Physician-initiated video calls are irreplaceable tools for showing surrogates important aspects of a patient’s condition. But they also raise ethical concerns about manipulation.

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Following are highlights from an article published in the AMA Journal of Ethics® (@JournalofEthics) by Laura Kolbe, MD, MPhil, assistant professor of medicine and assistant clinical ethicist at New York-Presbyterian/Weill Cornell Medical Center. The article was co-authored by Ryan H. Nelson, PhD, Joelle Robertson-Preidler, PhD, Olivia Schuman, PhD, and Inmaculada de Melo-Martín, PhD, MS.

Using the hypothetical case of an 80-year-old woman hospitalized with sepsis whose family has not been able to see her in person because of COVID-19 restrictions, the authors explored how physician-initiated video calls can help surrogates work through the difficulty of decision-making but also unduly influence their perceptions.

In the case, the woman’s attending physician believes a switch to comfort care is warranted, and has directed the team to “change her family’s mind” in that direction by doing more video calls with the family when the patient “appears uncomfortable or distressed.”

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It is increasingly common for patients and their surrogates to interface with clinical teams over video, not just because of COVID-19 but also because of growing acceptance of technology.

“When clinicians are the ones who are setting up these interactions,” specifically when they’re arranging for surrogates to view a loved one so they can come to a specific decision regarding goals of care, “those moments are not ethically neutral,” Dr. Kolbe said in an accompanying author interview.

Informed consent is the primary means of respecting autonomy in clinical medicine. It requires freedom of choice. Still, good decision-making often depends on others’ input.

“While coercion undermines autonomous decision-making and rational persuasion is compatible with it, a range exists between these extremes involving varying degrees of manipulation,” the authors wrote. “Generally speaking, A manipulates B when A intentionally subverts B’s rational capacity by employing trickery, deception, pressure or a similar tactic to get B to do what A wants.”

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The authors laid out this advice for physicians to avoid manipulation when using video calls for surrogate decision-making.

Normalization. Standardize the use of video calls so they provide many of the same benefits as in-person visitation. Use them on a regular basis in ethically uncomplicated situations.

Process. Look to inform rather than to influence a decision, and focus on informed decision-making rather than achieving a particular outcome. 

Patient assent. Obtain patient assent when possible. Also, respect patients’ wishes about displaying their bodies, particular wounds and other bodily areas.

Transparency. Be open about the purpose of showing certain features of the body, as well as about the salience and affective impact of bodily imagery. Note that seeing a loved one in a state of illness or suffering can be an intense experience and weigh heavily on surrogates’ minds.

Substituted judgment. Explain how viewing the patient’s body can promote the patient’s preference for surrogacy. 

Selectivity and framing. Reflect on the selective use and the framing of video visits, including their choice of narrative detail and the compositional arrangement of the images of the body.

The bottom line is physicians and hospitals should make sure their ethical standards for video calls conform with those for in-person visits.

“It’s all too easy for clinicians to use selective framing and to take advantage of the particular affective salience of seeing the body of a loved one in order to nudge the decisions that surrogates make,” Dr. Kolbe said. “Clinicians should primarily be using the video calls to inform rather than influence a decision.”

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