Ethics, googling patients, and organ transplantation

[ixchel]

While back there was a discussion about the ethics of googling patients, which seemed to be divided between some feeling it's no big deal, and others feeling it's wrong.

I'd love to hear thoughts about this:

(http://www.medscape.com/viewarticle/819559?src=wnl_edit_specol)

Hi. I am Art Caplan, from the Division of Medical Ethics at the New York University Langone Medical Center in New York City.

Do you use the Internet? Are you on Facebook? Are you someone who likes to tweet? What if your patients do that? What if you know that your patient has a Facebook page or you find out they are tweeting, or they ask you, "Will you friend me?" Should you use the Internet to keep an eye on your patients?

This question came up for me in a very real way when a physician associated with a transplant program asked me what I thought about the following situation. A gentleman who needed a liver transplant was told that he had to remain sober for a year to be eligible to receive that transplant. He said he would be. He was tested perhaps once every couple of months to see whether he had any alcohol in his bloodstream. They knew he had a problem with alcohol because he had a DWI (driving while intoxicated) that had resulted in a criminal conviction because someone was injured. That history was known to them. His sister said he was doing fine. He swore he was doing fine.

But the patient tweeted a picture of himself in a bar with a beer in his hand, and someone on the staff of the transplant unit -- not the surgeon, but someone who worked there -- saw that tweet. The information was passed on to the transplant team. The question became, do we exclude him based on this picture?

I think tweets and Facebook pages are public. If you are putting information up there and someone sees it, in legal parlance, it can, will, and should be used against you.

On the other hand, if it is going to be used against someone, that person should be given the right to explain. Maybe it is an old picture. Maybe someone who did not like him posted that picture. Maybe it is a false Twitter account and the patient is not running it. I believe this is information that may be used to challenge what the patient says, but the patient has the right to respond, to explain, to say that it is a mistake or whatever they may want to say in response to that.

This was life and death, so if he had to start over again and promise to stay sober and be tested more frequently now, because the transplant team did not trust him, he might well die before he got his liver. I think that is what happened in this case.

This raises other interesting questions. Let us say you told a patient to go on a diet, and all of a sudden you see them reviewing barbecue joints and fried chicken shacks on Yelp. Is that okay? Should you reach out to see what they are doing out there? Some physicians have laughed and said to me, "I don't have time to be doing any of that." Sadly, we barely have time now to have a good conversation with patients, much less to chase them all over the Internet.

But information may come to you indirectly. It may be passed along thirdhand. My view is that public information is something that has to be taken into account. But if you are going to do that, you had better share that with the patient, giving them the right and the opportunity to explain what someone says they have seen on social media.

I am Art Caplan at the Division of Medical Ethics at NYU Langone. Thanks for watching.

1. Was it ethical to look up the patient?

2. Is it ethical to deny the transplant?

3. What would you do, if you were on the transplant team?

[Esme12, ASN, BSN, RN]

Good article....I think if you put it out there you need to be accountable. I don't think Googling them on purpose is a good thing but if you do don't advertise it. However in this case the patient should be given a change to explain. Like the MD said....it might be an old picture.

[ixchel]

Good article....I think if you put it out there you need to be accountable. I don't think Googling them on purpose is a good thing but if you do don't advertise it. However in this case the patient should be given a change to explain. Like the MD said....it might be an old picture.

This situation sort of blurs the line, huh? Perhaps add to the consent, "by signing herein, the patient agrees to be googled for compliance monitoring..." lol I mean, if potential employers are expected to do it, maybe high risk patients (I.e. Transplants, addictions, etc.) might be an arena where this expectation might be reasonable? I do think telling them up front should be expected, though.

Makes me wonder why the person decided to google this person in the first place. This probably sounds terrible, but I tend to forget patients' names by the time I hit the elevator. I couldn't imagine jotting a name down and googling it when I get home.

[chrisrn24]

I see nothing wrong with googling a patient but you shouldn't reach out to them or in any way let them know you were snooping.

[toomuchbaloney]

Is looking the patient up on social networking sites part of the protocol for the transplant team?

What are the criteria for verifying that the images are not altered and represent current and factual activities?

How does the transplant team discuss the images with the transplant patient or is the information kept secret from the patient?

Is the team member who "discovered" the images being paid for that time or are they following social activities patients on their personal time?

I would question why the team member lacks trust in the current protocol.

I would question in what other ways the team member is stalking transplant patients outside of the workplace.

I would question the professional boundaries of the team member and their ability to protect the privacy rights of the transplant patients.

I would NOT advocate withholding transplant based upon such activity by a team member.

[Ruby Vee, BSN]

I've googled patients -- although not to the extent of viewing their facebook or twitter pages. We had a patient who was a published author and proud of it; I hadn't heard of her, so I googled her to see what she had written. Another patient claimed to be "a local celebrity," and since I hadn't heard of him, I googled him. I've never bothered to google a patient who hadn't actually challenged me to do so, however. And I think that using what you find on the internet to make treatment decisions is not particularly ethical. I'm with Esme -- give him a chance to explain.

[jadelpn, LPN, EMT-B]

If we google anyone on the facility computer, then we are let go. Period.

In this instance, I would be curious as to why the member of the staff was "following" patients on social media to begin with. Creepy, stalker like, and without any explaination from the patient, well, he died while waiting for a transplant.

Mind your business when you are out of work. No need to be hashtagging or friending. Because a caregiver has little idea what goes on in a patient's life outside of the confines of the hospital what could the possible motivation and/or goal be to invade someone's private life? To "catch them in the act"? That a caregiver is obsessing about this outside of the workplace is down right whacked.

[fetch, BSN, RN]

While I also find it kind of strange to google a former patient, in the example provided he doesn't say that's what happened. It's implied, but not stated.

But the patient tweeted a picture of himself in a bar with a beer in his hand, and someone on the staff of the transplant unit -- not the surgeon, but someone who worked there -- saw that tweet.

There are plenty of times where on social media I see pictures of people who I don't necessarily know, but who know one of my friends (or family members or coworkers). And sometimes I see a picture of two people that I didn't realize knew each other. The wording of the example honestly makes me think the staff member didn't deliberately seek this person out. More like the patient and Friend Bob took a picture together at the bar, one or both of them placed it on social media, and then the staff member saw a picture of their friend Bob with someone who looks familiar, hey wait isn't that the guy who was in here last week for testing for a liver transplant?

If you aren't deliberately seeking out information on your patients, but the information comes to you in a public forum, do you have a responsibility to report?

[ixchel]

f you aren't deliberately seeking out information on your patients but the information comes to you in a public forum, do you have a responsibility to report?[/quote']

I was stuck on this question, too. The article's title did have something about googling patients, so it is unclear.

The thing I'm stuck on is if it would be inappropriate to approach a patient about this picture because the staff member never should have googled them in the first place, what if this patient really was non-compliant? Will you be taking a liver from someone who is compliant? My feelings are fuzzy on this because of the significance of the non-compliance. And even if the photo was discovered accidentally, I'm leaning toward saying something. Give the patient an opportunity to explain it. However, many people who have battled addiction for a long time (I'm assuming this person did, AEB the need for a new liver) can lie without skipping a beat. Can you believe his story? Perhaps resetting the clock for that year and enforcing compliance screening would be a good option.

But that still doesn't address the issue - was it okay to view the photo and then report it? I had very different, clear feelings when we were talking about a student nurse looking up a patient on Facebook.

[jadelpn, LPN, EMT-B]

I was stuck on this question, too. The article's title did have something about googling patients, so it is unclear.

The thing I'm stuck on is if it would be inappropriate to approach a patient about this picture because the staff member never should have googled them in the first place, what if this patient really was non-compliant? Will you be taking a liver from someone who is compliant? My feelings are fuzzy on this because of the significance of the non-compliance. And even if the photo was discovered accidentally, I'm leaning toward saying something. Give the patient an opportunity to explain it. However, many people who have battled addiction for a long time (I'm assuming this person did, AEB the need for a new liver) can lie without skipping a beat. Can you believe his story? Perhaps resetting the clock for that year and enforcing compliance screening would be a good option.

But that still doesn't address the issue - was it okay to view the photo and then report it? I had very different, clear feelings when we were talking about a student nurse looking up a patient on Facebook.

Don't ever approach a patient regarding social media pictures. Ever. Whether it is a picture that was taken 20 years ago, 20 minutes ago, not anyone's place but the transplant team who may or may not monitor compliance in that fashion. And because most transplant teams did not fall off the turnip truck yesterday, most are very, very strict about an overall picture, testing, and the like.

Pictures in social media are not always dated, can be completely changed at the click of a button, or put up without the knowlegde or consent of the person in the picture.

With all that being said, I am not sure I know of many people who are awaiting a liver transplant who are whooping it up at bars. Most are far too ill to do much more than get out of bed. And sometimes, they can't even do that.

So unless you are the compliance person of a transplant team, and know and follow policy regarding the same, it is inappropriate, in my opinion, to "report" a picture from social media whether it be from a friend of a friend or accidently looked at, or someone who wanted to "catch" a possible uncompliant patient.

Not your fish to fry.

[OCNRN63, RN]

Seems to be a huge coincidence that a member of the transplant team just happened to see the tweet. Sounds to me like someone dimed him out.