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Abstract
The rapid emergence and exploding usage of online social networking forums, which are frequented by millions, present clinicians with new ethical and professional challenges. Particularly among a younger generation of physicians and patients, the use of online social networking forums has become widespread. In this article, we discuss ethical challenges facing the patient–doctor relationship as a result of the growing use of online social networking forums. We draw upon one heavily used and highly trafficked forum, Facebook, to illustrate the elements of these online environments and the ethical challenges peculiar to their novel form of exchange. Finally, we present guidelines for clinicians to negotiate responsibly and professionally their possible uses of these social forums.
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Professional boundaries help to safeguard the patient–doctor relationship and to establish a framework for an interaction that benefits the patient. There is considerable medical literature concerning sexual boundaries, financial relationships, and gift giving in the patient–doctor relationship.1 2 3 4 However, only recently have articles on the ethics of using emerging online technologies appeared.5 Indeed, a recent study suggests that nearly two-thirds of medical students, as well as a growing number of residents, have a personal profile and regularly use Facebook, a popular online social forum.6 As soaring numbers of physicians and patients use this and similar forums, we must define guidelines for online professionalism and grapple with the ethical dilemmas that usage of these forums presents.
Facebook is a photo-sharing, social networking website with a membership exceeding 200 million active users.7 Its considerable following and easy accessibility to online personal information are making more complex how we meet and interact with each other and will predictably change how we approach medical practice. As online social forums grow in number and sophistication and as their use becomes more widespread, physicians must consider the ethics surrounding these tools in order to prevent situations harmful to patients or themselves. In particular, physicians must be thoughtful and cautious to avoid problematic dual relationships, protect patient privacy and weigh risks and benefits of self-disclosure. Exploration of these ethical issues and examination of relevant ethical principles to guide the use of online social forums is the goal of this article.
Facebook began at Harvard College but quickly spread nationally to other university campuses and beyond; the site now reports that the majority of its users are college graduates. Current medical students, postgraduate trainees and medical practitioners across specialties use Facebook and similar online forums. This activity is probably most common among younger medical students and physicians, who have come of age in the information era. Younger physicians use online forums for social reasons and also for professional networking. They may find it difficult to receive mentorship and guidance regarding judicious and ethical usage of online social forums from older clinicians, who tend to have less experience with participating in these forums.
Facebook and other social networking sites (eg, MySpace) allow users to share personal information. Each user has a “profile”—a page that may include personal photographs, email address, home address, telephone number, place of employment, political affiliation, favourite movie, relationship status or sexual orientation. The profile specifies the individual’s friends and social events attended. Perceptive users can establish privacy settings that allow them to choose who has access to material. Usually, another user must be “added as a friend” to gain access to the complete profile details, associated photographs and other personal content. However, if users are not careful to establish conservative privacy settings, their photographs and other personal material could become accessible to people whom they did not invite as friends. A recent study revealed the worrying reality that only 37.5 per cent of medical students and residents make their Facebook sites private.6
The medical literature previously has considered ethical issues related to physicians’ having email relationships with patients.8 9 As with email, sensitive content on online social forums can be unknowingly and rapidly disseminated to others. However, social networking sites differ from email in important ways. For example, these sites allow multimedia content to be unwittingly disseminated to a large network of people, not just to intended recipients. The message is not just the deliberate explicit words of an email message, but rather the complex, multifaceted information and images that populate so many online profiles.
Ethical concerns about online social networking
Engaging in friendships with patients has not been a customary part of the patient–doctor relationship. Online friendships with patients are particularly problematic because they may open the door to interactions (online or in person, romantic or otherwise) that are extraneous to the patient–doctor relationship, do not prioritise the therapeutic interests of the patient and lead to potentially problematic physician self-disclosure. A recent study found that physician self-disclosures in the clinical setting “were often non sequiturs, unattached to any discussion in the visit, and focused more on the physician’s [needs rather] than the patient’s.”10 If physician self-disclosure is unhelpful in the face-to-face clinical interaction, it is likely to be equally unhelpful in online interactions. Physician self-disclosure in the former setting typically involves informal “chatting”, but the self-disclosures that can occur online are intensified by photographs and other highly personal content.
Interacting with patients on social networking sites can also create significant privacy concerns. Without cautious use of privacy settings, the physician who befriends a patient or the patient who befriends a physician could unwittingly compromise either party’s privacy. For example, if a psychiatrist were to become an online friend with a patient and discuss aspects of the treatment on the website, other online friends could learn potentially compromising information about the patient. This could be harmful to the patient by leading to social stigmatisation, employment discrimination or denial of insurance coverage, particularly as it becomes increasingly common for employers and others to monitor people’s online profiles.11 Physicians need to recognise this danger and avoid creating such vulnerabilities for their patients who use online social networking tools.
Additionally, physicians who use online social sites may become privy to information not intended for them. If a physician found Facebook photographs of a patient smoking cigarettes after denying being a smoker in a previous visit, can and should the physician discuss these photographs with the patient at the next office visit? Can and should the physician document the online finding in the patient’s medical record, thereby creating the risk of insurance discrimination? What if the patient had not intended the physician to see those photographs? Depending on the diligence and vigilance of the patient who uses an online social forum, a physician who becomes online friends with patients could discover compromising photographs of those patients. The physician who happens upon an embarrassing patient photograph and remarks on it during a subsequent clinical interview may risk damaging the therapeutic relationship by offending the patient or by violating the patient’s presumption of privacy.
Guidelines for physicians using online social networking sites
Because of these risks, we believe that under no circumstance should a physician initiate an invitation to a patient to become an online friend. However, when a patient invites a physician who uses a social networking forum to become an online friend, the physician may be caught off guard and could benefit from guidance regarding a professional and ethical response. Physicians should be thoughtful and cautious when they use online technologies such as Facebook and other networking sites, which are principally for social and recreational use (though they may also have uses for professional networking). We propose the following four guidelines for physicians who receive invitations to become online friends with patients and consider participating in online social forums:
Avoid entering into dual relationships by not immediately accepting an invitation to become an online friend with a patient. If not accepting the invitation might be experienced as hurtful to the patient and damaging to the therapeutic relationship, discuss these issues with the patient in a face-to-face interaction and explain why a dual relationship may be problematic and unethical. The physician could consider seeking ethics or risk management consultation to help shape a professional, therapeutic response to a request from a patient to become an online friend.
Respect patients’ privacy by carefully managing any information garnered about them on social networking sites or from other online information sources. Private information obtained on such a site should not be entered in the patient’s medical record without the patient’s knowledge.
Exercise restraint when disclosing personal information on social networking sites or other sites on the internet. Cautiously choose the content to be displayed and with which to associate oneself. For example, physicians might choose to become Facebook users but populate their site only with professional information, such as area of specialty, office address, academic affiliation and contact information.
Read and understand the site’s privacy settings in order to maintain control over who can access one’s online profile. Use conservative privacy settings, coupled with sober use of language and professional decorum, to afford oneself sufficient latitude to use the website while avoiding online interactions with patients. Any personal information presented by the physician should be discreet, considering that privacy technology is imperfect and can be compromised inadvertently or by a sophisticated hacker. Even with cautious privacy settings, physicians should not assume they can use online forums for social purposes only, as unforeseen breaches of privacy barriers may have a significant impact on their professional roles and relationships.
The emergence and exploding usage of online social networking forums have presented physicians with new ethical and professional challenges. Doctors are encouraged to be lifelong learners. With new surgical techniques, medications and imaging devices, doctors are pressed to assimilate new material quickly and remain up to date. Likewise, it is increasingly necessary that clinicians stay current on technological developments and changing social norms so that they are not surprised by unforeseen occurrences, such as an invitation from a patient to be an online friend. Online social networking sites are virtual public spaces used by millions and available to all. Physicians must individually negotiate such online social forums until clearer standards for online professional behaviour are established. In most cases, the risks of interacting with patients on online social forums appear to outweigh any current potential benefits.
Footnotes
Competing interests None.
Provenance and Peer review Not commissioned; externally peer reviewed.
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