AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. July 2011, Volume 13, Number 7: 454-460.

Conley Essay

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2010 Runner-Up Essay
Social Roles and Semi-Public Spaces on the Internet—The Case of Jason and Emily

Applicants to medical school are expected to live by their presentation of themselves and of their commitment to medical practice. It is not just a retrospective report but also a promise to which admissions officers should be able to expect them to adhere.

Christopher Langston

Emily, a medical school candidate, had high grades and MCAT scores and extensive volunteer experience. The committee members who interviewed her reported that Emily had spoken movingly about her desire to become a primary care physician in a rural setting.

The committee’s student member, Jason, looked up Emily on Facebook to see whether they had any friends in common. There he found a link to a blog post that attributed rising rates of contagious disease and unemployment to illegal immigrants. Emily had added: “I couldn’t agree more. People whose mothers just happened to sneak over the border at the right time are called ‘citizens’ when they’re just driving down wages, straining our infrastructure, and taking jobs that rightly belong to honest, hardworking taxpayers. Why should we take care of them?”

Emily’s Facebook post revealed a side of her that Jason knew the admissions committee hadn’t seen, and he wondered what he should do with this information.

Response

While on his medical school’s admissions committee, Jason discovers that Emily, an applicant, has written a comment on her Facebook profile that may conflict with both her self-presentation in her interview and her future professional commitments. What should Jason do? I will argue that Jason should report his discovery to the admissions committee, who should consider Emily’s Facebook comment as they review her application, though they shouldn’t grant it much weight without further investigation—indeed, Jason should investigate further. More generally, I will argue that admissions officers should gather and consider as much information as possible that is materially relevant to the professional conduct of applicants. But they must obtain this information systematically and fairly, including respecting applicants’ reasonable expectations of privacy, and they must weigh all information according to its appropriate context. Before arguing for this general policy and applying it to this particular case, we should review two factors that make this case challenging.

First, Jason acquired information about Emily in a questionable manner. Unlike other information about Emily in her application, the information that Jason uncovered on her profile was found by actively probing unconventional sources, apparently without forewarning applicants. Moreover, Jason visited Emily’s personal profile on Facebook, a network that is renowned for divulging its users’ personal information without their consent [1-3], which suggests that on the whole users believe their profiles contain private information [4]. These aspects of Jason’s actions invite comparison to violations of privacy or ill-gotten gains.

But such comparisons aren’t clear-cut. Jason didn’t violate Emily’s expectations of privacy in a plainly illegitimate manner. For example, he didn’t rummage through her garbage or call up her former lovers for confidential personal details; he merely used a completely public search engine open to anyone with Internet access. Indeed, Emily could have set her profile’s privacy settings to restrict access by outsiders like Jason if she didn’t want the general public to see its contents. Moreover, given Facebook’s wide, unrestricted availability, postings on Facebook may not even count as private information, but rather public, or semipublic, communication [4]; politicians now use Facebook as a platform to express their views to the public [5-7].

As a result of these features, anyone judging this situation is confronted with conflicting indications about whether Jason is entitled to this information and about the uses to which he can legitimately put it.

Second, the significance of Jason’s finding is uncertain. Jason discovered information about Emily that is provocative, but its utility and relevance aren’t self-evident. Anyone can appreciate that Emily’s remarks are unflattering; no one looks attractive or charming when expressing unpleasant emotions like anger and disgust, regardless of those attitudes’ appropriateness. But the mere possession of unflattering attitudes isn’t germane to physicians’ ability to discharge their professional duties. Certainly, physicians’ personalities affect their ability to do so, but personality is a slim wedge of professional conduct—the medical field tolerates a wide variety of personalities. So by drawing the admissions committee’s attention to this side of Emily’s personality, Jason risks biasing the admissions committee against her personality alone; indeed, a similar risk would surface if Jason uncovered an especially rosy comment of Emily’s that might bias them toward her personality.

For Jason to run this risk, this information’s implications must give it broader professional, not just personal, significance. In this respect, it seems troubling that Emily endorses what seem to be alarmingly superficial beliefs about immigration’s social and economic dynamics [8, 9], especially considering what such beliefs seem to imply about her understanding of her own medical career plans. But ultimately one cannot tell if her endorsement is superficial without understanding the reasoning behind her beliefs, and her Facebook remarks do not present her reasoning.

Similarly, it seems troubling when Emily says, “Why should we take care of [illegal immigrants and their citizen children]?” But it is unclear how troubling this statement is because it is ambiguous. On the one hand, Emily may have intended her comment about “care” to apply only to government entitlement programs, since it follows a political commentary about “taxpayers.” Many reasonable physicians disagree about such programs without undermining their professional commitment to their patients. If this was Emily’s intention, her comment may have limited implications for her professional credentials. On the other hand, Emily’s comment may reflect more general indifference toward caring for the disadvantaged—indeed, caring for anyone. For a future doctor not only to hold such an attitude but also to express it openly is genuinely troubling, since physicians treat the suffering and thus disadvantaged. Moreover, such indifference suggests Emily’s range of concern for her patients may be much narrower than she indicated in her interview, and this raises further questions about her trustworthiness. Empathy and trustworthiness are foundational professional virtues for physicians, and if Emily’s comment reveals character deficiencies in these areas, then her comment strongly weighs against her professional credentials. However, since Emily’s comment is open to at least these two interpretations, no one should rush to judgment about her intentions, and so the relevance of her comment to her professional credentials is uncertain, even though it is highly tempting to infer the worst.

Given its complexities and uncertainties, this case makes a poor precedent for general policy; taken by itself, it prompts ethical judgments that are too subtle and conflicting to permit anyone to generalize with confidence about what admissions officers like Jason should do. Rather than draw on this case alone, any ethical recommendation should turn on Jason’s and Emily’s social and institutional roles, including these roles’ expectations and responsibilities.

Among their various duties, admissions officers like Jason are charged with accepting a class of medical students who will become the best doctors (with qualifications about complementary skills, intraclass diversity of interests, and so on). To discharge their task, admissions officers must systematically (so as to avoid bias) gather as much data as they can about candidates; they must sift the data for information materially relevant to candidates’ future professional conduct; and they must weigh the evidence appropriately, according to its contextual salience, reliability, and predictive value. But simultaneously, in pursuing this goal officers must respect certain constraints, especially constraints of fairness. Thus, they cannot harass, bribe, or otherwise apply undue incentives to applicants to obtain information; they cannot lie to, mislead, or disproportionately discomfit applicants to manipulate or test them; and they cannot violate applicants’ reasonable expectations of privacy. Such encroachments on fairness are clearly prohibited; applicants should expect admissions officers to respect this boundary.

Medical school applicants like Emily are expected to present to the admissions committee their strongest qualifications and to describe their preparation for a medical career, including their history of motivation and initiative, their notable achievements, and their commitment to professional standards and values. But they are also constrained in meeting this expectation by important responsibilities. Most notably, they cannot lie, mislead, or omit information about themselves or their conduct, especially when such information is materially relevant to their medical career. In a similar manner, they are expected to live by the self-presentation that they give admissions officers; in effect, their presentation of themselves and of their commitment to medical practice is not just a retrospective report but also a promise to which admissions officers should be able to expect applicants to adhere, just as patients should be able to expect their doctors to adhere to such commitments.

In presenting these social roles and their associated expectations and responsibilities, I have tried to draw a fine line between (a) generic platitudes like “admissions officers should fulfill their duties” and “applicants should meet expectations” and (b) substantive, but exceedingly detailed lists of obligatory activities like “admissions officers should check applicants’ Facebook profiles” and “applicants should never discuss issue X on Facebook.” Instead, I have tried to choose descriptions that are both “substantive and generic” [10] like “materially relevant,” “undue incentives,” “reasonable expectation of privacy,” and “contextual salience.” These “thick” [11-15] terms have more descriptive, “world-guided” criteria of application than “thin” terms like “responsibility” and “duty,” but nevertheless retain more normative, “action-guiding” criteria of application than purely empirical labels like “checking applicants’ Facebook profiles” and “discussing X on Facebook.” Such “thick” terms are common in the law (“cruel and unusual punishment” being the go-to example) [16] because they combine the substance and specificity of empirical descriptions with the generality and directive guidance of explicit rules.

When these social roles’ thick descriptions are applied to Jason’s and Emily’s scenario, it is clear that Jason should report his discovery to the admissions committee because it constitutes information that is materially relevant to Emily’s commitment to professional values and that was retrieved systematically and fairly, without violating Emily’s reasonable expectations of privacy. Emily posted her comment in a place where any person—including future patients—might come across it, and since it concerns commitments for which she is responsible now and during her medical career, it should be fair game during the application process. Furthermore, if Emily wanted her comments on Facebook to remain private and inaccessible to outsiders like Jason (or patients), then any reasonable person would have advised her to adjust her privacy settings accordingly. Jason’s visiting Emily’s profile without warning her was not especially transparent or considerate, but it was not for that reason unfair or impermissible.

The harder question is what evidential weight the admissions committee should place on Emily’s Facebook remarks. This question is difficult because it’s not clear what Emily’s remarks really mean or why she endorses them, and it’s hard to hold Emily responsible for this lack of clarity and completeness because she posted it on a web site devoted to informal discussion of personal topics, not professional ones. Readers (including patients) cannot reasonably expect the completeness or precision in Facebook posts (hardly more than in a coffee-shop conversation) that they would in a journal article, newspaper op-ed, or even a professional blog, and so they cannot hold the writer to the more stringent standards applicable to those forms of expression. Therefore, the admissions committee cannot legitimately grant much weight to this piece of information in evaluating Emily’s application.

Indeed, context would constrain the weight accorded to the information even if it were favorable to Emily. For example, when I applied to medical school, my peers were sure that admissions officers would conduct Internet searches on them, so they started blogging about their health care activities and posted Facebook pictures of themselves helping impoverished third-world children. Such self-conscious attempts to sway admissions officers do serve a legitimate purpose: they provide applicants with opportunities to exhibit themselves, including their diligence, conscientiousness, and forethought in anticipating admissions officers’ inquiries. But, given the potential for spin, such sources should not receive more evidential weight than conventional sources (grades, degrees, publications, recommendations, interviews), which are less susceptible to manipulation. This example exposes a tempting fallacy lurking in Jason’s and Emily’s scenario, namely that, since Jason discovered this information covertly it represents Emily’s “true,” genuine character, whereas the rest of her application is more feigned. But this inference is invalid: Facebook profiles and other Internet sources are just as (if not more) prone to manipulation or misinterpretation than conventional sources and require just as much (even more) careful attention to context. The fact that Emily’s comment was (at least) unflattering rules out the possibility that she manipulated her Facebook comment for her advantage, but other contextual features, such as its ambiguity and indeterminate significance, recommend equal caution in weighing its importance.

Since admissions officers are charged with gathering as much information as possible that is materially relevant to applicants’ professional conduct, Jason is obligated to follow up on Emily’s comment with an e-mail or phone call to ask her to clarify her remarks and to explain her reasoning. It would be rashly premature to assume that Emily’s comment was insensitive or revealed deception in her self-presentation; it would be inappropriate to grant it significant weight in evaluating her professional credentials; but it would be downright negligent to fail to follow up on in it to determine its full significance.



References

  1. Business: companies: Facebook, Inc. New York Times topics. http://topics.nytimes.com/top/news/business/companies/facebook_inc/index.html?scp=9 &sq=facebook%20privacy&st=cse. Accessed June 22, 2011.
  2. Kakutani M. Company on the verge of social breakthrough [review of The Facebook Effect by David Kirkpatrick]. New York Times. June 7, 2010. http://www.nytimes.com/2010/06/08/books/08book.html. Accessed June 22, 2011.
  3. Helft M, Wortham J. Facebook bows to pressure over privacy. New York Times. May 26, 2010. http://www.nytimes.com/2010/05/27/technology/27facebook.html. Accessed June 22, 2011.
  4. Felten E. Not an easy call. New York Times, May 25, 2010. http://roomfordebate.blogs.nytimes.com/2010/05/25/should-government-take-on-facebook/?scp=1&sq=should%20the%20government%20take%20on%20facebook&st=cse#edward. Accessed June 22, 2011.
  5. For one notorious example, see: Sarah Palin [Facebook]. http://www.facebook.com/pages/Sarah-Palin/109401155745959?ref=ts. Accessed June 22, 2011.
  6. For news coverage, including fact-checking of Facebook posts, see Holliday M. Sarah Palin turning to Facebook to spread her political views. Inside Facebook. August 18, 2009. http://www.insidefacebook.com/2009/08/18/sarah-palin-turning-to-facebook-to-spread-her-political-views/. Accessed June 22, 2011.
  7. Holan AD. PolitiFact’s Lie of the Year: “death panels.” St. Petersburg Times PolitiFact. December 18, 2009. http://politifact.com/truth-o-meter/article/2009/dec/18/politifact-lie-year-death-panels/. Accessed June 22, 2011.
  8. See, e.g., Herman C. Illegals: will they be taking jobs away from U.S. citizens?: the economics of the illegal to legal plan shouldn’t have a negative impact, say economists. ABC News. May 18, 2007. http://abcnews.go.com/Business/IndustryInfo/story?id=3189288&page=1. Accessed June 22, 2011.
  9. Sykes AO. The welfare economics of immigration law: a theoretical survey with an analysis of U.S. policy. In: Schwartz WF, ed. Justice in Immigration. Cambridge: Cambridge University Press; 1995. http://www.law.uchicago.edu/files/files/10.Sykes_.Immigration.pdf. Accessed June 22, 2011.
  10. Clark P. Velleman’s autonomism. Ethics. 2001;111(3):590-591.
  11. This distinction between “thick” and “thin” moral concepts (as opposed to a similar but fundamentally different distinction made popular by the anthropologist Clifford Geertz) was introduced by Williams B. Ethics and the Limits of Philosophy. Cambridge, MA: Harvard University Press; 1985: 128-130, 140-143, 150-152.
  12. For recent discussion, see Hurka T and Elstein DY. From thick to thin: two moral reduction plans. Canadian J Philosophy. 2009;39(4): 515-535. http://www.chass.utoronto.ca/~thurka/docs/thick_to_thin.pdf. Accessed June 22, 2011.
  13. Vayrynen P. Objectionable thick concepts in denial. Philos Perspect. 2009;23(1):439-469. http://www.personal.leeds.ac.uk/~phlpv/papers/OTCD.pdf. Accessed June 22, 2011.
  14. Putnam H. The entanglement of fact and value. The Collapse of the Fact/Value Dichotomy and Other Essays. Cambridge, MA: Harvard University Press; 2004: 28-45.
  15. Dancy J. In defense of thick concepts. Midwest Stud Philosophy. 1995;20(1):263-279.
  16. Dworkin R. Life’s Dominion. New York: Knopf; 1993: 132-144.

Christopher Langston is a medical student at the University of Massachusetts Medical School in Worcester and a PhD candidate in ethics at the University of Toronto. His doctoral work is on clarifying the concept of quality of life as it is used in medicine.

Jason’s Journal—Thoughts of an Ethically Conflicted Medical Student, July 2011

Social (Networking) Justice, July 2011

AMA Code of Medical Ethics’ Opinions on Confidentiality of Patient Information, July 2011

Anonymous Physician Blogging, July 2011

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