This is the second in a series of discussions of questions that have been posed to AACAP’s Ethics Committee. As before, please read the query below, then stop reading in order to give yourself a few minutes to prepare your response. Then, read a summary of the Ethics Committee’s responses.
Query: “We use video camera monitoring in patient rooms on our acute child inpatient setting.We do not record from these cameras. The monitors are in a private area of the nurses’ station, not visible to patients. The patients are informed and the parents sign consent. The parents are often pleased and have not complained as the patients are often dangerous to themselves or others and/or psychotic. Some rooms are singles, others doubles. The patients have privacy to change and attend to hygiene in their attached bathrooms.
The agency overseeing certification of patient care in our state has ordered us to stop the video monitoring, stating that this practice interferes with patient privacy. We have serious concerns about our patients’ safety. Please evaluate the relevant ethical considerations to help us in our response to the agency’s demands.”
Response: Reasoning about case-related ethical concerns often centers on fundamental ethical principles and their importance in the particular case relative to each other. In this case, one that raises the specter of Big Brother versus the rights of the individual, the principles of beneficence (doing good), nonmaleficence (avoidance of harm), and autonomy (freedom of individual will and action) play prominent roles. The right of the individual to privacy versus the need of the inpatient child and adolescent psychiatrist (CAP) to provide safety of the patient for whom (s)he bears clinical responsibility are the primary conflicting concerns.
Albert Derivan, M.D., a member of the Ethics Committee, addresses the matter as follows: “It is the duty of the physician to care for his or her patients. Children and adolescents admitted to an inpatient psychiatric facility are in need of constant care and monitoring. The treating physician should make a judgment as to the nature of this need and it should be so noted on the order sheet. Appropriate orders follow. Thus, suicidal patients are placed on suicide precautions; runaway risks are placed on runaway precautions, etc. As part of modern, necessary, and compassionate care, TV camera monitoring is available and thus often used. I believe such use has prevented patients from engaging in and committing both suicidal behaviors and other actions not in their best interests. TV monitoring does not infringe upon a patient’s rights any more than a cardiac monitor infringes on a patient’s rights in a cardiac unit, or an apnea monitor infringes on the rights of a newborn. A psychiatric facility is a place where very sick individuals come for care. The cameras help ensure the patient’s safety without which as good care cannot be rendered. Therefore, it is entirely ethical and appropriate to monitor patients with TV cameras. Permission to do so should be obtained from their parents or guardians. The children should be notified that it is taking place and their assent should be requested. The procedure is medical in nature and should be ordered by the treating physician; documentation of its use should be made in the patient’s record. The ethical basis for doing this stems from the principle of beneficence – the need to treat patients in a good and wholesome manner and to avoid their being harmed. It does not compromise patients’ autonomy when it is done in their best interests and for their protection.”
This stance was subscribed to by all the Ethics Committee members who responded. A couple of further comments should be made. That the monitoring “does not curb the patient’s autonomy” is not necessarily the case. It does intrude on the patient’s privacy, but, it would be argued, necessarily so and not to excess. Another member remarked that technological advances generally are not of themselves good or bad, though they might be used for benefit or for ill. Thus technological advances do not generally raise new ethical questions. Rather, the same old questions have to be raised, and reasoning process employed, to deal with the impacts of novel technical advances.
A last consideration. Who obtains benefit from the technological advance – the patients, the caretakers, or both? Insofar as the CAP’s responsibility is to the patient(s), their potential benefit is the primary concern. If video monitoring were to be employed primarily to aid the CAP’s/caretaking staff’s monitoring abilities, resulting in a hospital’s downsizing of staff numbers in turn producing insufficient patient care, the use of video monitoring in such a situation would be unethical. Similarly, if video monitoring were utilized on (relatively) intact, nonvulnerable, nondangerous, but nevertheless disturbed patients, its use would definitely be open to question.
Ideally, technological advances result in win-win situations for both CAPs and their patients. Ultimately, each situation must be decided on its individual merits.