Of douches, online identity, and ethics

Aug 22 2011 Published by under Medicine

We need to have a little talk, you and me.  There has been a lot going on here on the internet in the last few days, most of which I've been unable to comment on more than briefly due to a vacation far from well-lubricated intertubes.  This evening, let's pull a nice demitasse and see if we can sort out some of this insanity.

Every morning, whether I need it or not

First, a well-respected internet health writer nearly lost his job for his online activities. Whether or not this was a good legal choice by the blogger's employer is nearly irrelevant.  As often happens on the internet, the writer got involved in a heated discussion with some psycho, thin-skinned reader (all simply my opinion of course) who then contacted the state entity by whom Our Hero is employed.  Perhaps not wanting to be linked with the word "douchebag" used in a non-official context, they told Our Hero, "can it or leave."

There are a number of important lessons here.  First, pseudonymity is your (non-legal) right; keeping the pseudonym from being cracked is not.  While outing someone's online identity may, in fact, be "douchey", it's not illegal.  And whether or not one's employer is behaving strictly within the law in firing your profane behind, the trouble stirred up is, in the real world, real, and you will probably lose.  It is therefore wise to remember that what you say online will quite likely be linked to your real name some day.

In addition to any avocational blow-back from internet discussions, there  are ethical concerns, especially to those of us in health care.  During a twitter meet up last night, I made a comment about medical ethics and social media and got a well-justified (though polite) query from a participant wondering what I was talking about.

Before answering her question, though, let's explore a "speech" issue here.  I know nothing---nothing!---about the law.  But what, from a non-legal perspective, makes an online discussion any different than one at a cocktail party?  If I were to call someone a "self-important, ignorant douchebag" at a party, would the target of my derision be justified in calling my employer?  Would my employer even take the call without laughing?  Is it the lasting nature of online writing, the public context that makes it more seemingly "harmful"?  If the exchange had taken place via email rather than on-blog would that have made a difference?

From the standpoint of protecting oneself, no.  If someone chooses to harass you for something you say and your employer decides to take them seriously, you're out of luck unless you have legal recourse, but even if you do, your job, while still technically in existence, may be made impossible to perform.  But what is said on open forums on the internet is enduring and is, at least potentially, available to a wide audience, making a claim of defamation (or whatever legal term is appropriate) more plausible to this lay person.  Still, the whole thing is pretty douchey.

In health care, though, everything changes. When I spent a larger percentage of my time teaching, I would give a yearly lecture to the medical residents about social media and medical ethics.  First there is a legal layer to all communications about patients.  The Health Insurance Portability and Accountability Act of 1996 (HIPAA) makes privacy a top concern.  Any "protected health information" (PHI) can be disclosed only under certain circumstances.  For example, if you want life insurance, you will sign a release allowing them access to all of your health information.  You don't have to sign, but they don't have to sell you insurance.  But once given that information, they cannot turn around and give it to your employer, your mom, or the New York Times without your explicit permission.

Doctors like to talk about cases, and HIPPA does not prevent this (once again, I'm no legal eagle), but the case should be discussed for "treatment purposes".   Also, doctors frequently talk about interesting cases simply for educational purposes.  Since there is rarely need to identify the specific patient, privacy is not usually violated.

But with the explosion of social media, these discussions are no longer limited to doctors' lounges.  I regularly field questions from other providers about the appropriateness (not the legality!) of posting certain information on facebook, twitter, and blogs.  For example, a colleague contacted me about posting an X-ray online for discussion with other providers.  The film was edited so that no patient demographics were visible.  This online venue was, however, a semi-public one, not a closed physician-only forum.  The film was unusual enough, and the temporal relationship to the incident close enough that the patient could perhaps be identified.  I recommended he not post it.

There are many subtle pitfalls for health care professionals online.  If I were to say, "I work in a clinic that treats chlamydia," this would differ from saying "I treated a lot of chlamydia in my clinic this month," which is also different from saying, "Last night I treated a horrible case of chlamydia."   Each statement brings me closer to having potentially revealed someone's protected health information.

I have argued in the past (though I can't seem to find the link) that medical ethics should be a pre-requisite for applying to medical school.  Many young doctors have no idea what they are getting into ethically, and some can't handle it.  Social media are the least of these problems, but a significant one nonetheless.  Stressed out medical students and residents want to vent to each other, and it seems natural to do so on facebook and twitter, but it often turns out to be a bad idea both ethically and for one's employment status.

Speech, while free, is not without consequences, and sometimes it's the good guys that get burned.  But we must also consider our own status as being either professionally or socially privileged in such a way that we may behave unethically in our discussions.

5 responses so far

  • I have argued in the past (though I can't seem to find the link) that medical ethics should be a pre-requisite for applying to medical school.

    Wut?? Shouldn't medical ethics be taught *in* medical school??

  • Dan says:

    The association of ethics with "family values" has led there to be a dearth of ethics training outside of required-by-law and fig-leaf-for-MBA.
    There are many academic topics in which I would gladly sacrifice some depth to bump up the promotion of ethics (and good citizenship) at every academic level.
    I'm not talking about mind control, just that if someone is acting like a jerk-weasel they should have the training to realize it.

  • "Speech, while free, is not without consequences, and sometimes it's the good guys that get burned. "

    Sometimes freedom is a two way street and individuals are the Frogger frog. One should be aware of that before hoping out into the road.

  • "Wut?? Shouldn't medical ethics be taught *in* medical school??"

    I think Pal's point was that's too late to be introduced to the fundamentals of med ethics; they need to understand what they're getting into before they commit to med school.

    • PalMD says:

      Yes. I don't know about other professions,but the ethical duties of doctors often conflict with the doctor's own belief. They must understand this before they commit to a lifetime of it.