Downloaded from jme.bmj.com on September 13, 2014 - Published by group.bmj.com
JME Online First, published on November 29, 2013 as 10.1136/medethics-2013-101341 Viewpoint
Social networking sites: a clinical dilemma? Daniel Lawrence Maughan,1 Alexis Economou2 1
Social Psychiatry Group, Department of Psychiatry, Oxford University, The Centre for Sustainable Healthcare, Oxford, UK 2 Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK Correspondence to Dr Daniel Lawrence Maughan, Social Psychiatry Group, Department of Psychiatry, Oxford University, The Centre for Sustainable Healthcare, Cranbrook House, 287-291 Banbury Road, Oxford OX2 7JA, UK; [email protected] Received 9 January 2013 Revised 30 July 2013 Accepted 5 November 2013
ABSTRACT Social networking sites (SNS) are having an increasing influence on patients’ lives and doctors are far from certain about how to deal with this new challenge. In our literature search, we could find no research on how doctors could engage positively with SNS to improve patient outcomes or create more patient-led care. We need to acknowledge the fact that a review of a patient’s SNS page has the potential to enhance assessment and management, particularly where a corroborant history is hard to attain. As doctors, we need to think clearly about how to adapt our practice in light of this new form of communication; in particular, whether there is a case for engaging with SNS to improve patient care.
When social networking sites are affecting the health outcomes of patients, should doctors change their practice to ensure ongoing high quality clinical care?
experience it; but … the most social of maladies to those who observe its effects.’3 Perhaps then, it is human nature to want to communicate our distress to others. Alternatively, being preoccupied with a delusional conspiracy may lead you to inform others of perceived dangers. Crucially though, when people are mentally disordered they do not always choose to communicate to their psychiatrist or GP. Previously, when letters have been written or delusions disclosed it has seemed reasonable that the person receiving the communication should be at least partly responsible for acting in the other’s best interest. In the case of Van Gogh, the prostitute called the police and he was taken from the brothel to a psychiatric hospital. In the UK, if you are a doctor or nurse or have a close relationship with the person you may be legally required to provide a duty of care in such circumstances.4 In this age of social networking, where the average person has 190 online friends5 and messages might be read many thousands of miles away, it is less clear who has a duty of care.
THE DILEMMA Social networking sites (SNS) are having an increasing influence on patients’ lives and doctors are far from certain about how to deal with this new challenge. Consider the example of a young male patient who is being managed by his community mental health team due to a depressive relapse of his bipolar disorder. During relapse, he writes open messages on his SNS about wanting to end his life. His friends read the messages but sadly are too late to intervene and the patient commits suicide. If his mental health team had had access to his SNS page, could they have averted this outcome? As doctors, we need to reflect on our practice in light of this new form of communication and consider whether there is a case for engaging with SNS in order to improve patient care. This article reviews ways in which SNS are impacting on how mental illness presents and considers whether clinical practice should adapt in light of these changes.
TRADITIONAL FORMS OF COMMUNICATION
To cite: Maughan DL, Economou A. J Med Ethics Published Online First: [please include Day Month Year] doi:10.1136/ medethics-2013-101341
Historically, people suffering with mental health issues have used a variety of methods to communicate their distress. One method has been to write letters to their friends, family or doctor. Sigmund Freud received frequent letters from patients and often replied to unsolicited requests for advice from members of the public.1 Van Gogh famously did not choose to write; rather, he communicated his distress by chopping off his ear and giving it to a prostitute at his favourite brothel.2 There are diverse reasons for communicating thoughts and feelings. It has been suggested that madness is ‘the most solitary of afflictions to the people who
Maughan DL, et al. Article J Med Ethics 2013;0:1–3. Copyright author (ordoi:10.1136/medethics-2013-101341 their employer) 2013. Produced
MODERN COMMUNICATION In recent years, SNS have become incredibly popular. One site has over 1 billion users per month.5 This communication revolution has led to a widespread habit of sharing daily ups and downs online. Research suggests that online SNS profiles reflect actual personality, not self-idealisation as previously thought.6 Therefore, we are, in a sense, presenting our ‘mental state’ to friends and family on SNS. This is of course an exciting new way to build and sustain relationships. But in creating this method of building and sustaining relationships, SNS have also created a forum for people to communicate indicators of relapse or the intention to harm themselves or others. There are two main forms of SNS. One allows users to create their own highly personalised page upon which they can write messages. The other is a type of mini-blogging site which allows users to opt in or out of sending and receiving small messages from other users. Users on both sites can be either individuals or organisations. Facebook is the most popular of the former type of SNS and Twitter the most popular of the latter.7 Both forms of SNS allow for varying levels of confidentiality for each message. Messages can be sent to a specific individual, to all their friends or followers or can be accessed by the public. Many SNS users have posted suicide messages using SNS. This is a trend covered extensively by the media, but not yet by the academic literature. To date, there has been great variability in responses to these types of messages. In some cases, people have not responded to SNS messages which
by BMJ Publishing Group Ltd under licence.
1
Downloaded from jme.bmj.com on September 13, 2014 - Published by group.bmj.com
Viewpoint suggested imminent suicide, resulting in tragic loss. In other cases, emergency services have been notified by friends and the person saved. Furthermore, there have been several high-profile murder cases where, in the lead up to the incident, the person has communicated disturbing, aggressive comments on SNS. In some cases, the SNS messages indicate a high likelihood that the person was mentally ill at the time. Currently, there is no consensus as to who is responsible for responding to these messages and it may be that the online version of the bystander effect is occurring. This is where the presence of others reduces the likelihood of an individual intervening in an emergency situation. In this case, having a large number of online friends or followers causes a diffusion of responsibility. This sense of unaccountability may be accentuated as the consequences of not acting have not yet been fully established.
effective way of engaging with friends of the young people involved. In addition, following the London 2011 riots, police used a SNS mobile application to track down and arrest people.14 It might seem reasonable for police to engage with communities using SNS, or even to use it to track down suspected criminals, but their expertise does not lie in recognising potential mental illness and its associated risks. Therefore, maybe they are not best suited to this monitoring role.
WHERE DOES MEDICAL RESPONSIBILITY LIE?
SNS are the vehicle for this clinically valuable information to the online world and as such potentially should be responsible for monitoring such information. Currently, SNS are providing principles of online behaviour and guidelines for certain situations such as threats, self-harm or harassment. Most also provide links to mental health charities. Recently, one SNS launched a Samaritans suicide risk alert system that allows users to report friends who they think may be suicidal.11 Interestingly, this system continues to leave the responsibility of surveillance to the user’s friends. Involvement of online friends or followers is crucially important as the following case illustrates. Oxfordshire emergency services were notified when someone in America raised an alarm after reading a 16-year-old friend’s SNS message. Police found the person at home, still conscious following an overdose. He subsequently made a full recovery after treatment.12 Is it appropriate that responsibility for responding to SNS messages lies with online friends? One paper suggests that friends are likely to evaluate communications of distress in a different way to trained professionals and may be more likely to underestimate their seriousness.13 Perhaps the police or government authorities could monitor SNS for risk related information? The police have responded to SNS culture by attempting to create a conversation with the public through SNS. A spokesperson for police in Scotland stated, ‘Many forces are now realising that traditional methods of getting messages out, which we have relied on in the past, are having less impact and are reaching fewer people.’ Following a number of suicides in the Dundee area, police used SNS as an
Currently, there is no official role for primary care or mental health services in recognising, assessing or responding to risk related information on SNS. Such an extension of professional care could aid assessment and management of patients. One option could be to create a mental health services ‘SNS buddy’ that could respond to messages written on SNS which suggest increased risk or relapse. Corporations are able to ‘befriend’ or follow individuals on SNS. If the person has agreed to a disclaimer, corporations are then allowed to monitor their page or messages for marketing relevant information. A similar system could be set up where mental health services could ‘listen in’ and respond to certain words or phrases that are associated with either risk or relapse. This could act as an early warning system and lead to rapid, responsive management by informing those mental health workers involved with the patient of risk related messages. Being monitored by professionals may cause concern due to ethical considerations. ‘Listening in’ to patients’ SNS could lead to a paternalistic approach and reduce patient autonomy. However, health services would only gain access to patients’ information with informed consent. Doctors, however, may be reluctant to respond to information on SNS due to concerns about professional boundaries. Acting in such a manner starts a quasi doctor–patient relationship in which doctors may be at increased risk of providing negligent recommendations. Accessing and monitoring a person’s personalised Facebook page is likely to be more ethically problematic than signing up to follow a person’s Twitter posts. This is due to the different nature of these two forms of SNS. Facebook allows for greater personalisation of profiles and includes personal photos whereas with Twitter, communication only consists of text messages of up to 140 characters. This personal dimension of Facebook might lead to greater resistance from patients about being monitored by health services. It could be perceived as a greater intrusion into their personal lives compared with reading a patient’s Twitter messages. The addition of photos and videos on Facebook would likely lead to further ethically problematic situations; for example, how to respond to risk related images such as a photo of a knife or noose. Additionally, when Twitter messages are written they are then sent to each of their follower’s Twitter page, contrastingly, to read some types of Facebook messages you are required to visit a person’s page. Here again, engaging with Facebook would be more ethically problematic than Twitter as monitoring would require frequent visits to the patient’s personal page, whereas Twitter would require choosing to follow the patient and subsequently their messages would be sent through to your Twitter page. To date, there is no legal precedent or case law that provides guidance on how doctors should respond after having read a patient’s post on SNS. Medical defence organisations advise that doctors carefully consider their justification for reading a patient’s SNS profile. These concerns are valid; however, SNS have become a central part of our patients’ everyday lives and are therefore a forum where signs of mental illness may be
2
Maughan DL, et al. J Med Ethics 2013;0:1–3. doi:10.1136/medethics-2013-101341
THE CLINICAL DILEMMA SNS are a valuable source of clinical information which are not being used by doctors. If these communications are acted on, it could lead to improved mental health or even lives being saved. It appears that SNS are such a different method of communicating that their rapid spread has left doctors unsure how to respond. Professional bodies such as the General Medical Council (GMC) have recently provided doctors with guidance on the use of social media.8 Evidence suggests that a significant proportion of medical trainees post inappropriate content and frequently breach patient confidentiality.9 10 Against this background, it is perhaps unsurprising that the GMC’s guidance, despite mentioning potential benefits of using SNS, is mainly directed towards providing a framework within which doctors can have an online digital presence and not succumb to professional boundary transgressions.
POTENTIAL OPTIONS
Downloaded from jme.bmj.com on September 13, 2014 - Published by group.bmj.com
Viewpoint expressed. An ethically robust framework that allows doctors to engage positively with this digital dimension of patients’ lives could increase availability of clinical and risk related information while ensuring patient autonomy and professional boundaries are upheld.
DISCUSSION Research about SNS and mental health is focused on how doctors should avoid professional boundary violations on SNS.15 This theme is also reflected in the GMC guidance on the subject. In our literature search, we could find no research on how doctors could engage positively with SNS to improve patient outcomes or create more patient-led care. However, the emerging discourse on digital professionalism may well provide a platform for moving towards a more positive approach to engaging with social media.16 There is abundant research on how people with different personality types engage with SNS but very little on how people with different types of mental illness engage with SNS. This knowledge would be helpful as it could inform doctors how they might best engage with SNS to improve patient’s health outcomes during periods of relapse. Furthermore, as use of SNS increases and as our knowledge about how mental illness presents on SNS improves, these online behaviours may well begin to be incorporated into diagnostic criteria. Whether doctors should engage with this digital age of communication will depend largely on ethical issues as there are clear clinical advantages to be gained. Redefining a doctor’s professional boundaries will be an important part of this process alongside issues such as confidentiality and both patient and doctor autonomy. If we do not engage with SNS, we might become increasingly alienated from the world our patients live in. The Hippocratic Oath states: ‘In every house where I come I will enter only for the good of my patients’. In a sense, we are entering a patient’s virtual house when we read their SNS messages. If we do so only for the good of our patients, perhaps it would be a reasonable step for doctors to take. Contributors DLM and AE are advanced trainees (SpRs) in general adult psychiatry in Oxford Deanery and are researchers with Oxford University, Department of Psychiatry. DLM is a member of the Social Psychiatry Department at Oxford University; this article is therefore within his field of expertise. AE has significant
Maughan DL, et al. J Med Ethics 2013;0:1–3. doi:10.1136/medethics-2013-101341
research experience in mental health informatics; this article is therefore within his field of expertise. Both authors contributed to the design. DLM wrote the initial manuscript draft. Both authors contributed to the critical revisions and final approval of the manuscript. Sources of information used are cited in the paper as references and have been obtained through literature searches and internet searches. All authors have read and understand the Instructions for Authors. Guarantor: DLM. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 2 3 4 5
6 7
8
9 10 11 12 13
14
15 16
Pergament D. Internet psychotherapy: current status and future regulation. Health Matrix Clevel 1998;8:233–79. Brooks D. The Vincent van Gogh Gallery. Toronto, Canada. http://www.vggallery. com/misc/faq.htm MacDonald M. Mystical bedlam: magic, anxiety and healing in seventeenth-century England. Cambridge: Cambridge University Press, 1981. Resuscitation Council (UK). The legal status of those who attempt resuscitation. London: Resuscitation Council, Aug 2010. http://www.resus.org.uk/pages/legal.pdf The Associated Press. Number of active users at Facebook over the years. Yahoo! Finance, 23 Oct 2012. http://finance.yahoo.com/news/number-active-usersfacebook-over-years-214600186–finance.html Tosun L. P. Motives for Facebook use and expressing “true self” on the Internet. Comput Hum Behav 2012;28:1510–7. Barrow O. Top 15 most popular social media sites. Dayton Business Journal, 17 Dec 2012. http://www.bizjournals.com/dayton/news/2012/12/17/ top-15-most-popular-social-media-sites.html Halliday J. London riots: police to track rioters who used BlackBerrys. The Guardian, 9 Aug 2011. http://www.guardian.co.uk/technology/2011/aug/09/london-riotsblackberrys-police General Medical Council. Doctors’ use of social media. London: GMC, 25 Mar 2013. http://www.gmc-uk.org/Doctors__use_of_social_media.pdf_51448306.pdf Thompson LA, Dawson K, Ferdig R, et al. The intersection of online social networking with medical professionalism. Gen Intern Med 2008;23:954–7. Chandra S, Chatterjee P. Digital indiscretions: New horizons in medical ethics. Australas Med J 2011;4:453–6. Facebook adds Samaritans suicide risk alert system. BBC News, 7 Mar 2011. http:// www.bbc.co.uk/news/technology-12667343 A suicidal teenager from Oxford has been saved after a friend on the Facebook website living in America alerted police. Metro, 4 Apr 2009. http://www.metro.co. uk/news/609710-facebook-message-saves-suicidal-boy Owens C, Owen G, Lambert H, et al. Public involvement in suicide prevention: understanding and strengthening lay responses to distress. BMC Public Health 2009;9:308. McDonald J, Sohn S, Ellis P. Privacy, professionalism and Facebook: a dilemma for young doctors. Med Educ 2010;44(8):805–13. Ellaway R. eMedical teacher # 38: digital professionalism. Med Teach 2010;32:705–7.
3
Downloaded from jme.bmj.com on September 13, 2014 - Published by group.bmj.com
Social networking sites: a clinical dilemma? Daniel Lawrence Maughan and Alexis Economou J Med Ethics published online November 29, 2013
doi: 10.1136/medethics-2013-101341
Updated information and services can be found at: http://jme.bmj.com/content/early/2013/11/29/medethics-2013-101341.full.html
These include:
References
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P
JME Online First, published on November 29, 2013 as 10.1136/medethics-2013-101341 Viewpoint
Social networking sites: a clinical dilemma? Daniel Lawrence Maughan,1 Alexis Economou2 1
Social Psychiatry Group, Department of Psychiatry, Oxford University, The Centre for Sustainable Healthcare, Oxford, UK 2 Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK Correspondence to Dr Daniel Lawrence Maughan, Social Psychiatry Group, Department of Psychiatry, Oxford University, The Centre for Sustainable Healthcare, Cranbrook House, 287-291 Banbury Road, Oxford OX2 7JA, UK; [email protected] Received 9 January 2013 Revised 30 July 2013 Accepted 5 November 2013
ABSTRACT Social networking sites (SNS) are having an increasing influence on patients’ lives and doctors are far from certain about how to deal with this new challenge. In our literature search, we could find no research on how doctors could engage positively with SNS to improve patient outcomes or create more patient-led care. We need to acknowledge the fact that a review of a patient’s SNS page has the potential to enhance assessment and management, particularly where a corroborant history is hard to attain. As doctors, we need to think clearly about how to adapt our practice in light of this new form of communication; in particular, whether there is a case for engaging with SNS to improve patient care.
When social networking sites are affecting the health outcomes of patients, should doctors change their practice to ensure ongoing high quality clinical care?
experience it; but … the most social of maladies to those who observe its effects.’3 Perhaps then, it is human nature to want to communicate our distress to others. Alternatively, being preoccupied with a delusional conspiracy may lead you to inform others of perceived dangers. Crucially though, when people are mentally disordered they do not always choose to communicate to their psychiatrist or GP. Previously, when letters have been written or delusions disclosed it has seemed reasonable that the person receiving the communication should be at least partly responsible for acting in the other’s best interest. In the case of Van Gogh, the prostitute called the police and he was taken from the brothel to a psychiatric hospital. In the UK, if you are a doctor or nurse or have a close relationship with the person you may be legally required to provide a duty of care in such circumstances.4 In this age of social networking, where the average person has 190 online friends5 and messages might be read many thousands of miles away, it is less clear who has a duty of care.
THE DILEMMA Social networking sites (SNS) are having an increasing influence on patients’ lives and doctors are far from certain about how to deal with this new challenge. Consider the example of a young male patient who is being managed by his community mental health team due to a depressive relapse of his bipolar disorder. During relapse, he writes open messages on his SNS about wanting to end his life. His friends read the messages but sadly are too late to intervene and the patient commits suicide. If his mental health team had had access to his SNS page, could they have averted this outcome? As doctors, we need to reflect on our practice in light of this new form of communication and consider whether there is a case for engaging with SNS in order to improve patient care. This article reviews ways in which SNS are impacting on how mental illness presents and considers whether clinical practice should adapt in light of these changes.
TRADITIONAL FORMS OF COMMUNICATION
To cite: Maughan DL, Economou A. J Med Ethics Published Online First: [please include Day Month Year] doi:10.1136/ medethics-2013-101341
Historically, people suffering with mental health issues have used a variety of methods to communicate their distress. One method has been to write letters to their friends, family or doctor. Sigmund Freud received frequent letters from patients and often replied to unsolicited requests for advice from members of the public.1 Van Gogh famously did not choose to write; rather, he communicated his distress by chopping off his ear and giving it to a prostitute at his favourite brothel.2 There are diverse reasons for communicating thoughts and feelings. It has been suggested that madness is ‘the most solitary of afflictions to the people who
Maughan DL, et al. Article J Med Ethics 2013;0:1–3. Copyright author (ordoi:10.1136/medethics-2013-101341 their employer) 2013. Produced
MODERN COMMUNICATION In recent years, SNS have become incredibly popular. One site has over 1 billion users per month.5 This communication revolution has led to a widespread habit of sharing daily ups and downs online. Research suggests that online SNS profiles reflect actual personality, not self-idealisation as previously thought.6 Therefore, we are, in a sense, presenting our ‘mental state’ to friends and family on SNS. This is of course an exciting new way to build and sustain relationships. But in creating this method of building and sustaining relationships, SNS have also created a forum for people to communicate indicators of relapse or the intention to harm themselves or others. There are two main forms of SNS. One allows users to create their own highly personalised page upon which they can write messages. The other is a type of mini-blogging site which allows users to opt in or out of sending and receiving small messages from other users. Users on both sites can be either individuals or organisations. Facebook is the most popular of the former type of SNS and Twitter the most popular of the latter.7 Both forms of SNS allow for varying levels of confidentiality for each message. Messages can be sent to a specific individual, to all their friends or followers or can be accessed by the public. Many SNS users have posted suicide messages using SNS. This is a trend covered extensively by the media, but not yet by the academic literature. To date, there has been great variability in responses to these types of messages. In some cases, people have not responded to SNS messages which
by BMJ Publishing Group Ltd under licence.
1
Downloaded from jme.bmj.com on September 13, 2014 - Published by group.bmj.com
Viewpoint suggested imminent suicide, resulting in tragic loss. In other cases, emergency services have been notified by friends and the person saved. Furthermore, there have been several high-profile murder cases where, in the lead up to the incident, the person has communicated disturbing, aggressive comments on SNS. In some cases, the SNS messages indicate a high likelihood that the person was mentally ill at the time. Currently, there is no consensus as to who is responsible for responding to these messages and it may be that the online version of the bystander effect is occurring. This is where the presence of others reduces the likelihood of an individual intervening in an emergency situation. In this case, having a large number of online friends or followers causes a diffusion of responsibility. This sense of unaccountability may be accentuated as the consequences of not acting have not yet been fully established.
effective way of engaging with friends of the young people involved. In addition, following the London 2011 riots, police used a SNS mobile application to track down and arrest people.14 It might seem reasonable for police to engage with communities using SNS, or even to use it to track down suspected criminals, but their expertise does not lie in recognising potential mental illness and its associated risks. Therefore, maybe they are not best suited to this monitoring role.
WHERE DOES MEDICAL RESPONSIBILITY LIE?
SNS are the vehicle for this clinically valuable information to the online world and as such potentially should be responsible for monitoring such information. Currently, SNS are providing principles of online behaviour and guidelines for certain situations such as threats, self-harm or harassment. Most also provide links to mental health charities. Recently, one SNS launched a Samaritans suicide risk alert system that allows users to report friends who they think may be suicidal.11 Interestingly, this system continues to leave the responsibility of surveillance to the user’s friends. Involvement of online friends or followers is crucially important as the following case illustrates. Oxfordshire emergency services were notified when someone in America raised an alarm after reading a 16-year-old friend’s SNS message. Police found the person at home, still conscious following an overdose. He subsequently made a full recovery after treatment.12 Is it appropriate that responsibility for responding to SNS messages lies with online friends? One paper suggests that friends are likely to evaluate communications of distress in a different way to trained professionals and may be more likely to underestimate their seriousness.13 Perhaps the police or government authorities could monitor SNS for risk related information? The police have responded to SNS culture by attempting to create a conversation with the public through SNS. A spokesperson for police in Scotland stated, ‘Many forces are now realising that traditional methods of getting messages out, which we have relied on in the past, are having less impact and are reaching fewer people.’ Following a number of suicides in the Dundee area, police used SNS as an
Currently, there is no official role for primary care or mental health services in recognising, assessing or responding to risk related information on SNS. Such an extension of professional care could aid assessment and management of patients. One option could be to create a mental health services ‘SNS buddy’ that could respond to messages written on SNS which suggest increased risk or relapse. Corporations are able to ‘befriend’ or follow individuals on SNS. If the person has agreed to a disclaimer, corporations are then allowed to monitor their page or messages for marketing relevant information. A similar system could be set up where mental health services could ‘listen in’ and respond to certain words or phrases that are associated with either risk or relapse. This could act as an early warning system and lead to rapid, responsive management by informing those mental health workers involved with the patient of risk related messages. Being monitored by professionals may cause concern due to ethical considerations. ‘Listening in’ to patients’ SNS could lead to a paternalistic approach and reduce patient autonomy. However, health services would only gain access to patients’ information with informed consent. Doctors, however, may be reluctant to respond to information on SNS due to concerns about professional boundaries. Acting in such a manner starts a quasi doctor–patient relationship in which doctors may be at increased risk of providing negligent recommendations. Accessing and monitoring a person’s personalised Facebook page is likely to be more ethically problematic than signing up to follow a person’s Twitter posts. This is due to the different nature of these two forms of SNS. Facebook allows for greater personalisation of profiles and includes personal photos whereas with Twitter, communication only consists of text messages of up to 140 characters. This personal dimension of Facebook might lead to greater resistance from patients about being monitored by health services. It could be perceived as a greater intrusion into their personal lives compared with reading a patient’s Twitter messages. The addition of photos and videos on Facebook would likely lead to further ethically problematic situations; for example, how to respond to risk related images such as a photo of a knife or noose. Additionally, when Twitter messages are written they are then sent to each of their follower’s Twitter page, contrastingly, to read some types of Facebook messages you are required to visit a person’s page. Here again, engaging with Facebook would be more ethically problematic than Twitter as monitoring would require frequent visits to the patient’s personal page, whereas Twitter would require choosing to follow the patient and subsequently their messages would be sent through to your Twitter page. To date, there is no legal precedent or case law that provides guidance on how doctors should respond after having read a patient’s post on SNS. Medical defence organisations advise that doctors carefully consider their justification for reading a patient’s SNS profile. These concerns are valid; however, SNS have become a central part of our patients’ everyday lives and are therefore a forum where signs of mental illness may be
2
Maughan DL, et al. J Med Ethics 2013;0:1–3. doi:10.1136/medethics-2013-101341
THE CLINICAL DILEMMA SNS are a valuable source of clinical information which are not being used by doctors. If these communications are acted on, it could lead to improved mental health or even lives being saved. It appears that SNS are such a different method of communicating that their rapid spread has left doctors unsure how to respond. Professional bodies such as the General Medical Council (GMC) have recently provided doctors with guidance on the use of social media.8 Evidence suggests that a significant proportion of medical trainees post inappropriate content and frequently breach patient confidentiality.9 10 Against this background, it is perhaps unsurprising that the GMC’s guidance, despite mentioning potential benefits of using SNS, is mainly directed towards providing a framework within which doctors can have an online digital presence and not succumb to professional boundary transgressions.
POTENTIAL OPTIONS
Downloaded from jme.bmj.com on September 13, 2014 - Published by group.bmj.com
Viewpoint expressed. An ethically robust framework that allows doctors to engage positively with this digital dimension of patients’ lives could increase availability of clinical and risk related information while ensuring patient autonomy and professional boundaries are upheld.
DISCUSSION Research about SNS and mental health is focused on how doctors should avoid professional boundary violations on SNS.15 This theme is also reflected in the GMC guidance on the subject. In our literature search, we could find no research on how doctors could engage positively with SNS to improve patient outcomes or create more patient-led care. However, the emerging discourse on digital professionalism may well provide a platform for moving towards a more positive approach to engaging with social media.16 There is abundant research on how people with different personality types engage with SNS but very little on how people with different types of mental illness engage with SNS. This knowledge would be helpful as it could inform doctors how they might best engage with SNS to improve patient’s health outcomes during periods of relapse. Furthermore, as use of SNS increases and as our knowledge about how mental illness presents on SNS improves, these online behaviours may well begin to be incorporated into diagnostic criteria. Whether doctors should engage with this digital age of communication will depend largely on ethical issues as there are clear clinical advantages to be gained. Redefining a doctor’s professional boundaries will be an important part of this process alongside issues such as confidentiality and both patient and doctor autonomy. If we do not engage with SNS, we might become increasingly alienated from the world our patients live in. The Hippocratic Oath states: ‘In every house where I come I will enter only for the good of my patients’. In a sense, we are entering a patient’s virtual house when we read their SNS messages. If we do so only for the good of our patients, perhaps it would be a reasonable step for doctors to take. Contributors DLM and AE are advanced trainees (SpRs) in general adult psychiatry in Oxford Deanery and are researchers with Oxford University, Department of Psychiatry. DLM is a member of the Social Psychiatry Department at Oxford University; this article is therefore within his field of expertise. AE has significant
Maughan DL, et al. J Med Ethics 2013;0:1–3. doi:10.1136/medethics-2013-101341
research experience in mental health informatics; this article is therefore within his field of expertise. Both authors contributed to the design. DLM wrote the initial manuscript draft. Both authors contributed to the critical revisions and final approval of the manuscript. Sources of information used are cited in the paper as references and have been obtained through literature searches and internet searches. All authors have read and understand the Instructions for Authors. Guarantor: DLM. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 2 3 4 5
6 7
8
9 10 11 12 13
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Social networking sites: a clinical dilemma? Daniel Lawrence Maughan and Alexis Economou J Med Ethics published online November 29, 2013
doi: 10.1136/medethics-2013-101341
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References
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