These case studies in ethics are adapted with permission from LW Roberts, JG Hoop: Professionalism and Ethics: Q&A Self-Study Guide for Mental Health Professionals. Arlington, VA: American Psychiatric Press, Inc., 2008, pp 120–122

A 26-year-old woman with major depression is hospitalized because she is suicidal. Three days after admission, her psychiatrist documents in the progress notes that the woman, although still depressed, is no longer suicidal. The insurance reviewer notifies the psychiatrist that the patient will need to be discharged to outpatient treatment. The woman has little support outside the hospital, and the psychiatrist does not feel that she is stable enough for discharge. The patient is struggling financially andcannot afford to pay out of pocket for continued hospitalization. Which of the following is the most ethical course of action?

• Discharge the patient as requested by the insurance reviewer and arrange for outpatient follow-up.

• Continue the hospitalization even though the patient may have to pay the bill.

• To gain insurance coverage for more hospital days, document in the medical record that the patient is again suicidal.

• Suggest that the patient call her insurance company and say that she may hurt herself if she does not have coverage for more hospital days.

• Phone the insurance reviewer to explain the need for continued hospitalization without implying that the patient is suicidal.

Psychiatrists who would never consider lying for their own benefit may nonetheless be tempted to do so on behalf of their patients. Surveys indicate that a substantial minority of physicians will alter or even falsify a diagnosis, prognosis, or recommended treatment to obtain a procedure or medication that they feel is necessary or important to a patient. Such deception is most common regarding reporting to insurance companies. Physicians may rationalize lying to insurers or managed care companies because they feel that the companies are only motivated by profits, are medically uninformed, or force physicians to practice substandard medicine.

Even if these are legitimate concerns, they do not justify falsification of records. Documenting that a patient is suicidal when she is not is a failure to honor the ethical duty of veracity, or truth telling, which requires the positive obligation to convey information and impressions accurately as well as the negative obligation not to mislead or deceive through omissions or alterations of the truth. Deceiving insurance companies may create some short-term benefit for patients (and save physicians' time by avoiding the need to make appeals), but it may also have far-reaching deleterious consequences—including the loss of the clinician's credibility, criminal charges of fraud against the clinician or the facility where he or she works, sanctions against the physician by the state medical board, or cancellation of the patient's insurance coverage. Although it may seem that a patient would be grateful for the physician's attempts to “game the system” on her behalf and that the therapeutic relationship would thereby be strengthened, it may be more likely that a patient would question the doctor's integrity and begin to mistrust his or her other decisions.

In this case, suggesting that the patient directly request further hospitalization unfairly burdens her with the physician's responsibility; encouraging her to overdramatize her symptoms is blatantly unethical. Making an appeal to the insurance company for further consideration of the patient's clinical needs and circumstances is the optimal course of action. If the request is denied, as it may well be, the physician and patient should work together to create the best treatment plan possible given the limitations (1, 2). Answer: E

A psychiatrist is treating a 21-year-old woman for complicated grief related to the death of her parents in an automobile crash. The psychiatrist lost his own parents when he was a teenager, and he identifies strongly with this patient. He often sees her after regular clinical hours and has cancelled other appointments to see her on short notice.

Which ethical pitfall is the psychiatrist in danger of committing?

• Abandonment of the therapeutic alliance.

• Breach of confidentiality.

• Divided loyalties as a dual agent.

• Erosion of professional boundaries.

• Practicing outside his scope of clinical competence.

This clinical scenario involves a patient who can be considered difficult because she resembles the clinician in a way that threatens his ability to maintain professional boundaries. The concept of difficult patients encompasses a broad spectrum, ranging from the type of patient in this vignette to patients with hostile, aggressive, or unlikable personalities who evoke strong negative reactions. The psychiatrist's habit of seeing this patient after hours and canceling other appointments to see her suggests that therapeutic boundaries are being threatened.

Abandonment of the therapeutic alliance describes a situation in which a clinician may pay less attention to a patient, subtly encourage the patient to leave treatment, or simply stop seeing the patient. Confidentiality breaches occur when clinicians share information about patients with others inappropriately. Divided loyalties as a dual agent refer to a therapist's simultaneous allegiance to more than one party. Scope of clinical competence pertains to the psychiatrist's ability to recognize his areas of expertise as well as his limitations as a treatment provider (1). Answer: D