We have been asked to respond to the following scenario:
A nurse client told me that her kid just informed her that she can no longer taste or smell. The nurse knows the drill and said that she is going to quarantine her child for two weeks from school. I asked about her, and what she was planning on doing herself. She replied, “I’m going to work. I need to.” She works in a health care facility. My question ethically is: What do we do about a client who is a health care provider who may well be infected, but insists on going to work and tells you so?
Psychologists have an obligation to protect patient confidentiality unless the patient gives authorization or permission, the disclosure is permitted or required by law, or a court orders the release of the information. A major question becomes whether the laws of the state require or permit disclosures.
The psychologist should look to the “duty to warn” or “duty to protect” statutes of the state — and get legal consultation. However, these statutes usually require intent to create a danger of harm against an identifiable victim and in most if not all states, that standard would not apply in this situation. The actual risk to her patients may be minimized — although not eliminated — if the health care facility tests all its employees periodically or takes their temperature before every shift.
Because public welfare (the ethical principle of general beneficence) is involved, psychologists have a responsibility to make every effort to persuade patients to act more responsibly if they believe that their interventions have a likelihood of success.
Generally, psychologists should be able to talk to most patients about COVID-19 related behavior. Efforts to persuade this patient to act more responsibly can vary according to the motives of the patient, her life circumstances and the degree of risk she poses given the nature of her work.
The psychologist should listen carefully to the nurse to understand her motives. Is she a COVID-19 minimizer — a person who believes that its health risks have been exaggerated for political purposes? Or does the nurse appreciate the health risks but is under tremendous financial pressure? Or does the nurse have sociopathic tendencies and simply has little concern for the impact of her actions on others? The answers to these questions can help guide the practitioner’s response.
If the patient identifies with a group that minimizes the health impact of COVID-19, the psychologist can appeal to the patient’s sense of public responsibility to others and note that public safety protections from COVID-19 are normative even among many political conservatives. She should avoid the trap of trying to debunk falsehoods or arguing with the patient as this may just prompt counterarguments and defensiveness.
If the patient is reluctantly going to work because of pressing financial issues, then the psychologist can help the nurse think through the financial issues, seek to identify alternative sources of income or ways to cut expenses, ask the patient to reconsider the relative weight she is giving to her financial issues compared to her responsibility as a nurse, and/or explore other steps to minimize risk, such as asking the nurse about the possibility of minimizing contact with others while she is at work.
Finally, if the nurse has sociopathic tendencies it may be worthwhile to emphasize the repercussions to her if she became sick and it was revealed that she had been exposed to COVID-19 and failed to notify her employer as required by agency policy and state guidelines.
Although there are some exceptions based on patient need, psychologists usually should not accept the nurse’s decision to return to work without a discussion of the issues and an effort to get the nurse to reconsider her decision. Legal consultation about the state duty to protect or duty to warn laws may be indicated and psychologists should document their actions and rationales.
Samuel Knapp, Ed.D., ABPP, is the director of professional affairs for the Pennsylvania Psychological Association and has written extensively on ethics, ethical decision-making and suicide prevention. He may be reached at Samuelknapp52@yahoo.com. 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.