Matt Freeman DNP, MPH
“How are things at home?” It can jumpstart a conversation about emotional health, giving the patient a chance to have control over how little or how much he or she would like to disclose. My own variation has been, “How is your mood and your stress level?” Patients often say, “the usual amount of stress.” Others become tearful. Others find an unexpected opportunity to share what is happening in their lives.
I do not know what Andreas Lubitz would have said. Perhaps he would have talked about his dashed hopes to marry Kathrin Goldbach, or his reported frustration with flying shorter fights rather than the more prestigious long-haul routes with Lufthansa. But he might have said nothing at all.
I think back to the handful of patients I have had in my career who have been commercial pilots. I even remember chatting with one of them about his mood. He was exhausted by his schedule, his pay was abysmal, and his wife was also a pilot, thereby putting a great strain on their marriage. As is the standard of care with a patient with a mood disorder, I asked, “Have you had any thoughts of hurting yourself or others?” He said no.
What if he had said yes?
The rules for breaching patient confidentiality vary by country and—in the US—by state. But there is a consistent theme: plan, means, and intent. If my own patient had been specific with his plan and time range, I would have probably been able to get him admitted to mental health facility, and—in collaboration with others—most likely able to contact the airline’s medical department.
But what if he just said, “Sure, I have thoughts of hurting myself? Sometimes I wonder what would happen if the plane I was flying crashed.” I would be asking a lot of questions at that point, probably consulted with a mental health provider, but if he expressed this in vague terms—a melancholic fantasy—it would have been inadequate to sever our private doctor/patient relationship. I could urge him to see a therapist, encourage antidepressants, invite a short-interval follow-up, discussed what actions to take if he felt increasingly suicidal or homicidal, but my powers would have ended there.
All of us fear another Germanwings 9525 or Egyptair 990, but suicides are notoriously difficult to predict. If the European or American governments suddenly required all pilots to answer the question, “Are you having thoughts of hurting yourself or others?” before flying, the answer would be “no.”
Egyptair Boeing 767-300, similar to the aircraft that crashed near Nantucket on 31 October 1999
Actively suicidal patients, particularly men, typically keep their plans closely guarded. It is not too difficult for a severely depressed patient to outfox a standardized depression inventory, even the probing questions of a therapist or primary care provider.
Although the details of Andreas Lubitz’ medical history are still blurry, he could have just said, “No, I do not feel like hurting myself or others.” There is no polygraph, “trick question,” nor blood test that would have predicted a murder-suicide. Psychologists usually have the ability to estimate behavior within a 48-hour window, but that depends on the patient disclosing a lot of information.
From media reports, Andreas Lubitz had some red flags: a previous history of a mood disorder, recent treatment, a trigger (the breakup), and reportedly erratic behavior. How many pilots, truck drivers, those whose jobs require firearms or access to explosives would meet a similar description?
Who is the client?
My first practice out of school was in occupational medicine. I often saw truck drivers, firefighters, police officers, air traffic controllers, and others who needed medical examinations for employment. In the overwhelming majority of cases, the goal was to ensure that I “rubber stamped” the paperwork.
US law requires that any medical examination be conducted post-offer. In other words, the patient had already been given the job, and it was my responsibility to ensure that there were no barriers. The medical examination did not serve to address health concerns, prevent illness, nor screen for disease. It served an administrative purpose.
Although most patients take it in stride, some view it as a marked invasion of privacy with no benefit to public safety. It is indeed awkward, unpleasant, or threatening to answer detailed health and mental health questions, disrobe, get poked and prodded, all because an employer requires it.
Regulatory bodies, like the Federal Aviation Administration and Federal Motor Carrier Safety Administration stipulate guidelines for these examinations. But healthcare providers are faced with a dilemma: if pilot, driver, firefighter, or other examinations are part of one’s livelihood, it would be dangerous to have a reputation for saying “no.” This could lead to unemployment for the patient and a vacancy for the employer.
The client for these examinations is not the patient himself or herself. The client is the employer and/or the government agency. Patients therefore lack the comfort of a private and established doctor/patient relationship. When a patient comes to see me on his or her own for routine medical examination, it is a “health-seeking behavior,” and he is or she is perhaps more likely to share more extensive thoughts about mental health, substance abuse, and other problems.
There is one further problem: patients can sometimes shop around. Pilots and drivers seeking medical certification can go to any FAA or DOT-approved healthcare provider. If the first examination does not go well for some medical reason, the pilot or driver can merely hope that the next examiner does not ask the same questions, conducts a less thorough examination, or the patient might just be a bit less truthful in his or her responses.
There is no clear flight path ahead.
Loosening confidentiality laws raises many ethical concerns. Psychological screening may be helpful but has the peril of self-disclosure: an affirmative answer to a screening question can cost one his or her livelihood.
Environmental mitigation, such as ensuring two personnel in the flight deck has the rather obvious dark side: Lubitz could have incapacitated a pilot or flight attendant seated to his left and continued to crash the plane. In the US, pilots and flight attendants do not pass through checkpoints to detect weapons in many airports since they travel through “Known Crew Member” (KCM) ID checkpoints. In fact, many pilots are Federal Flight Deck Officers (FFDOs), who are permitted to carry firearms on board.
Amid the grief and fear in the aftermath of the crash and its investigation the most salient call is one for dialogue. Ethicists, mental health professionals, occupational health providers, and primary care providers need to open a greater discussion about suicidal and homicidal behavior. Although a statistical rarity, the consequences are catastrophic. Now is the time to talk more about protecting privacy while protecting the public, ensuring access to care, and guaranteeing further research in suicidology.