Continuing my series of responses to the New York Times’, The Ethicist, without imposing values, here is my take on today’s post, “Can Therapists Fake Their Own Online Reviews?”
I am caught between competing ethical requirements. I am a mental-health professional with substantial experience; some people call me an expert. I recently expanded my private-practice hours. To increase patient numbers, I joined an online referral service (at considerable expense). Here’s where the ethical dilemma comes in: Like most “locator” sites, the service includes “customer” ratings. The site reps instructed me to have current patients complete the ratings. My professional training (I’m a psychotherapist) made it very clear that it is a big no-no to solicit testimonials from patients; doing so can badly interfere with the treatment relationship. Patients are in treatment for their own needs and should not be required to consider the therapist’s other actual or prospective patients. (Psychotherapy isn’t a simple commercial transaction.) So my professional-ethics training tells me to leave any ratings up to any patients who find me through the site, which then asks them to rate me. This would mean virtually no traffic through the site.
Discussions with fellow clinicians have revealed that many if not most have “primed the pump” with favorable “reviews,” written by friends or family members or by the therapists themselves. This thought makes me very queasy! But it seems to be a necessary action in the online marketplace. Basic ethics say not to lie, especially self-servingly. Still, I’m wondering about the ethics of depriving potential patients of the ability to find me (by remaining essentially invisible on the site) and to see if I might be able to help them.
So what do you think of this solution? I have submitted a few ratings to the site, directly quoting my actual, satisfied patients but using made-up names. My thinking is that the patients’ spontaneous comments about our work are real, but I haven’t made an improper demand of anyone. Furthermore, because I genuinely believe I may be able to help a potential patient who might read the reviews, fudging their origins doesn’t seem like too bad a con. I think the worst harm my actions might cause is that someone meets with me once and determines that I’m not the right therapist for him or her; that’s actually fine and a pretty common event. And readers know better than to take customer reviews too seriously, right?
My response: Your request, after describing the situation and your thoughts on it, is to be told what you’ve decided as the best course of action isn’t too wrong. You didn’t ask for alternatives. You didn’t ask for help. You asked for judgment and justification.
You’re also asking opinion. If there were an objective measure of right and wrong you wouldn’t ask a newspaper columnist. You’d use the objective measure. How much more right is that person’s opinion than your own? You’ve come up with a plan. Why can’t you rely on your opinion?
On a personal note, I understand kids asking their parents to tell them right, wrong, good, and bad. I can understand adults asking for other ways of looking at something and for help solving problems. I can understand adults asking for legal advice. I don’t understand adults asking to be told right, wrong, good, or bad. At what point do you say, “I’m mature enough to know my values enough to act on them with confidence? I wouldn’t ask this question if the writer had asked for perspective, advice, or help, but he or she didn’t. He or she asked for judgment and permission.
The New York Times response:
You speak of competing ethical requirements. I understand what one of them is: honesty. What I don’t get is what the countervailing ethical requirement is supposed to be. The only candidate you offer is a supposed ethical duty to make your powers as a healer known to people who need them. If there were such a duty, talented psychotherapists would mostly be violating it. So what you have, on the one side, is a wrong; on the other side, a bunch of excuses.
This is a common form of dishonesty, you point out. “But everybody does it” is an excuse we learn in grade school. Parents can reply, with the Bible: “Thou shalt not follow a multitude to do evil.” (That’s Exodus 23:2. Exodus 23:1 begins, “Thou shalt not raise a false report.”) Now, “evil” seems a bit tough here, because what you’re doing is less harmful than it might be. Many people discount these customer ratings, because they are aware that these reports, like yours, are often fakes. They indeed “know better than to take customer reviews too seriously.” But then your reports are either going to have little effect or they’ll selectively persuade the ignorant and the credulous. Taking advantage of people with these epistemic weaknesses is exploiting the vulnerable.
You maintain that your form of fakery is better than the straight-out inventions of others, because your ratings are based on things that clients have actually said. But because these are not real reports, readers are not getting a reflection of the real views of your clientele: What if a fair sampling would include some critics? You suggest that it’s a “fairly common event” for people to decide that you’re not the right therapist for them. Bothering to rate someone positively is a sign of satisfaction; it’s conceivable that the fact your clients haven’t done so is itself evidence of something. I’m putting aside the issue of whether metrics of consumer enthusiasm are entirely appropriate in the realm of psychotherapy. (Imagine Dora on Sigmund Freud: “Worst. Analysis. Ever.”)
That you are embedded in this ethical morass is not, of course, your fault. It sounds as if the people who created the website you signed up for have invented a permanent temptation to dishonesty and done little to obviate it. (A “closed-loop” system — which aims to restrict comments to registered, verified patients who have seen the practitioners — is harder to game in the way you describe.) The web, like every technology, creates new opportunities both for doing wrong and for doing right. Print made possible the wide circulation of lies as well as of truths; so, too, did the telegraph, the radio and television. Indeed, language itself is like this: no lies, no truths. There are three mechanisms for counteracting falsehoods: exposure, the education of consumers and the conscience of the producers. The last of these, as your letter suggests, isn’t to be relied upon. Your one consolation, and ours, is that your dishonesty is a mere grain of sand on the great mountain of falsehood. Still, you should take these fake ratings down. If you want to replace them, why not write, under your own name, a paragraph summarizing the comments of satisfied patients?
This past week, my primary-care physician called me with some startling news: iron-deficiency anemia. She was so concerned with my results that she ordered a colonoscopy and upper endoscopy to look for internal bleeding and recommended I take ferrous gluconate to increase my iron levels.
I have no history of iron deficiency or anemia. The more I thought about it, the more I thought of a possible cause. I have been donating blood on a regular basis for the last several years at a local bloodmobile. After the first few times, I was turned away because my iron level was found to be too low. Next blood drive, no problem. The latest was another story. The staff nurse pricked my finger and told me my iron was too low but then said something along these lines, “Oh, let me get so and so, she can always get the proper reading.” Just like that, my iron level was high enough to donate, which I did. When I asked how that could be, she said, “She knows how to get the proper reading, she has to poke a little deeper.” Hmm.
My doctor now thinks that donating blood could be the reason for my iron-deficient anemia. She was shocked to learn that the staff in the bloodmobile neglected to suggest I contact my doctor and blatantly manipulated the results to make me eligible to donate blood.
Is it my responsibility to alert the teaching hospital that operates these blood drives? I feel horrible that someone has possibly been given my iron-deficient blood. Maura Toomey, Brookline, Mass.
My response: First, these two statements seem to contradict each other: “I have no history of iron deficiency or anemia” and “I was turned away because my iron level was found to be too low.”
Second, all you asked was if it was your responsibility to alert. Whether others consider something your responsibility seems a question of opinion on an abstract concept.
I’m going to digress from answering the question to wonder why you wouldn’t contact them, independent of others’ opinions. I see no downside to contacting them and the potential for what seems clear to improve others’ lives. Are you concerned you will suffer by contacting them or make the nurses look bad?
This is why I teach skills instead of abstract philosophy. Then you see the issue not as something to debate about without acting but as an opportunity to act and help people. If you don’t have skills, you miss opportunities to connect with people and help solve their problems. Even if you don’t have the skills, you could ask your doctor to contact the hospital, keeping your identity confidential.
How does a newspaper columnist’s opinion on responsibility help the people receiving the iron-poor blood, except through influencing your behavior, which learning skills would have done directly?
The New York Times response:
The helping professions may themselves be in need of help: That seems to be the lesson of the day. It looks as if you have important information about the way some blood donations are conducted in your area. What the staff nurse said suggests that what happened to you may have happened to others. A large-scale 2011 study found iron deficiency in a large portion of regular donors — about two-thirds of the women and half of the men — and those were just people whose donations had been accepted. As your doctor is aware, regular donation can result in (and worsen) iron deficiency and anemia. And of course, there are good recipient-side reasons iron-deficient blood, which doesn’t carry oxygen very well, should be avoided. (Anemia can also be a symptom of transmissible diseases.) So for the sake of both donors and recipients, it’s a bad idea to ignore signs of anemia in those who donate at blood drives. You should indeed notify the hospital that runs the bloodmobile. It may be too late to stop your blood from being used, because it’s not going to be stored for more than six weeks. But sharing your experience with the relevant officials could help prevent this abuse of the proper protocols from continuing.