Ethics post: Psychologists, does it matter who butters your bread?

Can we act ethically while looking out for number 1?

I’m a disability consultant. People who have never met me or know very little about what I do sometimes call me a “hired gun.” In relation to my work on Social Security disability claims they imply things that essentially intimate I’m going to deny everyone the first time they apply. Why? Do they think I have an incentive to try to prevent people from getting disability benefits? It is an interesting question. In my work with disability insurance companies, they definitely are the ones buttering my bread (though my primary income typically comes from Social Security disability claims).

Who butters your bread? There is an idiom “know which side your bread is buttered on.” It essentially boils down to knowing who to be nice to in order to benefit yourself. However, leading with “what will butter my bread?” has rarely been a successful ethical decision-making strategy. I’d also like to think that most of us are able to manage those impulses and maintain an ethical framework for decision-making.

However, the judge in the case Maiden v. Aetna (N.D Indiana) 2016 WL 81489 essentially accused the psychologist consulting for the disability insurance company of paying attention to what side his bread was buttered on. In Maiden v. Aetna there was an allegation that the reviewing doctors were biased in favor of Aetna because Aetna paid them. The judge wrote in relation to these independent consultants that “one might reasonably wonder just how independent the reviewers [the judge named them specifically] really are. Their bread has been buttered by Aetna before; each of them has been hired by Aetna multiple times to conduct these kinds of disability reviews.” There were concerns that the reviewers cherry-picked evidence in favor of Aetna. The judge noted that a consultant “may have financial incentive to be hard-nosed in his claims evaluation…”

Taking an approach like the judge suggests would be contrary to our ethical principles, standards and guidelines. For example, in the Specialty Guidelines for Forensic Psychology Guideline 1.02 it notes forensic practitioners “strive for accuracy, impartiality, fairness, and independence.” It notes “forensic practitioners recognize the adversarial nature of the legal system and strive to treat all participants and weigh all data, opinions, and rival hypotheses impartially. When conducting forensic examinations, forensic practitioners strive to be unbiased and impartial, and avoid partisan presentation of unrepresentative, incomplete, or inaccurate evidence that might mislead finders of fact.”

The potential ethical concerns of knowing which side your bread is buttered on doesn’t only impact the forensic consultant. The treating provider also has factors working on them. They may perceive an advocacy duty to the patient. They are also, of course, being paid by the patient. More compellingly, they may fear a negative impact on the treatment relationship and a potential reprisal from their patient such as a board complaint or malpractice lawsuit. Their resulting risk-management approach may be to keep their patient happy and offer favorable opinions for their patient centered primarily on their self-report. This risk management/advocacy perspective from a treating provider can potentially impact the opinions a treatment provider offers. However, this also can put a treatment provider at ethical risk. Treating providers should be careful of situations where multiple relationships may arise. They may begin to perform the dual role of forensic expert offering opinions while also trying to maintain a treatment relationship and advocate for their patient. This can lead to ethics problems. The Specialty Guidelines for Forensic Psychology Guideline 4.02.01: Therapeutic-Forensic Role Conflicts notes “providing forensic and therapeutic psychological services to the same individual or closely related individuals involves multiple relationships that may impair objectivity and/or cause exploitation or other harm.” Psychologists are to “make reasonable efforts to refer the request to another qualified provider.” Treating providers should be very cautious in relation to how they respond to requests from their patients to offer forensic-oriented opinions.

The fun and amusing news about this?

Psychologists: You can now purchase a 4 ethics CE credit continuing education course that comes with a list of over 70 referral sources for medical records file reviews and independent medical examinations by going to one of my other websites:

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