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 167–169, 176–178.

A patient with bipolar disorder applies for life insurance. He signs a consent form for the release of his medical records to his insurance company, and the company subsequently requests a copy of his entire clinical record from the psychiatrist.

Which of the following is the most appropriate action for the psychiatrist to take?

• Advise the patient of the need for confidentiality of treatment records.

• Ask the insurance company if a treatment summary would suffice.

• Comply with the request and send a copy of the entire record.

• Explain to the insurance company the need for confidentiality of psychotherapy records.

• Refuse to send the records, citing doctor/patient confidentiality.

Often insurance companies do not require complete psychotherapy records to determine coverage and are satisfied with a treatment summary including diagnosis, dates of treatment, and prognosis. Although patients have the right to waive confidentiality, they are not always cognizant of the full implication of the release-of-information forms they sign. When releasing confidential patient information for any reason, physicians should release only the minimum amount of information required for the particular situation. In addition to checking with the insurance company, it is also useful to discuss with the patient the implications of the waiver of confidentiality (1, 2). Answer: B

A psychiatrist working in a university mental health clinic has been treating a 45-year-old used car salesman for bipolar disorder and cocaine dependence. The patient presents for follow-up complaining of excruciating new-onset back pain and difficulty walking. The psychiatrist refers him to the university's urgent primary care clinic. The patient returns to the psychiatrist's office 4 hours later, saying that the primary care physician treated him skeptically after he told her of his history of drug abuse. The doctor refused to prescribe pain medications or to order an X ray or MRI of his back and suggested he should just “tough it out.”

Which of the following is the psychiatrist's most appropriate ethical course of action?

• Advise the patient of his right to sue the physician for malpractice.

• Call the chief of staff and report the physician for unethical behavior.

• Call the hospital ethics committee for an emergency consult.

• Call the primary care physician and request further medical work-up.

• Treat the back injury to the best of the psychiatrist's ability.

Psychiatrists have an important role to play in educating their medical colleagues about the appropriate treatment of so-called “difficult” or stigmatized patients, whose clinical needs are often dismissed more readily than those of other patients. Advising the patient to sue the colleague is unprofessional and distracts from the immediate goal of providing for the clinical needs of the patient. The psychiatrist should not treat the patient's back pain himself, because this most likely departs from his scope of practice and could place the patient at risk for substandard care. Calling the urgent care physician and explaining the reasons for requesting a medical work-up, and in the process providing education about addiction, may accomplish both the goal of getting good care for the patient and the goal of helping the physician rethink her attitude toward such patients (3, 4). Answer: D

A patient experiencing a mixed mood episode of bipolar disorder presents to the emergency room with extreme abdominal pain. The treatment team believes that the patient has an “acute belly” because of a rapidly progressing and life-threatening volvulus. The patient vacillates between consenting to and refusing the life-saving surgery. Which of the following is the most ethical course of action?

• Administer a Mini Mental State Examination.

• Bring in a consulting psychiatrist for a second opinion on the patient's mental state.

• Call the hospital attorney.

• Perform the surgery.

• Wait until an alternative decision maker can be found.

Many ethical dilemmas in clinical care involve a conflict between clinical indications and patient preferences (5). The patient's preferences are crosswise with what is deemed medically beneficial, creating a conflict between duties of beneficence (promoting patient welfare) and respecting patient autonomy (respecting patient wishes). To work through such dilemmas, one must first explore fully and thoughtfully the patient's preferences as well as the clinical indications. Why does the patient refuse treatment? Does the patient have the cognitive and emotional capacity to make this decision at this time? How urgent is the clinical situation, and is time available for discussion, collaboration, and perhaps compromise? Clinical standards for medical decision-making capacity include a genuine appreciation of the medical situation, the nature of the recommended care, and potential alternative courses for care along with the benefits, risks, and consequences of each alternative. In addition, the individual should have the ability to communicate a choice and to understand the information relevant to the medical situation. Decisions need to be arrived at through reasoning and must be consistent with the patient's values and goals. In this case, the patient appears incapable of recognizing the facts of his own medical situation. As a result, he cannot appreciate the potential consequences of his medical situation (1, 5, 6). Answer: D