John C. Linton, PhD
The most recent revision of the APA Ethical Principles of Psychologists and Code of Conduct (2002) was years in the making, and psychologists felt it offered comprehensive guidance for practice. But the attack on the World Trade Center in September of 2001 exposed limitations in the code. As the US went to war in the Middle East, sections 1.2 and 1.3, which allowed psychologists to resolve conflicts between their ethical obligations and those of legal authority or organizational demands by adhering to the latter, allegedly permitted military psychologists to follow orders and participate in the interrogation of prisoners in ways that were deemed inhumane and in violation of the Geneva Convention. Other professional organizations and the national media took notice, and the pressure on APA to close this ethics loophole mounted, not only from outside but also from within APA, and led to years of angst and public discord among psychologists. APA Council finally resolved this dilemma in 2010 with a revision of the code, which now expressly forbids these standards to be used to justify the violation of human rights (Farberman, 2010).
This series of events was a telling example of the creation of an aspirational and enforceable code of professional behavior at a given point in time, naive to dramatic changes that would face practitioners during the ensuing years, for which the code could provide only limited utility or guidance. In addition to military interrogations, the code of 2002 could also not advise about deep web search engines and electronic social networking, which have radically altered concepts of personal privacy and ethics (Lehavot, Barnett, & Powers, 2010), or electronic medical records that would make patient files widely accessible, for good or ill.
While professions have matured ahead of their codes of conduct for generations, the pace of this maturation is now swiftly accelerating. Given psychology ís broad application to the human condition, the ethics of professional practice in general, and clinical health psychology in particular, will be tested by rapid transformations in the bioethical landscape. Technological innovations in medicine that were once remarkable are now commonplace, and no longer contained within certain geographic borders; they are now global, bypassing regulation or control by any specific government or national scientific organization. Because these advances can occur abruptly and without warning, forecasting them is difficult. A new medical challenge or problem arises, and biomedical researchers respond with knowledge and expertise to confront the challenge, develop new technology, and provide tools to clinicians to resolve the problem. Health psychologists can therefore be confronted suddenly with a novel clinical situation they were not aware was coming, and be faced with making choices about ethical practice that could not have been anticipated by their existing codes of conduct. This suggests the need for a fluid and responsive ethics code which, given the pace that such codes are generally developed and changed, is aspirational but unlikely.
The following are areas where professional psychologists might need to respond over the next decade, with our code of ethics attempting to keep up. The list is not intended to be all inclusive, but focuses on those areas that might be most relevant to clinical health psychologists. Of the areas listed, all or none may come to pass, but they provide some guidelines for our thinking as we prepare for the changes to come.
Transhumanism (Schneider, 2009) refers to the notion that in contrast to the generally accepted belief that humans have completely evolved, in fact they have not developed to their potential. Transhumanists contend our future evolution will be rapidly and considerably altered by emerging technology, and this next stage of evolution will produce future humans that are far more gifted mentally and physically than they are now. So rather than being apprehensive about increasing technology, transhumanists embrace it, and are concerned more about those who might be left behind if they are not technologically enhanced. As noted by Kurzweil (2009) “nanotechnology may reprogram our genes away from aging and disease, and in 25 years we may have billions of nanobots keeping us healthy at the level of every cell in our body, and backing up the information in our brains.” Under the rubric of trans- humanism three areas of possible ethics focus are presented: the use of “smart drugs” in the healthy; genetic engineering of the human germline; and the development of synthetic biology.
Cognitive Enhancing Drugs
Drugs for amplifying human cognition have been used for years, and psychologists are well acquainted with the use of stimulants such as Ritalin for attention deficit hyperactivity disorder or Provigil to enhance focus and concentration in those with excessive daytime sleepiness. Medications like Aricept are also prescribed to slow the progression of dementia or help to control its memory related symptoms. Healthy individuals currently use some of these drugs illegally in order to enhance their ability to attend, concentrate or remember in their daily activities, with such drugs increasingly common on college campuses and in the military (DeSantis, Noar, & Webb, 2009; Eastman, 2007; McCabe, Knight, Teter, & Wechsler, 2005). In the future these drugs might be used legally and routinely for the same purpose, and this prospect has generated a lively debate as to its potential to advance human functioning versus possible unintended consequences.
In their seminal paper on this topic in Nature, Greely et al. (2008) suggest that cognitive enhancing drugs that are safe and effective will benefit not only individuals but also society, and should be legalized. They are of the opinion that this is the natural order of human evolution, and if managed well could increase human potential. Ethicists have responded that this will provide those using cognitive enhancing drugs an unfair advantage in society, and that it will essentially amount to breaking the rules or cheating. Greely et al.’s response to this position is that rather than leaving the rules intact, society’s regulations should change to incorporate this necessary next step in human development.
Another claim is that using such drugs is unnatural, but supporters note that humans engage in a variety of unnatural activities such as living in houses, wearing clothes, and driving vehicles. A concern is also that using such drugs in a non-clinical population amounts to drug abuse, which is countered by proponents who deny it is abuse if the drugs are distributed and taken properly.
Concerns for psychologists could include how taking such drugs will change the lives of those who take them, and the lives of those who do not. Will there be concerns about distribution of legal cognitive enhancing drugs based on socioeconomic status and drug costs? And is this any more of an issue than the fact that the more affluent are now able to afford other assistive technology such as highspeed computer access for themselves and their children? Will there need to be new norms on educational screening tests such as the SAT, MCAT, LSAT, etc. or will there need to be two versions, one for students taking these drugs and another for those who do not? Similarly, will we need new norms specific to those using legal drugs for standardized intelligence and cognitive tests?
Inheritable Genetic Modifications
Genetic engineering of the human germline is a rapidly evolving field of proactively mutating human cells to improve an individual’s health or functioning. Somatic cells are specific to the individual, and any mutations are not passed onto offspring in genetic material. But mutated germ cells will be passed on, and become essentially immortal, reproducing indefinitely. Such tinkering with the germline has yet to be attempted in humans, but is likely on the way (Cloud, 2010). On the positive side, genetic engineering can lead to cures for disease and disability in the individual and his or her progeny. On the other hand, it could be used strictly to enhance one’s positive traits in the absence of sickness or infirmity. While not necessarily a disreputable action per se, the use of such engineering to augment desirable characteristics for the populace and their children could have a considerable effect on the balance of society (Caplan, 2000; Frankel & Chapman, 2000). Having plastic surgery to improve one’s facial presentation may be defensible, but the new and improved nose will not be passed onto the patient’s child, yet genetically derived cosmetic changes could be. Deciding what improvements will be made and how they will affect future generations will unlock new areas of research and consultation for psychologists, who will be learning as they navigate these uncharted waters. Should parents make decisions that might have a profound effect on their descendents ad infinitum? What role should or will psychologists play in assessing a person’s motives and capacity to make such decisions? In whose best interest must we act?
Applications of Synthetic Biology
Synthetic biology is the attempt to design novel biological components to improve human life. Like a plot from a science fiction movie, chunks of DNA can now be ordered from international DNA synthesis companies, and these bits can be fused together to create new biological parts (Singer, 2006). Much like genetic engineering, patients will potentially benefit from the development of scientific creations to meet their needs. On the surface a miraculous step forward in addressing human suffering, this advance also has a potentially darker side that concerns biosecurity. Much like the fear that nuclear weapons might fall into the wrong hands, given how accessible these DNA pieces are, the same technology could be applied by criminals to make bioweapons. For example, a motivated terrorist might recreate the smallpox virus, or even more deadly new “designer” pathogens (Tucker & Zilinskas, 2006). The debate over the risks versus benefits of supporting and developing such technology will surely have political overtones, but might also open debate on the social science of this technology in terms of accessibility, and its potential to alter the lives of individuals in ways that we cannot currently grasp (European Group, 2009). Psychologists might play a role in these debates through research and evolving clinical knowledge.
Assisted Suicide (AS)
Once considered a prohibited topic, the legality, morality and clinical wisdom of facilitating an individual’s suicide has moved into public debate. To clarify, euthanasia is defined as directly performing acts that will hasten death, for example when another party injects a patient with or places deadly medication into a running intravenous drip. Assisted suicide is where an individual is provided with the means to end life, but no other party is then involved; patients make the ultimate decision and act directly and alone to employ the provided technique, for example personally opening the IV line to release the fatal drug into their own bodies. Debates regarding assisted suicide have intensified as the baby boomer generation is aging and end of life decisions are prominent, and their history of valuing social control and independence drives a more open dialogue about assisted suicide. Because of the human drama and universal themes involved, national and international media are focused on this issue, as states and countries debate the pros and cons of allowing assisted suicide (Materstvedt et al., 2003). Professional organizations have varying opinions about AS; for example the American Medical Association opposes physician assisted suicide (American Medical Association, 1992), whereas the American Psychological Association currently takes a position that neither endorses nor opposes assisted suicide (American Psychological Association, 2010).
While euthanasia is illegal in the US, a number of states and foreign countries have either legalized assisted suicide or are studying the possibility of doing so. Proponents argue that assisted suicide is a fundamental human right, but regardless of one’s position on that dispute, ethical considerations abound. The first considers the possibility that vulnerable populations will be disadvantaged by a majority culture, for example that the physically or mentally disabled, or those of limited economic means, especially among ethnic minorities, might be encouraged to choose assisted suicide as a defensible solution to their medical challenges (Blendon, Szalay, & Knox, 1992). Also of concern is the concept of “disability burnout,” or the stage reached when patients endure long enough that the desire to continue living is extinguished, at which time they may opt to end their lives rather than continue to struggle, a decision that may reflect weariness rather than suffering or a terminal condition (Gill, 2004).
Supporters of assisted suicide consider it ethically justified because of the concepts of autonomy, where a competent individual should be allowed to choose death; justice and fair treatment of all cases, since competent patients can legally refuse life-saving treatments, so the choice to end life is essentially the same; compassion, whereby assisting a suicide is a compassionate response to intolerable suffering; individual liberty, where the interest of the state blocks or limits the patientís personal liberty; and openness of discussion, which allows that assisted suicide already takes place, but in secret because of its illegality. Legalizing the practice would promote an open dialogue among all parties (Braddock, 2008).
Opponents consider assisted suicide not ethically justified because it contradicts the sanctity of life, which is a fundamental tenet of both religious and secular traditions, and therefore immoral; is active, and therefore different from passively allowing a terminally ill patient to die; shows potential for abuse, a cost containment strategy and treatment option for those lacking support and access to care; violates professional integrity in those who have taken an oath against assisted suicide, and harm the clinician’s reputation by association; and the fallibility of professionals, wherein mistakes are to be anticipated, errors are made in the diagnosis of the terminal nature of a disease, depression is missed, or pain is inadequately treated. In these cases opponents contend the state has a duty to protect patients from these inevitable professional miscues (Braddock, 2008).
Perhaps the most prominent concern for psychologists is the patient’s cognitive status or capacity to consent. Psychologists will be asked to appraise the cognitive facility of patients to make decisions regarding their end of life care.
Clinicians will judge whether patients are clinically depressed, their symptoms truly insufferable, or their psychological calamities capable of being resolved in some other way. But the professional guidelines for the assessment of such competence to decide are poorly formed, and notable in that the individual clinician’s personal opinion regarding assisted suicide affects his or her opinion about the assessment of competence; those clinicians ethically opposed to AS advocate a higher threshold for patient competence to choose AS, and a more extensive review of the decision once it is made (Ganzini, Leong, Fenn, Silva,&Weinstock, 2000).
Widespread legalization of assisted suicide in the US will oblige psychologists to construct theories and techniques to address this most important issue (Hastings & Robbennolt, 2004), which will doubtless continue to exist within a minefield of strong and contrasting personal opinions and passions, including those of psychologists.
Rationing of Health Care Using Age as a Marker of Efficacy
Western societies are challenged by the fact that the life expectancy of its citizens is increasing due to improvements in lifestyle and medical care, with a particular increase in the “old old.” Governments are faced with the competing obligation to make certain that elders in the future can expect to have continued progression of their function and the quality of their medical services, but also to address the mounting cost of providing this care. Health care costs continue to spiral upwards, and caring for older patients absorbs much of that rising financial burden. As such there is discussion of the need for a reduced societal commitment to the elderly to avoid the insolvency of the system, and it is likely that these costs might be targeted for restrictions (Callahan, 1996).
One supporting argument for age-based limiting of care is that increased spending for seniors deprives younger patients of resources that are rightfully theirs, and thus the ratio of cost to benefit justifies and validates age related rationing of medical services for seniors. Those in opposition stress that age is a weak marker for predicting clinical benefit, and further emphasize that such rationing will lead society to be less and less troubled about this apparent devaluing of elders (Gordon, 2000). Psychologists have been well schooled in the treatment of older patients (American Psychological Association, 2004; Hinrichsen, 2010), but have not been trained to face situations where medical and mental health care are rationed. Through research and clinical experience they might be called upon to help shape the allocation of resources among older patients.
Professionals are placed in a difficult position when asked to screen for problems if services to address them are not readily available. For example the suggestion that primary care physicians routinely screen all their patients for depression must be tempered with the fact that these physicians do not have the time or expertise to comprehensively treat those found to endorse depressive symptoms, and mental health referral systems may be limited in their ability to handle a large influx of depressed patients (Linton, 2004). Psychologists may face a similar ethical quandary when diagnosing dementia or geriatric depression if rationing withholds services from older patients, eliminating their chance to be treated. This trend might offer a challenge or an opportunity for psychologists. Psychologists in settings that care for the elderly might lose jobs or be relocated to working with younger patients, but since psychoactive medication accounts for a good deal of the cost associated with care of older patients, if such medications are restricted or eliminated, there may be an opportunity for psychologists to expand their roles by filling the void with non-pharmacological (and hopefully more cost effective) behavioral interventions.
Emerging Technology for Health Records and Patient Contact
Nothing suggests a rapid rate of change more than the explosion of electronic technology as it pertains to the practice of psychology. Psychologists once kept notes on paper files, and communicated with patients by letter and phone, and with referral sources by mail. The ethics code then had to consider the transmission of information via facsimile machines, and then email communication with patients and other professionals. Next were the issues involved in conducting patient consultations through telemedicine videoconferencing, with consideration of professional licensing when consultations are done state to state, and privacy for the patients involved. With the development of less costly and more readily available technology such as smart phones and inexpensive videoconferencing hookups computer to computer, the evolution of electronics will continue to lead the ethics code into new territory. Balancing the use of electronic medical records with protecting patient information is delicate and ecoming increasingly complex (Richards, 2009).
Particularly important is the promising technology associated with the maintenance of electronic personal health records. For years individuals have kept paper copies of their health care records to assist them in their dealings with the health care system, but these records have typically included relatively limited information such as immunization history or drug allergies. The danger of keeping paper records was underscored after Hurricane Katrina, when thousands of evacuees required medical care in other parts of the country without even the most basic personal health information such as lists of their medications. Not only were their personal paper files destroyed, but paper files in hospitals and clinics were also ruined in the storm-related flooding (Endsley, Kibbe, Linares, & Colorafi, 2006).
The future belongs to electronic medical records, and that transition is underway in large health facilities across the country as well as in small medical practices, where systems such as those proposed to be sold through large retail stores will be affordable for clinicians with limited professional staff. In the near future patients will be issued their own health record in a miniaturized format. It will likely be a portable, interoperable digital file in which clinically significant health data can be secured, handled and transferred. The platforms for portable personal health records might include smart cards, personal digital assistants, smart phones and USB devices that could connect to any computer. These platforms will be able to exchange data with all other health care information systems, including those that are office or hospital based (Endsley et al., 2006).
Allowing patients access and control of their files could increase the efficiency and quality of care and enhance patient safety, but might raise concerns about the privacy of personal health information, and the accuracy of records if patients are allowed in some systems to enter their own data. Portable patient cards further pose a confidentiality risk in terms of being lost or stolen, or shared with other parties in ways that might not be in the patientís best interest. One can envision an acquaintance or family member accessing the patient’s card surreptitiously, and learning that the psychologist has noted what the patient said about the person doing the “snooping.” In such cases it is impossible to assure the patient of the privacy of the relationship. How this will affect the practice of psychology is unclear. The days of withholding clinical files from patients are long gone, but when they can download each consultation onto their own smart phones immediately for instant access, the provider-client relationship may be altered in ways we have not as yet considered. How that might shape the format of our record keeping remains to be seen.
Practice will also continue to be influenced by social networking, where both patients and psychologists might maintain sites that permit an in depth social understanding of one another outside of a therapeutic relationship. As social networking becomes ever more commonplace and revealing, psychologists must be alert to avoid potentially exploitative dual relationships that might result. Guidelines are slowly emerging (Zur, 2010), and those wishing to manage their on line “fingerprint” may wish to consult services such as reputationdefender.com.
Neuroethics and Brain Imaging
An emerging science involves efforts to find neuroimaging correlates of individual differences in intelligence and personality, largely through the use of functional magnetic resonance imaging (fMRI). The fMRI is a specialized type of MRI scan that measures the change in blood flow related to neural activity in the brain or spinal cord, and is thought to be able to revolutionize the study of mental activity (Wolpe, 2009). Wolpe states (p. 87) that “it is not an exaggeration to say that the fMRI to measure subjective mental experiences is the most important imaging technique since the X-ray.”
The fMRI has the potential to examine a brain and to some degree reveal one’s thoughts, for example to reflect deception or racial bias. Criminal justice and intelligence agencies are funding studies of the potential adaptation of the fMRI for behavioral prediction and lie detection; for example one might expose a detainee to a dialect in a foreign language and determine their word recognition via the fMRI, helping to classify them as friend or foe. Proprietary companies are providing services such as the “No Lie MRI” for use in consumer and voting preferences, known as neuromarketing (Farah, 2009).
Given that the right to privacy includes the right to protect one’s innermost thought process, the principal risk is how these new imaging technologies might be used in one’s personal life, for example by employers and marketers, and the potential for threats to individual autonomy (Wolpe, Foster, & Langleben, 2005). Psychologists have used skilled interviewing and psychological tests to proverbially peer into the soul for a century, but the fMRI might provide greater precision and fidelity than our procedures have been able to offer. Given that much still needs to be determined regarding the utility of techniques such as the fMRI to understand mental processes, if this practice gains acceptance, psychologists will need to examine the potential benefits and ethical liabilities of neuroimaging for the assessment and treatment of their patients.
Forbidden Knowledge and Personalized Medicine
For centuries religion has dictated to the faithful that there are things we are not to know, particularly about our futures, assuming that this is known to a deity, and humans are not to question or confront their fate. But this notion has been challenged by the introduction of genetic testing, which can reliably predict one’s future with great accuracy. Once contained exclusively within the medical realm controlled by professionals, this information is now available to the general public, much like pregnancy and paternity tests. Using genetic home testing kits available in drug stores, individuals can scrape the inside of their cheeks or produce saliva, and send the resultant DNA material away for testing (Pappas, 2010). According to marketers, for a nominal fee individuals will supposedly receive a detailed and accurate assessment of their genetic ancestry and personal history, as well a map of their medical future, including their risk for particular diseases such as diabetes, cystic fibrosis and prostate cancer, with no need to visit a health professional.
These kits are not regulated by the Food and Drug Administration, but marketers claim the tests provide a service, since individuals can make life style changes as needed to address their future risks for disease. The use of home genetic tests might flourish and become part of the mainstream of modern medicine, or be a fad that proves ineffective and passes. And for most diseases science is unsure why some fall victim and others don’t, even with similar genetic profiles (Stein, 2010).
Bio-ethicists are worried that consumers will misunderstand or misuse their test results. The information received might be upsetting or misinterpreted without expert input. While much of this concern has to date been speculative, the Coriell Personalized Medicine Collaborative (Christman, 2008) is a large scale, long-term, evidence based study that plans to enroll and provide personal genetic information at no charge to 100,000 volunteer participants, in part to examine how consumers will integrate awareness of their own prognostic genetic findings into their health care decision making. The outcome of this study should produce bedrock information for future planning in personalized medicine.
How might psychologists be asked to contribute to research and intervention with those who have learned their fate well in advance of its reality? And how will this new found knowledge potentially alter the face of clinical health psychology? Will patients be more motivated for changes in lifestyle habits as a result of knowing their future risk, or fatalistic and disinterested in attempting to alter what they see as inevitable?
Psychology has for many years practiced within fairly predictable boundaries, and the code of ethics has provided direction and security. But changes might be coming that the code cannot anticipate, and it is unlikely that a static set of aspirational and enforceable guidelines could provide more than the most general advice as these changes evolve.
Psychologists must anticipate these changes and remain flexible as they face emerging ethical challenges over the next decade and beyond.
Grateful acknowledgement is offered to Dr. Arthur Caplan, Director of the Penn Center on Bioethics, for his consultation on this paper.
Dr. Linton is Professor and Vice Chair in the Department of Behavioral Medicine and Psychiatry at the West Virginia University School of Medicine in Charleston. He is Past President of the ABPP Clinical Health Psychology Board, and serves on the ABPP Board of Trustees and the ABPP Ethics Committee. Dr. Linton is Past President of the Association of Psychologists in Academic Health Centers. He is a long time member of the National Register, served on the National Register Appeal Board, was featured in the National Register Legacy of Excellence Series, and in 2009 was awarded the National Register Lifetime Achievement Award.
This article was originally published in the Journal of Clinical Psychology in Medical Settings (2010) 17:278-284 and is reprinted with permission. CPMS is the official journal of the Association of Psychologists in Academic Health Centers (APAHC).
APAHC was established in 1982 to serve the interests of psychologists in academic health centers and medical schools and supports psychologists' participation in academic health center governance, research, education, and clinical care. For more information on APAHC and the CPMS, see www.div12.org/section8/index.html.