapeutic action remains limited.

Psychiatric treatment of the VIP: some paradoxical risks.

Abstract One might expect that VIPs—individuals with wealth, fame, or power—would typically receive excellent care when treated for psychiatric disorders. Often, this is the case, but paradoxically, VIP status may compromise the quality of psychiatric treatment. In this article, we present four case examples, representing disguised amalgamations of actual cases from our experience, demonstrating how VIP patients may sometimes receive suboptimal psychiatric care. These cases show certain similarities; typically, there was no serious doubt about the general nature of the treatment that should be undertaken, but the treatment team was unable to deliver that treatment in the usual manner because of various outside pressures created by the VIP status of the patient and by the patient’s entourage. One possible solution to this problem, when feasible, is to assign treatment to a team specifically experienced with VIP patients. A strong and united treatment team, accustomed to the unusual difficulties and pressures often encountered with VIP patients, can be prepared to act promptly, firmly, and unanimously to devise an appropriate treatment plan and then maintain this plan true to its course despite these pressures.