Therapy in the time of COVID-19:  A look at one ethical issue

Therapy in the time of COVID-19: A look at one ethical issue

By Samuel Knapp, Ed.D., ABPPP Michael Gottlieb, Ph.D., APBB and Mitchell M. Handelsman, Ph.D
July 28, 2020 - Last updated: July 27, 2020

Consider this scenario:
During a therapy session, a patient stated that the media was hyping the threat of coronavirus, that it was no worse than the regular flu, and that he was still going out with friends for non-essential social activities.

At a time when much of the United States is under “shelter in place” orders to thwart the spread of the coronavirus, we still hear reports of individuals who dismiss concerns about COVID-19 and circumvent public-health instructions on distancing themselves from others. Some of these attitudes may be fueled by disinformation websites or blogs, leading one researcher to refer to an infodemic on coronavirus (Vlessides, 2020).

Of course, risk falls along a continuum and conscientious citizens need to balance the risk of exposure with the welfare of others. One can appreciate the dilemma of patients who must decide whether to go to work and risk exposure, or how to care for an elderly parent who needs their assistance. However, the worrisome situation discussed in this article is exemplified in the opening vignette and concerns patients who egregiously and unnecessarily expose parents, children, neighbors, or other members of the public to infection.

Every psychologist needs to check the laws in their own state, but let us assume the situation described in the scenario we presented above would not qualify under “duty to warn or protect” standards because the patient has not made an immediate threat of imminent physical harm to an identifiable third party. Consequently, psychologists must rely on their ethical judgment to guide their interventions. We offer a decision-making model that can guide psychologists based upon principle-based ethics.

According to Ross (1930/1988), moral agents, including psychologists and trainees, can evaluate the morality of their behavior based on several overarching ethical principles. Beauchamp and Childress (2019) opined that the moral principles of beneficence, nonmaleficence, respect for patient autonomy, and justice were especially salient for health care professionals. Later, Kitchener (1984) added fidelity and Knapp and VandeCreek (2004) identified general beneficence (obligations to the general public) as also being salient for psychologists.

Ross anticipated that moral principles will sometimes collide and suggested a methodology to follow when these conflicts occur.

When I am in a situation in which more than one of these prima facie duties is incumbent on me, what I have to do is to study the situation as fully as I can until I form the considered opinion (it is never more) that in the circumstances one of them is more incumbent than any other. (1930/1998, p. 268)

Beauchamp and Childress (2019) expanded on this methodology and presented several steps to follow when one moral principle temporarily outweighs another. The most salient steps are to: determine if there are better reasons for acting on behalf of one overarching ethical principle than the other; determine if the intervention is likely to succeed; and minimize the level of infringement to the offended principle.

When a patient expresses an intent to circumvent public-health measures and place the well-being of others at risk, a conflict arises between respecting the autonomy of patients to do as they please (ignore or grossly minimize the risks to the public, such as by needlessly violating public-safety measures) and protecting the public by attempting to alter the behavior of patients. We also could note that attempting to alter the behavior might also harm beneficence or nonmaleficence (to the extent that it harms the quality of the psychologist-patient relationship, or the life of the patient). Let us consider the three steps in addressing this autonomy/general beneficence dilemma.

Is there reason to prioritize one principle over the other? Ross only stated that one principle should override another based on “a considered opinion” that one “is more incumbent” than the other. We assume that in a pandemic, general beneficence takes precedence over respecting patient autonomy, beneficence or nonmaleficence.

Is an intervention likely to succeed? Psychologists need to consider whether they would be likely to convince the patient to adopt more socially responsible behavior. There may be unique clinical features that make the intervention likely to fail. Perhaps the patient has paranoia or, at least, overvalued ideas. The patients’ thinking could make challenges to their assumptions or behaviors unlikely to succeed and damaging to the therapeutic relationship.

Can the intervention minimize harm to patient autonomy? Ideally, psychologists would be able to persuade patients to alter their behavior without harming, or causing only minimal harm to, the psychologist-patient relationship. It might be best to start with an inquisitive approach and ask patients to explain the reasons behind their actions. Then, psychologists can assess further the specific social or psychological factors that maintain the harmful behavior.

Psychologists should not discount the possibility that some patients are still acting out of lack of information (pure ignorance) and that an educational approach may be enough.

Other patients may passively acknowledge the benefits of social distancing and other precautions but have not yet translated those ideas into actions. Psychologists can remind these patients that individuals, as a rule, consistently overrate their personal vulnerability to illnesses (Dunning, Heath, & Suls, 2004). They can discuss the ways that confirmation bias (“My friends haven’t gotten sick yet.”) may influence their patients’ behavior. Finally, they can appeal to their patient’s prosocial motives. For example, among health-care professionals, handwashing interventions that focused on the well-being of patients tended to get a better response than interventions that focused on personal well-being (Grant & Hoffman, 2011). Perhaps the finding that focusing on public well-being improves health-care behaviors could also apply to patients of psychologists as well.

Psychologists can help patients think through concrete steps on how to be responsible to their family, friends, and community while, at the same time, meet their social or personal goals. They can discuss pragmatics about how to get groceries, keep relationships going, minimize unsafe interactions with others, and/or reduce risk in other ways.

Other patients may be acting out of misinformation, or out of more complex motives. Misinformation may come for many reasons, including a reliance on non-credible sources, or a perception that some have overemphasized the dangers primarily to discredit President Trump. Such patients may present a greater challenge, because nobody likes to be told that what they believe is wrong.

Psychologists need to frame their comments in a manner that, for example, would minimize politicizing the discussion or appearing to attack the intelligence or good intentions of patients.

References available from author

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Samuel Knapp, Ed.D., ABPP, is the director of professional affairs for the Pennsylvania Psychological Association and has written extensively on professional ethics, ethical decision making and suicide prevention. He may be reached at: Michael C. Gottlieb, Ph.D., ABPP, is a forensic and family psychologist in independent practice in Dallas, Texas, and a clinical professor at the University of Texas Southwestern Medical Center in Dallas. His interests include ethical decision making and the psychology-law interface. Mitchell M. Handelsman, Ph.D., is a professor of psychology and a CU Presidents Teaching Scholar at the University of Colorado Denver. He has published widely in the areas of teaching and professional ethics.

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