Case vignette: cybertherapy

Dr. Neuro Transmitter, a psychotherapist in Paramus, New Jersey, provides services through an online, real-time consultation service known as CyberShrink, Inc., of Dallas, Texas. He is paid by the hour for his consultation services to subscribers who are billed by credit card through CyberShrink. One afternoon he logs on and is connected via private "chat channel" to a new subscriber to the service. She is Ann Hedonia of Simi Valley, California. Ten minutes into the session, Dr Transmitter recognizes that Ms. Hedonia is seriously depressed with suicidal ideation and is feeling on the edge of her ability to cope. He gently suggests that perhaps she ought to think about hospitalization near her home. Ms. Hedonia replies, "Even you don't care about me! That's it. I'm going to do it!" and disconnects. Discussion questions: Is offering psychotherapy services online ethical? What are Dr. Transmitter's obligations in general and at this particular moment to Ms. Hedonia? Suppose Ms. Hedonia has a complaint about Dr. Transmitter. From whom can she seek a remedy? Which state's laws apply regarding professional practice, confidentiality, or licensing qualifications? Must Dr. Transmitter be licensed in any state to offer this service?     

Managed care and informed consent

Arguments for efficiency in health care delivery have been used to support some level of withholding of information about available treatment options from patients in managed care systems. To the extent that such arguments prevail, they may necessitate changes in the established understanding of and commitment to informed consent and the disclosure of information to patients.     

Senile dementia and informed consent

Senile dementia in the elderly is a prevalent condition which requires ongoing medical treatment. This disease causes a deterioration of cognitive processes and, consequently, it is likely to impair the capacities required to give informed consent to needed medical care. However, a diagnosis of senile dementia does not necessarily indicate that the afflicted individual is incompetent. The means of assessing competency in dementia patients and their likely impairments according to five standards is described in this paper. Recommendations for obtaining consent from the competent dementia patient are made and mechanisms for providing special protection to the incompetent patient in the consent process are discussed.     

Case vignette: genetic secrets

Mrs. Thomas, age 50, became concerned after experiencing intermittent uncontrollable jerky body movements. She contacted her family physician and, following a full diagnostic evaluation, learned that she is experiencing early symptons of Huntington's disease. This illness is a degenerative disease of the central nervous system, which will ultimately lead-to physical incapacity, dementia, and death. The disease is known to be transmitted genetically as an autosomal dominant trait, with the first onset of symptoms usually occurring in middle age. For example, the child of an affected person has a 50% chance of inheriting the gene, and thus the illness, and a 50% chance of passing it on to their children. Mrs. Thomas is unaware of any history of the disease among others in her family; however, her father was an adopted child, who died in an automobile accident at the age of 37 and may well have been a carrier of the gene. It is highly likely that other members of her family, including her siblings and children, may be carriers of the gene and ultimately transmit it to their children before clinical symptoms of the disease develop. Her own son married last year, and her two brothers have children of childbearing age. Genetic screening and counseling are available for those at risk for Huntington's disease; however, Mrs. Thomas does not want to discuss her diagnosis with family members, fearing that they may blame her and that she may lose her job and friends if the information becomes public knowledge. What advice would you give to the health-care providers caring for Mrs. Thomas regarding the assorted rights, duties, and obligations surrounding this situation?     

Case vignette: premature surrender

Three commentaries are offered on the following case: George, age 57, is a previously healthy man who recently underwent surgery for removal of a low-grade malignant thymoma. At the time of admission to the hospital, George stressed to the staff that he had long ago signed a "living will," which he renewed immediately after he learned of his cancer diagnosis. At the time of surgery, the tumor was found to extend into his mediastinum; although it was removable, this required revision of part of the sternum and grafting of the vessels feeding the heart chambers. Because of the resultant tissue damage and neuronal hyperactivity, George experienced postoperative episodes of cardiac arrhythmia and bronchospasm. Unanimous medical opinion was that this situation was a temporary problem that would resolve itself as the tissues healed. Until that time, however, it will be difficult to wean him from ventilatory support. When his stay in the intensive care unit became prolonged, George and his family began to insist that his status be changed to "do not resuscitate" and reminded the staff about his longstanding living will. All of this is happening despite the fact that the patient and family seemingly comprehend that although the short-term interventions are invasive, there is a high probability of a successful outcome. George's cancer prognosis is excellent, and, although he may well have an episode of life-threatening arrhythmia, he is likely to respond to resuscitation interventions. Once the immediate postoperative period is over, his potential for a long and productive life with full capacities is excellent. Consider the following questions: (a) Should George's expressed wishes be respected, or should the staff take additional steps to help him survive the postoperative period, even if that means violating his stated wishes? and (b) What steps might the staff follow in sorting through this problem?     

Client preferences for informed consent information

Thirty-five current therapy clients, 47 former clients, and 42 college students with no therapy experience rated 27 items in terms of importance for inclusion in informed consent discussions. The current and former client samples rated information about inappropriate therapeutic techniques, confidentiality, and the risks of alternative treatments as most important, and information about the personal characteristics of the therapist and the therapist's degree as least important. The results of this study provide evidence for differential informed consent disclosure practices.