Because of this special nature of mental disorders, psychiatrists, in their efforts to prevent and alleviate mental suffering, assume a role of unusual significance in their patients’ lives and in society. Even more than other physicians, psychiatrists may be called on to use their own values, life experiences, communication abilities, and human relatedness as well as their clinical knowledge and judgment to help their patients. Psychiatrists bring into play their interpersonal skills to transform the feelings, ideas, and relationships of people living with mental illness. They often explore highly sensitive personal information and confront very difficult, disturbing issues of great consequence to their patients. They may be called on to prescribe medicines that change the content and process of an individual’s thoughts. Psychiatrists may be required to administer medications against the wishes of an acutely distressed person. While controversial, psychiatrists are called on—and, in many situations, are required by law—to restrict the liberties of a seriously, unstably ill person in order to keep him or her safe or to protect others in the community.
All of these therapeutic activities certainly involve the appropriate use of expertise. More important, from the perspective of ethics, these therapeutic activities entail the disciplined use of interpersonal, institutional, and societal power in an effort to bring about benefit and prevent harm. It is for this reason that caring for persons living with mental illness must also be accompanied by extraordinary ethical commitment.
Several philosophical bioethics principles underlie ethical practices in caring for persons with mental illness (Table 1T1) (1, 3—8). Altruism in the context of health care is the commitment of service to benefit others, even at the cost of personal sacrifice. Respect for persons represents the clinician’s ethical obligation to regard the ill individual fully, genuinely, intrinsically. In this sense, the ill individual’s life history; personal, cultural, and spiritual values; preferences; and dignity should all be acknowledged for their inherent importance. Respect for autonomy is the idea that clinicians have the obligation to honor the ill individual’s right to determine what happens to his or her body and mind, that is, the individual’s self-governance.
Beneficence is the obligation to seek to help patients by relieving their suffering and by finding ways to enhance their quality of life. Nonmaleficence is the ethical duty to avoid harm. Clinical competence and scope of practice are closely related to these bioethics principles; they reflect the commitment to apply specialized expertise in the care of the patient, seeking benefit and not stepping outside of one’s scope of knowledge and skill so that the potential for harm is minimized. The principle of fidelity is the commitment of the clinician to serve the well-being of the patient "faithfully," placing the interests of the patient above personal gain. Integrity conveys the sense of consistently honorable conduct and adherence to the values of the profession. Confidentiality relates to the duty to protect a patient’s information, whether it is learned through disclosure, discovery, or observation in the course of a patient’s care. Veracity is the duty to be honest—to tell the truth and not mislead through acts of commission or omission. At the societal level, justice is the principle of fair and equitable distribution of health care resources and of nondiscrimination. Respect for the law is the obligation to abide by laws, state and federal regulations, and other such rules of society.
These abstract bioethics principles find expression in everyday clinical practices and safeguards (3—5, 9—11). Informed consent is perhaps the most widely recognized ethical safeguard in clinical care and research (9, 11). Similarly, the ethical and legal safeguards surrounding involuntary treatment are paramount in psychiatric care (4). Another example is the practice of having release-of-information forms signed to document that permission has been obtained when disclosing personal health data to outside entities, such as insurance companies and family members. In psychotherapy, careful adherence to clear, predictable therapeutic boundaries in the therapist-client relationship represents an exceptionally important ethical safeguard (12—14). Documentation of potential conflicts of interest, particularly in research situations, is an additional protection that has grown in importance in recent years. The Tarasoff duty-to-warn and duty-to-protect protections represent other concrete practices in which bioethics principles are translated to clinical settings.
Skills that may help psychiatrists approach and resolve ethical dilemmas in the care of people living with mental illness are briefly outlined here (Table 2T2) (1, 5, 10, 15). The first ethical skill is the ability to recognize ethically important aspects of a patient’s care. Doing so involves sensitivity to the conflicts and tensions that might exist in the situation, for example, in balancing the patient’s preference to live independently when the ability to maintain self-care habits is compromised by illness. The sidebar on the facing page, "Case Illustrations and Relevant Ethical Principles," presents several case examples related to this skill domain. Optimally, mastery of this skill involves ethical awareness and sensitivity as well as a working knowledge of the nomenclature and fundamental concepts of the fields of bioethics, clinical ethics, and, to some extent, forensic psychiatry.
The second skill pertains to the psychiatrist’s ability to evaluate his or her involvement, understanding, and potential sources of bias in the patient care situation. This capacity for self-observation and self-critique is a crucial ethical strength that psychiatrists, who are specifically trained in this skill, can bring to ethical patient care practices. It should help minimize the potential for harm to patients, including, for instance, in preventing boundary transgressions in psychotherapy. This second skill is directly linked to the third and fourth skills. The third is the clinician’s capacity to recognize his or her psychological discomfort and to see it as an important signal of potential ethical issues or problems in the care of the patient. The fourth is the ability to identify one’s areas of clinical expertise and to work within this scope, except under unusual circumstances. The feeling of "being in over one’s head" is a vital cue, ethically as well as clinically. A less seasoned or less sophisticated clinician might react to this feeling negatively or defensively rather than seeing it as an invaluable indicator that can help the clinician steer clear of serious ethical binds or poor clinical decisions.
Another critically important clinical ethics skill is to know when external resources are necessary to provide competent, ethical care to a patient. This skill involves the ability to gather additional information or additional expertise, including the appropriate use of supervisors and consultants (e.g., clinical or ethical specialists) to clarify ethical choices. This skill may be especially important in dealing, for instance, with suicidal patients, sexually traumatized persons, people with personality disorders, or persons with extensive addiction issues or a legal history; these patients may have multiple problems, and their psychological and interpersonal patterns may introduce complex ethical tensions in the therapeutic relationship.
The expansion of valuable resources related to ethics and psychiatry in recent years has been impressive. Codes of ethics, policy documents, and other aids have been created, and the central code endorsed by the field of psychiatry is that of the American Medical Association regarding professional physician conduct (Table 3T3). A large body of empirically derived information has been developed in diverse areas, such as informed consent and decisional capacity in serious mental illness and forensic and clinical issues in end-of-life care (16—20). Excellent policy guidelines, textbooks, and resource documents also have been generated through the diligent efforts of experts and mental health advocates (8, 21—23). Becoming familiar with the resources that can be brought to bear on mental health ethics dilemmas may be extremely helpful to psychiatric practitioners.
Another key skill is the ability to perform rigorous, defensible ethical problem solving. For some practitioners, this may involve learning how to apply a formal ethical decision-making model to help analyze and choose a sound course of action in ethically complex circumstances (3, 24). The most widely studied bioethics model, developed by Beauchamp and Childress (15), emphasizes the cardinal ethics principles of beneficence, autonomy, nonmaleficence, and justice. In this approach, discerning how these principles relate to and inform a patient’s care brings about greater conceptual clarity, which in turn helps in determining an appropriate course of action. Similarly, Hundert (24) has proposed a strategy in which latent conflicting values are identified and are resolved through explicit prioritization and clarification.
Sidebar: Case Illustrations and Relevant Ethical PrinciplesFN1
Note that all of these cases present interesting issues with regard to the stringency of standards for informed consent or refusal of treatment.These cases were prepared by the author with assistance from Cynthia M. A. Geppert, M.D., Ph.D.
The mother of a 44-year-old man with active alcohol dependence and significant depressive symptoms wishes to speak with his treating psychiatrist. The patient has not given permission for the psychiatrist to reveal information to his family, although it is acknowledged that he is receiving mental health treatment. The clinic receptionist relays that the mother is very distraught and claims that it’s a "matter of life or death." The psychiatrist calls the patient at home and finds that he is very irritable and dysphoric. He nevertheless agrees to permit the psychiatrist to talk with his mother. "You can listen," the patient says, "but don’t say anything to her about me." The patient is asked to come to the clinic, and he does, accompanied by his mother.
Examples of relevant principles: Respect for the patient’s confidentiality, nonmaleficence, respect for the law
A 34-year-old woman diagnosed with obsessive-compulsive disorder is provided information about different treatment approaches. She prefers not to use any medications. She requests psychotherapy alone rather than medication alone or combination therapy. The psychiatrist and the patient together develop a treatment plan involving an initial 6-month period of psychotherapy, with clear goals and criteria for moving toward the introduction of medications.
Examples of relevant principles: Respect for autonomy, beneficence
A 52-year-old man with long-standing bipolar illness has recently been admitted involuntarily after violently threatening his wife and physically damaging his home. He is offered medications that help him sleep, but he declines mood-stabilizing agents.
Examples of relevant principles: Beneficence, nonmaleficence, respect for the law, respect for autonomy
An 18-year-old college student with a serious eating disorder is treated successfully with antidepressant medication. She requests that her psychiatrist double her prescribed dose so that she can avoid an additional copayment every other month, making her medications last longer. She requests this because her financial resources are limited.
Examples of relevant principles: Veracity, nonmaleficence, justice, respect for the law
An elderly man who has lived in a remote area for his entire life is brought to the mental health clinic by a nephew. The elder has lost more than 20 pounds and does not appear to be taking care of himself well. On evaluation, he is cooperative and is found to be depressed. The psychiatrist believes that the patient needs a thorough physical workup. The elder adamantly refuses admission to the hospital in a nearby city.
Jonsen and colleagues have outlined a clinical ethics decision-making strategy that focuses on the ethical principles of fidelity, beneficence, clinical competence, and nonmaleficence (3). Analyses guided by this model are patient centered as opposed to society centered, and they focus on expertise-driven standards of care and use of best practices. This clinical decision-making model highlights four components; listed in descending order of importance, they are clinical indications, preferences of patients, quality of life, and socioeconomic or external factors.
Consider the example of a severely depressed and suicidal woman who is undergoing a life-threatening asthma attack and is brought by a neighbor to the emergency department. The patient states that she wishes for no intervention and refuses intubation, indicating that she wishes to die and that this is her "right." In this case, there are fundamental tensions between the principles of beneficence (i.e., providing emergency treatment in order to save her life) and autonomy (i.e., the stated preference to die). The clinical ethics model resolves this problem through the following logic. Intervention is clinically indicated and is likely to bring benefit. It is the appropriate standard of care in essentially all emergency contexts in this country, and it is the expectation and duty of a physician to respond in this manner. In addition, there are reasons to believe that the patient has significant mental illness processes—that is, preexisting depression with suicidality and acute distress and discomfort—that may be distorting her ability to formulate or express sustained, authentic wishes. Moreover, the consequences of not intervening are grave, and failure to act will very likely bring about irreversible harm. This approach is not meant to diminish the autonomy of the individual, but rather it acknowledges that forces may be operating that are already interfering with her genuine autonomy. In less acute situations, patient preferences and personal values can more substantively influence the course of care, such as in the case of a patient choosing from among psychotherapy, medication treatment, combination care, or no treatment with close follow-up for an anxiety or mood disorder.
In addition to these more general ethical frameworks, Drane (25) has presented a compelling "sliding-scale" model for upholding ethical and legal standards for decisional capacity and informed decision making. In this approach, higher-risk decisions made by patients—to either accept or decline recommended treatment—necessitate higher levels of decisional capacity and more rigorous consent processes. Lower-risk decisions, on the other hand, may require more modest capacity and informational and decisional processes. For example, the request for discharge made by a patient in the intensive care unit who is seriously medically ill and showing symptoms and signs of substance withdrawal will, in this model, be held to stringent standards for decisional capacity and informed refusal of treatment. In contrast, the choice to delay a serum cholesterol test in the context of an annual physical examination for a healthy individual will not. The wish to decline a lithium serum level determination and thyroid function testing by an individual who has received lithium treatment for many years would fall somewhere in between. It is an ethics skill to assess what level of stringency is needed, given the circumstances.
The next skill is the ability to anticipate and navigate ethically problematic, or high-risk, situations. Examples include "dual agency" situations (e.g., court evaluations, occupational health care, therapy for both an individual and members of his family, and so on), reporting suspected child abuse, caring for a "difficult" multiple-problem patient, dealing with confidentiality issues related to the care of an adolescent with a sexually transmitted disease, duty-to-warn or duty-to-protect issues, or decisions to commit a seriously ill person against his or her wishes (4—6). These situations represent ethical risk because the clinician is entrusted with using power in a manner that may impinge on traditions, expectations, and the usual rights of individuals (1, 4). The care of mentally ill persons living in underserved regions, such as many frontier and rural regions of the United States and in many countries throughout the world, also may be understood as posing distinct ethical risk. Personnel limitations, insufficient resources, and community features may interfere with the psychiatrist’s ability to intervene in the care of a patient in an optimally beneficial, minimally harmful, and least restrictive manner. Consider the example of the alcohol-dependent man with multiple charges of driving while intoxicated who is under a court order to participate in therapy and lives in a sparsely populated area of Alaska where his daughter is the only licensed alcohol counselor—in other words, a dual role conflict (26, 27). The exercise of clinical expertise, professional and societal responsibility, and interpersonal power in such circumstances requires great care and, at times, special protections.
Finally, it is critical to build and employ a rich repertoire of ethics safeguards that may offer additional protection in ethically difficult situations. Development of advance directives for psychiatric care or end-of-life care and the inclusion of alternative decision makers or advocates are a few examples of such safeguards. Others include more complete documentation in the care of multiproblem or "difficult" patients and the strengthening of confidentiality safeguards for "VIP" patients. Finally, seeking ethics committee consultation, obtaining supplemental supervision and consultation, and using formal legal proceedings or designations (e.g., financial guardianship) may be excellent methods of introducing further protections into these situations.
Ideally, integrating these bioethics principles and clinical ethics skills in caring for persons living with mental illness will feel like nothing more than common sense or "usual habits of good clinical practitioners." This is the central tenet of clinical ethics, a field that seeks to apply the insights from the multidisciplinary field of bioethics to address morally important aspects of everyday care for individual patients (3, 5).
This approach presupposes that careful efforts to address ethical considerations are indistinguishable from other aspects of clinical excellence. Clinical skills acquired during psychiatric training such as thinking rigorously, examining one’s own biases and impact, making latent issues explicit, seeking necessary expertise, and clarifying conflicts are absolutely fundamental to ethics in the care of persons living with mental illness. It is for this reason that psychiatrists may be especially well prepared for the ethical dimensions of their work. It is also for this reason, however, that psychiatrists are held to the highest standards of professional conduct in this ethically complex, ethically committed endeavor.