Moral Time: Does Our Internal Clock Influence Moral Judgments?

Does morality depend on the time of the day? The study "The Morning Morality Effect: The Influence of Time of Day on Unethical Behavior" published in October of 2013 by Maryam Kouchaki and Isaac Smith suggested that people are more honest in the mornings, and that their ability to resist the temptation of lying and cheating wears off as the day progresses. In a series of experiments, Kouchaki and Smith found that moral awareness and self-control in their study subjects decreased in the late afternoon or early evening.  The researchers also assessed the degree of "moral disengagement", i.e. the willingness to lie or cheat without feeling much personal remorse or responsibility, by asking the study subjects to respond to questions such as "Considering the ways people grossly misrepresent themselves, it's hardly a sin to inflate your own credentials a bit" or "People shouldn't be held accountable for doing questionable things when they were just doing what an authority figure told them to do" on a scale from 1 (strongly disagree) to 7 (strongly agree). Interestingly, the subjects who strongly disagreed with such statements were the most susceptible to the morning morality effect. They were quite honest in the mornings but significantly more likely to cheat in the afternoons. On the other hand, moral disengagers, i.e. subjects who did not think that inflating credentials or following questionable orders was a big deal, were just as likely to cheat in the morning as they were in the afternoons.

Understandably, the study caused quite a bit of ruckus and became one of the most widely discussed psychology research studies in 2013, covered widely by blogs and newspapers such as the Guardian "Keep the mornings honest, the afternoons for lying and cheating" or the German Süddeutsche Zeitung "Lügen erst nach 17 Uhr" (Lying starts at 5 pm). And the findings of the study also raised important questions: Should organizations and businesses take the time of day into account when assigning tasks to employees which require high levels of moral awareness?  How can one prevent the "moral exhaustion" in the late afternoon and the concomitant rise in the willingness to cheat?  Should the time of the day be factored into punishments for unethical behavior? 

One question not addressed by Kouchaki and Smith was whether the propensity to become dishonest in the afternoons or evenings could be generalized to all subjects or whether the internal time in the subjects was also a factor. All humans have an internal body clock – the circadian clock- which runs with a period of approximately 24 hours. The circadian clock controls a wide variety of physical and mental functions such as our body temperature, the release of hormones or our levels of alertness. The internal clock can vary between individuals, but external cues such as sunlight or the social constraints of our society force our internal clocks to be synchronized to a pre-defined external time which may be quite distinct from what our internal clock would choose if it were to "run free". Free-running internal clocks of individuals can differ in terms of their period (for example 23.5 hours versus 24.4 hours) as well as the phases of when individuals would preferably engage in certain behaviors. 

Some people like to go to bed early, wake up at 5 am or 6 am on their own even without an alarm clock and they experience peak levels of alertness and energy before noon. In contrast to such "larks", there are "owls" among us who prefer to go to bed late at night, wake up at 11 am, experience their peak energy levels and alertness in the evening hours and like to stay up way past midnight. It is not always easy to determine our "chronotype" – whether we are "larks", "owls" or some intermediate thereof – because our work day often imposes its demands on our internal clocks. Schools and employers have set up the typical workday in a manner which favors "larks", with work days usually starting around 7am – 9am. In 1976, the researchers Horne and Östberg developed a Morningness-Eveningness Questionnaire to investigate what time of the day individuals would prefer to wake up, work or take a test if it was entirely up to them. They found that roughly 40% of the people they surveyed had an evening chronotype! If Kouchaki and Smith's findings that cheating and dishonesty increases in the late afternoons applies to both morning and evening chronotype folks, then the evening chronotypes ("owls") are in a bit of a pickle. Their peak performance and alertness times would overlap with their propensity to be dishonest. 

The researchers Brian Gunia, Christopher Barnes and Sunita Sah therefore decided to replicate the Kouchaki and Smith study with one major modification: They not only assessed the propensity to cheat at different times of the day, they also measured the chronotypes of the study participants. Their recent paper ""The Morality of Larks and Owls: Unethical Behavior Depends on Chronotype as Well as Time of Day" confirms that Kouchaki and Smith findings that the time of the day influences honesty, but the observed effects differ among chronotypes. After assessing the chronotypes of 142 participants (72 women, 70 men; mean age 30 years), the researchers randomly assigned them to either a morning session (7:00 to 8:30 am) or an evening session (12:00 am to 1:30 am). The participants were asked to report the outcome of a die roll; the higher the reported number, the more raffle tickets they would receive for a large prize, which served as an incentive to inflate the outcome of the roll. Since a die roll is purely random, one would expect that reported average of the die roll results would be similar across all groups if all participants were honest. 

Their findings: Morning people ("larks") tended to report higher die-roll numbers in the evening than in the morning – thus supporting the Kouchaki and Smith results- but evening people tended to report higher numbers in the morning than in the evening. This means that the morning morality effect and the idea of "moral exhaustion" towards the end of the day cannot be generalized to all. In fact, evening people ("owls") are more honest in the evenings. 

 Not so fast, say Kouchaki and Smith in a commentary published to together with the new paper by Gunia and colleagues. They applaud the new study for taking the analysis of daytime effects on cheating one step further by considering the chronotypes of the participants, but they also point out some important limitations of the newer study. Gunia and colleagues only included morning and evening people in their analysis and excluded the participants who reported an intermediate chronotype, i.e. not quite early morning "larks" and not true "owls". This is a valid criticism because newer research on chronotypes by Till Roenneberg and his colleagues at the University of Munich has shown that there is a Gaussian distribution of chronotypes. Few of us are extreme larks or extreme owls, most of us lie on a continuum. Roenneberg's approach to measuring chronotypes looks at the actual hours of sleep we get and distinguishes between our behaviors on working days and weekends because the latter may provide a better insight into our endogenous clock, unencumbered by the demands of our work schedule. The second important limitation identified by Kouchaki and Smith is that Gunia and colleagues used 12 am to 1:30 am as the "evening condition". This may be the correct time to study the peak performance of extreme owls and selected night shift workers but ascertaining cheating behavior at this hour is not necessarily relevant for the general workforce. 

Neither the study by Kouchaki and Smith nor the new study by Gunia and colleagues provide us with a definitive answer as to how the external time of the day (the time according to the sun and our social environment) and the internal time (the time according to our internal circadian clock) affect moral decision-making. We need additional studies with larger sample sizes which include a broad range of participants with varying chronotypes as well as studies which assess moral decision-making not just at two time points but also include a range of time points (early morning, afternoon, late afternoon, evening, night, etc.). But the two studies have opened up a whole new area of research and their findings are quite relevant for the field of experimental philosophy, which uses psychological methods to study philosophical questions. If empirical studies are conducted with human subjects then researchers need to take into account the time of the day and the internal time and chronotype of the participants, as well as other physiological differences between individuals. 

 The exchange between Kouchaki & Smith and Gunia & colleagues also demonstrates the strength of rigorous psychological studies. Researcher group 1 makes a highly provocative assertion based on their data, researcher group 2 partially replicates it and qualifies it by introducing one new variable (chronotypes) and researcher group 1 then analyzes strengths and weaknesses of the newer study. This type of constructive criticism and dialogue is essential for high-quality research. Hopefully, future studies will be conducted to provide more insights into this question. By using the Roenneberg approach to assess chronotypes, one could potentially assess a whole continuum of chronotypes – both on working days and weekends – and also relate moral reasoning to the amount of sleep we get. Measurements of body temperature, hormone levels, brain imaging and other biological variables may provide further insight into how the time of day affects our moral reasoning. 

 Why is this type of research important? I think that realizing how dynamic moral judgment can be is a humbling experience. It is easy to condemn the behavior of others as "immoral", "unethical" or "dishonest" as if these are absolute pronouncements. Realizing that our own judgment of what is considered ethical or acceptable can vary because of our internal clock or the external time of the day reminds us to be less judgmental and more appreciative of the complex neurobiology and physiology which influence moral decision-making. If future studies confirm that the internal time (and possibly sleep deprivation) influences moral decision-making, then we need to carefully rethink whether the status quo of forcing people with diverse chronotypes into a compulsory 9-to-5 workday is acceptable. Few, if any, employers and schools have adapted their work schedules to accommodate chronotype diversity in human society. Understanding that individualized work schedules for people with diverse chronotypes may not only increase their overall performance but also increase their honesty might serve as another incentive for employers and schools to recognize the importance of chronotype diversity among individuals. 

 References: 

 Brian C. Gunia, Christopher M. Barnes and Sunita Sah (2014) "The Morality of Larks and Owls: Unethical Behavior Depends on Chronotype as Well as Time of Day", Psychological Science (published online ahead of print on Oct 6, 2014). 

 Maryam Kouchaki and Isaac H. Smith (2014) "The Morning Morality Effect: The Influence of Time of Day on Unethical Behavior", Psychological Science 25(1) 95–102. 

Till Roenneberg, Anna Wirz-Justice and Martha Merrow. (2003) "Life between clocks: daily temporal patterns of human chronotypes." Journal of Biological Rhythms 18:1: 80-90.   

 Note: An earlier version of this article was first published on the 3Quarksdaily blog.   


Gunia, B., Barnes, C., & Sah, S. (2014). The Morality of Larks and Owls: Unethical Behavior Depends on Chronotype as Well as Time of Day Psychological Science, 25 (12), 2272-2274 DOI: 10.1177/0956797614541989

The Road to Bad Science Is Paved with Obedience and Secrecy

We often laud intellectual diversity of a scientific research group because we hope that the multitude of opinions can help point out flaws and improve the quality of research long before it is finalized and written up as a manuscript. The recent events surrounding the research in one of the world's most famous stem cell research laboratories at Harvard shows us the disastrous effects of suppressing diverse and dissenting opinions.
The infamous "Orlic paper" was a landmark research article published in the prestigious scientific journal Nature in 2001, which showed that stem cells contained in the bone marrow could be converted into functional heart cells. After a heart attack, injections of bone marrow cells reversed much of the heart attack damage by creating new heart cells and restoring heart function. It was called the "Orlic paper" because the first author of the paper was Donald Orlic, but the lead investigator of the study was Piero Anversa, a professor and highly respected scientist at New York Medical College.

#94119222 / gettyimages.com

Anversa had established himself as one of the world's leading experts on the survival and death of heart muscle cells in the 1980s and 1990s, but with the start of the new millennium, Anversa shifted his laboratory's focus towards the emerging field of stem cell biology and its role in cardiovascular regeneration. The Orlic paper was just one of several highly influential stem cell papers to come out of Anversa's lab at the onset of the new millenium. A 2002 Anversa paper in the New England Journal of Medicine – the world's most highly cited academic journal –investigated the hearts of human organ transplant recipients. This study showed that up to 10% of the cells in the transplanted heart were derived from the recipient's own body. The only conceivable explanation was that after a patient received another person's heart, the recipient's own cells began maintaining the health of the transplanted organ. The Orlic paper had shown the regenerative power of bone marrow cells in mouse hearts, but this new paper now offered the more tantalizing suggestion that even human hearts could be regenerated by circulating stem cells in their blood stream.


A 2003 publication in Cell by the Anversa group described another ground-breaking discovery, identifying a reservoir of stem cells contained within the heart itself. This latest coup de force found that the newly uncovered heart stem cell population resembled the bone marrow stem cells because both groups of cells bore the same stem cell protein called c-kit and both were able to make new heart muscle cells. According to Anversa, c-kit cells extracted from a heart could be re-injected back into a heart after a heart attack and regenerate more than half of the damaged heart!

These Anversa papers revolutionized cardiovascular research. Prior to 2001, most cardiovascular researchers believed that the cell turnover in the adult mammalian heart was minimal because soon after birth, heart cells stopped dividing. Some organs or tissues such as the skin contained stem cells which could divide and continuously give rise to new cells as needed. When skin is scraped during a fall from a bike, it only takes a few days for new skin cells to coat the area of injury and heal the wound. Unfortunately, the heart was not one of those self-regenerating organs. The number of heart cells was thought to be more or less fixed in adults. If heart cells were damaged by a heart attack, then the affected area was replaced by rigid scar tissue, not new heart muscle cells. If the area of damage was large, then the heart's pump function was severely compromised and patients developed the chronic and ultimately fatal disease known as "heart failure".

Anversa's work challenged this dogma by putting forward a bold new theory: the adult heart was highly regenerative, its regeneration was driven by c-kit stem cells, which could be isolated and used to treat injured hearts. All one had to do was harness the regenerative potential of c-kit cells in the bone marrow and the heart, and millions of patients all over the world suffering from heart failure might be cured. Not only did Anversa publish a slew of supportive papers in highly prestigious scientific journals to challenge the dogma of the quiescent heart, he also happened to publish them at a unique time in history which maximized their impact.

In the year 2001, there were few innovative treatments available to treat patients with heart failure. The standard approach was to use medications that would delay the progression of heart failure. But even the best medications could not prevent the gradual decline of heart function. Organ transplants were a cure, but transplantable hearts were rare and only a small fraction of heart failure patients would be fortunate enough to receive a new heart. Hopes for a definitive heart failure cure were buoyed when researchers isolated human embryonic stem cells in 1998. This discovery paved the way for using highly pliable embryonic stem cells to create new heart muscle cells, which might one day be used to restore the heart's pump function without  resorting to a heart transplant.

The dreams of using embryonic stem cells to regenerate human hearts were soon squashed when the Bush administration banned the generation of new human embryonic stem cells in 2001, citing ethical concerns. These federal regulations and the lobbying of religious and political groups against human embryonic stem cells were a major blow to research on cardiovascular regeneration. Amidst this looming hiatus in cardiovascular regeneration, Anversa's papers appeared and showed that one could steer clear of the ethical controversies surrounding embryonic stem cells by using an adult patient's own stem cells. The Anversa group re-energized the field of cardiovascular stem cell research and cleared the path for the first human stem cell treatments in heart disease.

Instead of having to wait for the US government to reverse its restrictive policy on human embryonic stem cells, one could now initiate clinical trials with adult stem cells, treating heart attack patients with their own cells and without having to worry about an ethical quagmire. Heart failure might soon become a disease of the past. The excitement at all major national and international cardiovascular conferences was palpable whenever the Anversa group, their collaborators or other scientists working on bone marrow and cardiac stem cells presented their dizzyingly successful results. Anversa received numerous accolades for his discoveries and research grants from the NIH (National Institutes of Health) to further develop his research program. He was so successful that some researchers believed Anversa might receive the Nobel Prize for his iconoclastic work which had redefined the regenerative potential of the heart. Many of the world's top universities were vying to recruit Anversa and his group, and he decided to relocate his research group to Harvard Medical School and Brigham and Women's Hospital 2008.

There were naysayers and skeptics who had resisted the adult stem cell euphoria. Some researchers had spent decades studying the heart and found little to no evidence for regeneration in the adult heart. They were having difficulties reconciling their own results with those of the Anversa group. A number of practicing cardiologists who treated heart failure patients were also skeptical because they did not see the near-miraculous regenerative power of the heart in their patients. One Anversa paper went as far as suggesting that the whole heart would completely regenerate itself roughly every 8-9 years, a claim that was at odds with the clinical experience of practicing cardiologists.  Other researchers pointed out serious flaws in the Anversa papers. For example, the 2002 paper on stem cells in human heart transplant patients claimed that the hearts were coated with the recipient's regenerative cells, including cells which contained the stem cell marker Sca-1. Within days of the paper's publication, many researchers were puzzled by this finding because Sca-1 was a marker of mouse and rat cells – not human cells! If Anversa's group was finding rat or mouse proteins in human hearts, it was most likely due to an artifact. And if they had mistakenly found rodent cells in human hearts, so these critics surmised, perhaps other aspects of Anversa's research were similarly flawed or riddled with artifacts.

At national and international meetings, one could observe heated debates between members of the Anversa camp and their critics. The critics then decided to change their tactics. Instead of just debating Anversa and commenting about errors in the Anversa papers, they invested substantial funds and efforts to replicate Anversa's findings. One of the most important and rigorous attempts to assess the validity of the Orlic paper was published in 2004, by the research teams of Chuck Murry and Loren Field. Murry and Field found no evidence of bone marrow cells converting into heart muscle cells. This was a major scientific blow to the burgeoning adult stem cell movement, but even this paper could not deter the bone marrow cell champions.

Despite the fact that the refutation of the Orlic paper was published in 2004, the Orlic paper continues to carry the dubious distinction of being one of the most cited papers in the history of stem cell research. At first, Anversa and his colleagues would shrug off their critics' findings or publish refutations of refutations – but over time, an increasing number of research groups all over the world began to realize that many of the central tenets of Anversa's work could not be replicated and the number of critics and skeptics increased. As the signs of irreplicability and other concerns about Anversa's work mounted, Harvard and Brigham and Women's Hospital were forced to initiate an internal investigation which resulted in the retraction of one Anversa paper and an expression of concern about another major paper. Finally, a research group published a paper in May 2014 using mice in which c-kit cells were genetically labeled so that one could track their fate and found that c-kit cells have a minimal – if any – contribution to the formation of new heart cells: a fraction of a percent!

The skeptics who had doubted Anversa's claims all along may now feel vindicated, but this is not the time to gloat. Instead, the discipline of cardiovascular stem cell biology is now undergoing a process of soul-searching. How was it possible that some of the most widely read and cited papers were based on heavily flawed observations and assumptions? Why did it take more than a decade since the first refutation was published in 2004 for scientists to finally accept that the near-magical regenerative power of the heart turned out to be a pipe dream.

One reason for this lag time is pretty straightforward: It takes a tremendous amount of time to refute papers. Funding to conduct the experiments is difficult to obtain because grant funding agencies are not easily convinced to invest in studies replicating existing research. For a refutation to be accepted by the scientific community, it has to be at least as rigorous as the original, but in practice, refutations are subject to even greater scrutiny. Scientists trying to disprove another group's claim may be asked to develop even better research tools and technologies so that their results can be seen as more definitive than those of the original group. Instead of relying on antibodies to identify c-kit cells, the 2014 refutation developed a transgenic mouse in which all c-kit cells could be genetically traced to yield more definitive results - but developing new models and tools can take years.

The scientific peer review process by external researchers is a central pillar of the quality control process in modern scientific research, but one has to be cognizant of its limitations. Peer review of a scientific manuscript is routinely performed by experts for all the major academic journals which publish original scientific results. However, peer review only involves a "review", i.e. a general evaluation of major strengths and flaws, and peer reviewers do not see the original raw data nor are they provided with the resources to replicate the studies and confirm the veracity of the submitted results. Peer reviewers rely on the honor system, assuming that the scientists are submitting accurate representations of their data and that the data has been thoroughly scrutinized and critiqued by all the involved researchers before it is even submitted to a journal for publication. If peer reviewers were asked to actually wade through all the original data generated by the scientists and even perform confirmatory studies, then the peer review of every single manuscript could take years and one would have to find the money to pay for the replication or confirmation experiments conducted by peer reviewers. Publication of experiments would come to a grinding halt because thousands of manuscripts would be stuck in the purgatory of peer review. Relying on the integrity of the scientists submitting the data and their internal review processes may seem naïve, but it has always been the bedrock of scientific peer review. And it is precisely the internal review process which may have gone awry in the Anversa group.

Pygmalion and Glatea by Louis Gauffier (via Wikimedia - Public Domain)

Just like Pygmalion fell in love with Galatea, researchers fall in love with the hypotheses and theories that they have constructed. To minimize the effects of these personal biases, scientists regularly present their results to colleagues within their own groups at internal lab meetings and seminars or at external institutions and conferences long before they submit their data to a peer-reviewed journal. The preliminary presentations are intended to spark discussions, inviting the audience to challenge the veracity of the hypotheses and the data while the work is still in progress. Sometimes fellow group members are truly skeptical of the results, at other times they take on the devil's advocate role to see if they can find holes in their group's own research. The larger a group, the greater the chance that one will find colleagues within a group with dissenting views. This type of feedback is a necessary internal review process which provides valuable insights that can steer the direction of the research.
Considering the size of the Anversa group – consisting of 20, 30 or even more PhD students, postdoctoral fellows and senior scientists – it is puzzling why the discussions among the group members did not already internally challenge their hypotheses and findings, especially in light of the fact that they knew extramural scientists were having difficulties replicating the work.
Retraction Watch is one of the most widely read scientific watchdogs which tracks scientific misconduct and retractions of published scientific papers. Recently, Retraction Watch published the account of an anonymous whistleblower who had worked as a research fellow in Anversa's group and provided some unprecedented insights into the inner workings of the group, which explain why the internal review process had failed:

"I think that most scientists, perhaps with the exception of the most lucky or most dishonest, have personal experience with failure in science—experiments that are unreproducible, hypotheses that are fundamentally incorrect. Generally, we sigh, we alter hypotheses, we develop new methods, we move on. It is the data that should guide the science.
 In the Anversa group, a model with much less intellectual flexibility was applied. The "Hypothesis" was that c-kit (cd117) positive cells in the heart (or bone marrow if you read their earlier studies) were cardiac progenitors that could: 1) repair a scarred heart post-myocardial infarction, and: 2) supply the cells necessary for cardiomyocyte turnover in the normal heart.
 This central theme was that which supplied the lab with upwards of $50 million worth of public funding over a decade, a number which would be much higher if one considers collaborating labs that worked on related subjects.
 In theory, this hypothesis would be elegant in its simplicity and amenable to testing in current model systems. In practice, all data that did not point to the "truth" of the hypothesis were considered wrong, and experiments which would definitively show if this hypothesis was incorrect were never performed (lineage tracing e.g.)."

Discarding data that might have challenged the central hypothesis appears to have been a central principle.


According to the whistleblower, Anversa's group did not just discard undesirable data, they actually punished group members who would question the group's hypotheses:

"In essence, to Dr. Anversa all investigators who questioned the hypothesis were "morons," a word he used frequently at lab meetings. For one within the group to dare question the central hypothesis, or the methods used to support it, was a quick ticket to dismissal from your position."

The group also created an environment of strict information hierarchy and secrecy which is antithetical to the spirit of science:

"The day to day operation of the lab was conducted under a severe information embargo. The lab had Piero Anversa at the head with group leaders Annarosa Leri, Jan Kajstura and Marcello Rota immediately supervising experimentation. Below that was a group of around 25 instructors, research fellows, graduate students and technicians. Information flowed one way, which was up, and conversation between working groups was generally discouraged and often forbidden.
 Raw data left one's hands, went to the immediate superior (one of the three named above) and the next time it was seen would be in a manuscript or grant. What happened to that data in the intervening period is unclear.
 A side effect of this information embargo was the limitation of the average worker to determine what was really going on in a research project. It would also effectively limit the ability of an average worker to make allegations regarding specific data/experiments, a requirement for a formal investigation."

This segregation of information is a powerful method to maintain an authoritarian rule and is more typical for terrorist cells or intelligence agencies than for a scientific lab, but it would definitely explain how the Anversa group was able to mass produce numerous irreproducible papers without any major dissent from within the group.
In addition to the secrecy and segregation of information, the group also created an atmosphere of fear to ensure obedience:

"Although individually-tailored stated and unstated threats were present for lab members, the plight of many of us who were international fellows was especially harrowing. Many were technically and educationally underqualified compared to what might be considered average research fellows in the United States. Many also originated in Italy where Dr. Anversa continues to wield considerable influence over biomedical research.
 This combination of being undesirable to many other labs should they leave their position due to lack of experience/training, dependent upon employment for U.S. visa status, and under constant threat of career suicide in your home country should you leave, was enough to make many people play along.
 Even so, I witnessed several people question the findings during their time in the lab. These people and working groups were subsequently fired or resigned. I would like to note that this lab is not unique in this type of exploitative practice, but that does not make it ethically sound and certainly does not create an environment for creative, collaborative, or honest science."

Foreign researchers are particularly dependent on their employment to maintain their visa status and the prospect of being fired from one's job can be terrifying for anyone.
This is an anonymous account of a whistleblower and as such, it is problematic. The use of anonymous sources in science journalism could open the doors for all sorts of unfounded and malicious accusations, which is why the ethics of using anonymous sources was heavily debated at the recent ScienceOnline conference. But the claims of the whistleblower are not made in a vacuum – they have to be evaluated in the context of known facts. The whistleblower's claim that the Anversa group and their collaborators received more than $50 million to study bone marrow cell and c-kit cell regeneration of the heart can be easily verified at the public NIH grant funding RePORTer website. The whistleblower's claim that many of the Anversa group's findings could not be replicated is also a verifiable fact. It may seem unfair to condemn Anversa and his group for creating an atmosphere of secrecy and obedience which undermined the scientific enterprise, caused torment among trainees and wasted millions of dollars of tax payer money simply based on one whistleblower's account. However, if one looks at the entire picture of the amazing rise and decline of the Anversa group's foray into cardiac regeneration, then the whistleblower's description of the atmosphere of secrecy and hierarchy seems very plausible.

The investigation of Harvard into the Anversa group is not open to the public and therefore it is difficult to know whether the university is primarily investigating scientific errors or whether it is also looking into such claims of egregious scientific misconduct and abuse of scientific trainees. It is unlikely that Anversa's group is the only group that might have engaged in such forms of misconduct. Threatening dissenting junior researchers with a loss of employment or visa status may be far more common than we think. The gravity of the problem requires that the NIH – the major funding agency for biomedical research in the US – should look into the prevalence of such practices in research labs and develop safeguards to prevent the abuse of science and scientists.

Should Doctors ‘Google’ Their Patients?

Beware of what you share. Employers now routinely utilize internet search engines or social network searches to obtain information about job applicants. A survey of 2,184 hiring managers and human resource professionals conducted by the online employment website CareerBuilder.com revealed that 39% use social networking sites to research job candidates. Of the group who used social networks to evaluate job applicants, 43% found content on a social networking site that caused them to not hire a candidate, whereas only 19% found information that that has caused them to hire a candidate.

The top reasons for rejecting a candidate based on information gleaned from social networking sites were provocative or inappropriate photos/information, including information about the job applicants' history of substance abuse. This should not come as a surprise to job applicants in the US. After all, it is not uncommon for employers to invade the privacy of job applicants by conducting extensive background searches, ranging from the applicant's employment history and credit rating to checking up on any history of lawsuits or run-ins with law enforcement agencies. Some employers also require drug testing of job applicants. The internet and social networking websites merely offer employers an additional array of tools to scrutinize their applicants. But how do we feel about digital sleuthing when it comes to relationship that is very different than the employer-applicant relationship – one which is characterized by profound trust, intimacy and respect, such as the relationship between healthcare providers and their patients?


The Hastings Center Report is a peer-reviewed academic bioethics journal which discusses the ethics of "Googling a Patient" in its most recent issue. It first describes a specific case of a twenty-six year old patient who sees a surgeon and requests a prophylactic mastectomy of both breasts. She says that she does not have breast cancer yet, but that her family is at very high risk for cancer. Her mother, sister, aunts, and a cousin have all had breast cancer; a teenage cousin had ovarian cancer at the age of nineteen; and that her brother was treated for esophageal cancer at the age of fifteen. She also says that she herself has suffered from a form of skin cancer (melanoma) at the age of twenty-five and that she wants to undergo the removal of her breasts without further workup because she wants to avoid developing breast cancer. She says that her prior mammogram had already shown abnormalities and she had been told by another surgeon that she needed the mastectomy.

Such prophylactic mastectomies, i.e. removal of both breasts, are indeed performed if young women are considered to be at very high risk for breast cancer based on their genetic profile and family history. The patient's family history – her mother, sister and aunts being diagnosed with breast cancer – are indicative of a very high risk, but other aspects of the history such as her brother developing esophageal cancer at the age of fifteen are rather unusual. The surgeon confers with the patient's primary care physician prior to performing the mastectomy and is puzzled by the fact that the primary care physician cannot confirm many of the claims made by the patient regarding her prior medical history or her family history. The physicians find no evidence of the patient ever having been diagnosed with a melanoma and they also cannot find documentation of the prior workup. The surgeon then asks a genetic counselor to meet with the patient and help resolve the discrepancies. During the evaluation process, the genetic counselor decides to ‘google' the patient.


The genetic counselor finds two Facebook pages that are linked to the patient. One page appears to be a personal profile of the patient, stating that in addition to battling stage four melanoma (a very advanced stage of skin cancer with very low survival rates), she has recently been diagnosed with breast cancer. She also provides a link to a website soliciting donations to attend a summit for young cancer patients. The other Facebook page shows multiple pictures of the patient with a bald head, suggesting that she is undergoing chemotherapy, which is obviously not true according to what the genetic counselor and the surgeon have observed. Once this information is forwarded to the surgeon, he decides to cancel the planned surgery. It is not clear why the patient was intent on having the mastectomy and what she would gain from it, but the obtained information from the Facebook pages and the previously noted discrepancies are reason enough for the surgeon to rebuff the patient's request for the surgery.

Two groups of biomedical ethics experts then weigh in on the case and the broader question of whether or not health care professionals should ‘google' patients. The first group of ethics experts feels that uninvited patient ‘googling' is generally a bad practice for three main reasons:

1. It allows healthcare professionals to withdraw from their patients and start relying on online data and information gleaned from social networking sites instead of interacting with the patient and addressing the key issues head-on.
2. The ‘googling' of patients erodes the trust between the healthcare professional and the patient. Patients might feel a sense of betrayal that the healthcare professional "spied" on them.
3. An internet search or review or social network pages linked to the patient represents an invasion of the privacy of the patient. The patient should have the right to decide what information to disclose and what not to disclose, but by surreptitiously obtaining this information, the healthcare provide circumvents the right to privacy of the patient.

A separate panel of reviewers arrives at a very different conclusion and specifically points to this case as an example where it was imperative to ‘google' the patient. As this panel points out, the genetic counselor used a legal method to search the internet and found information on public Facebook profiles after having found many red flags and inconsistencies in the patient's medical history. By finding the information on Facebook, the surgeon and the counselor were able to prevent a self-injurious, deceptive and possibly fraudulent scheme of the patient to go forward. This panel of experts goes as far as saying that it would have actually been irresponsible to not perform the Google search after all the red flags and inconsistencies were identified.
As with all ethical dilemmas, it is difficult to find the correct answer. The first panel brings up good points that the relationship between a healthcare professional and a patient is characterized by trust and respect of privacy, but I tend to agree with the second panel in the case of this patient. It illustrates that the ‘googling' was able to avert an unnecessary and irreversible surgery. This was not just an indiscriminate ‘googling' or searching of private information on Facebook pages. The action was prompted by very real concerns about contradictory information regarding the patient's medical history. On balance, the benefit of avoiding the unnecessary surgery probably outweighed the risk of harming the trust between the healthcare professional and the patient – one which was already undermined by the patient's deception.

This case is rather unusual because it is probably quite rare that a surgeon or a genetic counselor would find valuable information on a patient by merely searching Google or Facebook for information. The type of information that could be of value to most healthcare providers is not usually disclosed on public sites or social network pages. For example, a cardiologist may be interested in finding out why a patient's cholesterol levels are not decreasing despite being placed on optimal medications and being advised to cut down the dietary intake of cholesterol. The cardiologist may suspect that the patient is not really taking the medications or perhaps eating much more dietary cholesterol than the patient is willing to disclose during the doctor's visits. However, it is unlikely that the patient's Facebook page will chronicle whether or not the patient secretly eats cheese omelets on a daily basis or chooses not to take his cholesterol medications.

On the other hand, other healthcare professionals could find important diagnostic clues when reviewing the Facebook page of a patient. Psychiatrists or psychologists may be able to get a much better sense of a patient's mental health and functioning by reviewing the daily posts and interactions of a patient with friends and family members instead of just having to rely on the brief snapshot when they interview the patient during a 30 minute visit.

The study ""To Google or not to Google: Graduate students' use of the Internet to access personal information about clients." by the psychologists DeLillo and Gale surveyed 854 students enrolled in clinical, counseling, and school psychology doctoral programs in the United States and Canada, asking them how they felt about using Google or social networking websites to learn more about their clients/patients. Interestingly, two-thirds of the psychologists-in-training felt that it was never acceptable or usually not acceptable to use web search engines in order to find additional information about their clients. This feeling was even more pronounced when it came to social networking sites: 76.8% of the students thought that this was never acceptable or usually not acceptable.

However, despite these feelings, 97.8% of the students had searched for at least one client's information using search engines such as Google, whereas 94.4% had searched for at least one client's information using social networking websites. Importantly, 76.8% of the therapists who had conducted the searches for client information on social networking sites also reported that it was either always or usually unacceptable! This suggests a significant dissonance between the ethical perception of the therapists and their actions. Furthermore, more than 80% of the therapists who had conducted the searches said that their clients were aware of the internet and social networking searches they were conducting.

The case study with the patient requesting the mastectomy and the high prevalence of using the internet to perform searches on patients/clients by psychologists highlights the ethical dilemmas that are emerging in our culture of digital sharedom. The internet with its often very public display of individual information may be a powerful tool for certain healthcare professionals, but we also need to develop ethical guidelines for how healthcare professionals should use this tool. For medical procedures and tests, healthcare professionals have to obtain informed consent from their patients, discussing the risks and benefits of the procedure or test. Should healthcare professionals also obtain informed consent from patients before they pry into their social media networks? Or would that defeat the purpose because the patients might change the privacy settings or change the content of their posts, knowing that healthcare professionals might be reviewing them? Should healthcare professionals in specialties such as psychology and psychiatry ‘google' all their patients – just like they now ask questions about substance abuse to all patients – or only if there are certain red flags?

The survey of psychologists-in-training highlights the cognitive dissonance that healthcare professionals may experience: They may reject such searches on their clients or patients in the abstract, but they may still choose to perform the searches, probably because they think it will allow them to provide better care for their clients and patient. Instead of relying of idiosyncratic decisions made by professionals, we have to establish the ethical ground-rules for how healthcare professionals can use search engines or social networking sites when obtaining information about individuals. We may have become so accustomed to invasions of our privacy by government agencies and corporations that we sometimes forget that privacy is instrumental in maintaining our individuality. Especially in relationships that are founded on an extraordinary degree of trust, such as those between healthcare professionals and their patients or clients, we need to ensure that this trust is not eroded by the dark side of sharedom.

Acknowledgements: I would like to thank Ryan Hunt from CareerBuilder for clarifying the survey results. An earlier version of this article was first published on  the 3Quarksdaily blog.

References:

1. Rebecca Volpe, George Blackall, and Michael Green; and Danny George, Maria Baker, and Gordon Kauffman, "Googling a Patient" Hastings Center Report 43, no. 5 (2013): 14-15.
2. DiLillo, David; Gale, Emily B. "To Google or not to Google: Graduate students' use of the Internet to access personal information about clients."Training and Education in Professional Psychology, Vol 5(3), Aug 2011, 160-166. doi: 10.1037/a0024441

Volpe R, Blackall G, & Green M (2013). Case study. Googling a patient. Commentary. The Hastings Center report, 43 (5), 14-5 PMID: 24092585





  DiLillo, D., & Gale, E. (2011). To Google or not to Google: Graduate students' use of the Internet to access personal information about clients. Training and Education in Professional Psychology, 5 (3), 160-166 DOI: 10.1037/a0024441

Four Year Old Boy Is Suspended From Pre-School For Plagiarism

SEPTEMBER 2, 2012 CHICAGO, IL – The Wisdom Truth Fortitude (WTF) Academy is the nation’s best elite pre-school. For an annual tuition of $57,000, three-year old child prodigies can enroll in the WTF Academy if they can pass a highly competitive entrance examination. When the WTF students graduate two years later, most of them have acquired the cognitive maturity that is normally found in middle school students. WTF Academy proudly advertises that 87% of its graduates ultimately end up going to an Ivy League college, and over half of these are accepted into these colleges before they become teenagers. This past week WTF Academy made headlines when it suspended the four-year old student Axel Foley for plagiarism.

Principal Edward Rooney made the decision after a plagiarism committee reviewed Axel’s work during the preceding year. The committee found numerous examples of misconduct, including recycling parts of an essay he had written when he was three years old and fabricating quotes of fellow students when he covered a bake sale for the pre-school newspaper. However, the most blatant case of Axel’s plagiarism was identified by his “Introduction to Postmodern Analysis” class teacher Ms. Derrida, who was grading a short story that Axel wrote. Ms. Derrida noticed that Axel used the phrase "You are made out of cardboard boxes, you must have a story to tell." Ms. Derrida knew that she had heard this phrase before, but could not remember where. “When I showed our standard anti-plagiarism video ‘Plagiarism in the Elementary Classroom’ to the incoming class of students, I finally realized what Axel had done”, Ms. Derrida explained. Apparently, Axel used the last line of that video for his short story. “Plagiarizing an anti-plagiarism video is one of the most egregious crimes that one can imagine”, Mr. Rooney stated at a press conference, “this is why we decided to immediately suspend Axel from WTF.”

Plagiarism has received a lot of press recently in light of the Jonah Lehrer controversy, the Harvard cheating ring and the fact that the German defense minister Guttenberg had to resign because large portions of his doctoral thesis were plagiarized. After Axel’s suspension and these other scandals, elite pre-schools all over the country are currently assembling plagiarism committees to review the work of the pre-schoolers. When we asked Axel for a comment, he responded with the words “If you copy from one author, it's plagiarism. If you copy from two, it's research.” 

The Desire to Regulate Desires

From Wikimedia Commons 

The lawyer and journalist Eric Berkowitz has written an excellent book entitled "Sex and Punishment: Four Thousand Years of Judging Desire" on how humanity devotes an extraordinary amount of time and effort to regulate human sexuality. 

Sara Wheeler has reviewed the book for the "Literary Review" and she points out:

What all this amounts to, in most of the human cultures that have ever existed, is the male fear of and wish to subjugate women.  

  

Continue reading Sara Wheeler's review here.

An excerpt of Berkowitz' book can be found on the Boing Boing website.