Ethics Commentary: Obsessive-Compulsive and Related Disorders: Ethical Issues in the Care of Obsessive-Compulsive Disorder: Clinical Ethics Case Examples
Sound ethical decision making is essential to astute and compassionate clinical care. Wise practitioners readily identify and reflect on the ethical aspects of their work. They engage, often intuitively and without much fuss, in careful habits: maintaining therapeutic boundaries, seeking consultation from experts when caring for difficult or especially complex patients, safeguarding against danger in high-risk situations, and endeavoring to understand more about mental illnesses and the expression of mental illness in the lives of patients of all ages, all places, and all walks of life. These habits of thought and behavior are signs of professionalism and help ensure ethical rigor in clinical practice.
Psychiatry is a specialty of medicine that, by its nature, touches on big moral questions. The conditions we treat often threaten the qualities that define human beings as individual, as autonomous, as responsible, as developing, and as fulfilled. The conditions we treat often are characterized by great suffering, disability, and stigma, and yet individuals with these conditions demonstrate such tremendous adaptation and strength as well. If all work by physicians is ethically important, then our work is especially so. As a service to Focus readers, in this column we endeavor to provide ethics commentary on topics in clinical psychiatry. We also proffer clinical ethics questions and expert answers in order to sharpen readers’ decision-making skills and advance astute and compassionate clinical care in our field.
Laura Weiss Roberts, M.D., M.A.
Obsessive-compulsive disorder (OCD) is a mental disorder characterized by unrelenting, unreasonable thoughts and fears (obsessions) and repetitive behaviors or compulsions. These thoughts and behaviors are time intensive and disruptive; they interfere with feeling fulfilled in one’s personal life and with work performance. The symptoms of OCD usually begin during adolescence, with more than half of affected persons having the onset of symptoms by their mid-20s. OCD may be complicated by significant depression. The risk for suicide is elevated in the context of OCD in that approximately one in eight individuals with OCD will attempt suicide.
Pharmacological and psychosocial treatments, often in combination, bring benefit to many people living with OCD. However, although many patients with OCD will respond favorably to treatment with clomipramine and cognitive-behavioral therapies (CBTs), some will not experience improvement. Deep brain stimulation is a promising interventional psychiatric therapy for a subset of patients with OCD who have not responded adequately to psychopharmacological and psychosocial treatments. Like repetitive transcranial magnetic stimulation, deep brain stimulation influences and modifies neural activity at the level of the circuit to produce improvements in psychiatric symptoms. Because of the invasiveness and potential risks associated with this neurosurgical intervention, many patients will not elect this innovative treatment despite the heavy burden of disease associated with OCD.
Case Illustration 1
Anita Laki is a 29-year-old woman who works as a physical therapist at a local sports medicine program. She was diagnosed with OCD at age 16 years and has done well with clomipramine. She and her husband would like to start a family. She and the prescribing psychiatrist work through a plan in which she initiates cognitive-behavioral treatment with a psychologist and, at the same time, begins to taper off her medication. Within a couple of weeks, she becomes preoccupied with two thoughts that consume most of her time. She worries continuously that her past exposure to a psychotropic medication has “contaminated” her eggs and that the baby will not “be okay.” She also reports feeling “terrified” that she will “lose control” and act on sexual thoughts about her patients. Ms. Laki usually cleans her house or engages in physical exercise to push away from these thoughts, with partial relief. During the past 4 or 5 days, Ms. Laki has begun waking up at night, worrying. She has been cleaning and exercising “almost continuously” and cannot settle down. She attended her second appointment with a psychologist and worked on CBT exercises, which she reports “really help a lot.” Ms. Laki called in sick to work the day before the appointment with her doctor. Her husband has only known her during the period in which her symptoms have been well managed with medication. She says that her husband is getting “freaked out” by her condition.
| 1.1 | Ms. Laki wishes to defer becoming pregnant until “sometime next year.” The psychiatrist clarifies that she is not making the decision based on fear of contamination, and he recommends a much slower tapering off of medication, along with more frequent appointments with both the psychiatrist and the psychologist. Which pair of ethical principles is most important in shaping the psychiatrist’s treatment recommendations?
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| 1.2 | The psychiatrist receives a call from the psychologist, who is concerned about the patient’s sexual thoughts about the athletes seen in the sports medicine clinic. The psychologist and psychiatrist agree that this obsessional theme is distressing to the patient. By “Googling” the patient and her workplace, the clinicians together verify that she works with adult clients/patients. The psychiatrist and psychologist decide to explore the situation further by reviewing the clinic’s website to make sure that her work does not involve contact with adolescent athletes. The clinicians agree to speak 3 days later, after they have both seen the patient in follow-up appointments. Which of the following statements does NOT accurately reflect APA’s ethical recommendations regarding the “Googling” of patients?
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Case Illustration 2
Bob Stevens is a 47-year-old man with a history of severe OCD who presents to an interventional psychiatrist’s office requesting deep brain stimulation for his condition. Mr. Stevens has had a diagnosis of OCD since childhood. He also has been diagnosed with Tourette's syndrome. For the past 6 months, Mr. Stevens reports that he has needed more time in the shower to “get it just right,” which sometimes takes more than 2 hours a day. Mr. Stevens spends several hours a day “buying food and sanitizing it”—taking the purchased food and transferring it to glass containers in his front yard before bringing it into the house. On mental status examination, Mr. Stevens is a neatly dressed, mildly overweight man who appears slightly older than his stated age. He is cooperative with the clinical interview and asks that his wife step out of the room when he is talking with the doctor. He is speaking normally, with appropriate affect. His thought form is linear. He denies hallucinations and reports no thoughts of self-harm.
| 2.1 | Mr. Stevens states that he has a subscription to Medscape and saw that there have been several open-label studies using deep brain stimulation technology and “it looks like it works!” The patient states that he has tried all selective serotonin reuptake inhibitor medications and CBT. The interventional psychiatrist obtains a thorough history and notes that the patient has not yet tried and failed clomipramine. The interventional psychiatrist also knows that deep brain stimulation for OCD carries the risk for an acute intracranial hemorrhage in 1% of patients. The interventional psychiatrist chooses to have Mr. Stevens try clomipramine before deep brain stimulation. Which of the following ethical principles is shaping this decision?
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| 2.2 | Mr. Stevens returns in several months and is noted to have severe symptoms despite adequate dosing of clomipramine. The interventional psychiatrist provides clinical information to assist the patient in seeking to have his insurance pay for the implant. The insurance company denies the request. With the patient’s consent, the interventional psychiatrist then directly contacts the insurance company to appeal the decision, stating that the patient is in dire need and that the procedure is clinically indicated. Furthermore, the psychiatrist argues, denying the request is discrimination against people with mental illness because deep brain stimulation has been performed routinely for other conditions. Which set of ethics principles is shaping the rationale for this appeal?
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Case Illustration 3
Mr. Smith is a 46-year-old man with longstanding and severe OCD who has undergone implantation with a deep brain stimulator. He is brought to the psychiatric emergency department by his wife for a first-ever manic episode in the context of a recent deep brain stimulator programming session. The stimulator had been adjusted upward because the psychiatrist wanted to “help the patient as quickly as possible.” The patient’s wife is very concerned and is hoping that the patient will be admitted to the hospital. During the past few weeks, his wife reports that the patient has needed “less and less” sleep and has been “buying expensive stuff that he has never bought before.” Most states have provisions for involuntary psychiatric admission when a person has evidence of a mental disorder that causes “grave passive neglect” or the potential for harm to self or others. The law does not directly discuss side effects of brain stimulation causing de novo psychiatric symptoms.
| 3.1 | Which of the following statements is the most accurate regarding a psychiatric admission for Mr. Smith at this time?
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When asked to allow for the interventional psychiatrist to turn off the device, the patient states that he refuses and likes the feeling “a lot.” It becomes apparent that the patient must have the device turned off against his wishes. The patient states “don’t take it away from me! I like this feeling! I feel amazing.” The interventional psychiatrist evaluates the patient carefully and determines that the patient’s judgment is compromised by his symptoms and that he is not capable of providing informed refusal to the recommended treatment plan. The interventional psychiatrist consults with two other colleagues, and together they decide to turn the device off although it is against the patient’s wishes.
| 3.2 | Which of the following ethical principles is in tension in this situation?
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| 3.3 | The patient wishes to decline the recommended treatment approach, which is to reduce the level of circuit stimulation in order to address the patient’s manic symptoms. Which of the following statements is most accurate regarding informed refusal of a recommended treatment?
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The patient accepts the recommendation to be admitted to the psychiatric unit for a brief stay. The interventional psychiatrist establishes a treatment plan in which the patient is to receive benzodiazepines “only.” The patient is not prescribed antipsychotics or mood stabilizers because the mania is NOT new-onset bipolar disorder but, rather, a circuit-level side effect of the deep brain stimulation device. The interventional psychiatrist is choosing this treatment route because he knows that the mania will resolve in a few days once the device has been turned off.
| 3.4 | Which ethical principle is shaping the decision to minimize exposure to psychotropic medication?
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Case Illustration 4
Dr. John Everly is a 32-year-old anesthesiologist who has been becoming more and more concerned with “precision” and “exactness” at work. He has always liked to be precise and chose the specialty of anesthesiology for that reason. Since he and his wife had their first child, however, he has been more stressed and worried. The patient presents to the psychiatrist’s office at the medical school to be evaluated for the first time. At that time, Dr. Everly is noted to have some symptoms of OCD. The patient agrees to try CBT but does not wish to try psychotropic medication. He states, “I know what these drugs do. I am an anesthesiologist – drugs are my job. Plus, I tried some of that stuff in college and it made me feel crazy.”
| 4.1 | The decision to accept the patient’s preference to seek psychosocial treatment is shaped by which of the following ethical principles?
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Dr. Everly returns to the academic clinic a few months later and confides in his psychiatrist that he has been treating his OCD with leftover ketamine that he has been saving from infusions for his pain management patients. The patient states that he saw a recent study mentioned on the news that suggested that ketamine is efficacious for treating treatment-resistant OCD. The psychiatrist carefully discusses the situation with Dr. Everly, who seems surprised by the psychiatrist’s concern. The patient provides a detailed log of his self-administered “treatment” with ketamine and the resulting effects, including symptom relief. The patient says, “This is an example of clinical innovation. We are at an academic institution. We do this all of the time!” Without revealing the name of the patient, the psychiatrist consults with a long-time psychiatrist mentor and with the attorney for the academic hospital. The psychiatrist then decides to contact the state medical board regarding the patient, concerned about the patient’s judgment as a physician with an active practice involving seriously ill patients undergoing life-threatening operations.
| 4.2 | Which of the following ethical principles is most relevant to the psychiatrist’s decision to report the situation to the state medical board?
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Answers
| 1.1 | The answer is B. The psychiatrist is honoring the patient’s preference while also seeking to prevent harm in the clinical situation. | ||||
| 1.2 | The answer is D. APA has a number of careful recommendations regarding the ethics of Googling patients. APA suggests that a conscientious clinician will consider the impact of information learned by Googling a patient upon the therapeutic relationship and course of treatment. Googling a patient is not, in and of itself, unethical if it is performed in the interest of promoting patient care and well-being. Googling a patient is unethical, however, if it is performed merely to satisfy the curiosity of the clinician. Whenever information derived from Googling a patient will affect treatment planning, it is important to corroborate the information. Psychiatrists and psychologists do not have to obtain informed consent before Googling a patient. | ||||
| 2.1 | The answer is E. The interventional psychiatrist chooses to try clomipramine before deep brain stimulation in an effort to reduce risk and the potential for harm to the patient. | ||||
| 2.2 | The answer is C. The clinician tries to persuade the insurance company, emphasizing the suffering of the patient as well as fairness and nondiscrimination in relationship to the care of psychiatric disorders. | ||||
| 3.1 | The answer is C. The patient may be admitted voluntarily to a psychiatric unit, although his symptoms are secondary to a neuropsychiatric intervention. | ||||
| 3.2 | The answer is A. The ethical dilemma here is that the psychiatrist must assess the ability of the patient to maintain autonomy while also making certain that the prescribed treatment is doing no harm. | ||||
| 3.3 | The answer is C. Informed refusal of a recommended treatment is based on the individual’s decisional capacity. The level of capacity needed depends on the level of risk posed by the choice to decline treatment (i.e., if greater risk is undertaken, then a very high standard for decision making is appropriate, ethically and legally). | ||||
| 3.4 | The answer is E. The aim is to minimize exposure to agents that may cause harm. Although administering the minimal amount of medication needed to treat a condition is always the ethical choice for a psychiatrist, one must additionally understand that deep brain stimulation–related mania as a side effect has a different etiology and time course that dictate an even more conservative medication strategy. | ||||
| 4.1 | The answer is A. The clinician’s decision to honor the patient’s preference to seek psychosocial treatment is shaped by the ethical principle of autonomy. | ||||
| 4.2 | The answer is E. The psychiatrist is obligated by law to report the behavior of the patient who is a physician with an active clinical practice involving seriously ill individuals undergoing life-threatening operations. The psychiatrist makes this judgment in consultation with others with relevant expertise and experience, and it is grounded in respect for the law rather than other ethical considerations. Each profession in society carries responsibility for ensuring that members of the profession are knowledgeable and skilled and are not impaired in their professional judgment and behavior. In most states, mandatory reporting leads to an investigation of the situation. The reporting clinician does not need proof of wrongdoing by the anesthesiologist-patient. | ||||
