Chapter 7: Ethical Aspects of Clinical Psychiatry

Ethics is an endeavor. It refers to ways of understanding what is good and right in human experience. It is about discernment, knowledge, and self-reflection, and it is sustained through seeking, clarifying, and translating. It is the concrete expression of moral ideals in everyday life. Ethics is about meaning, and it is about action.

Roberts 2002a

Psychiatrists understand the hardships and heroism of their patients—people who have been affected by illnesses or conditions that cause great suffering, are often misunderstood, and result in significant disability and, at times, loss of life (Link and Phelan 2006). They learn much about the most sensitive aspects of their patients⁷lives. They encounter and carry their patients⁷ most closely held thoughts, hopes, and fears. Psychiatrists witness the strengths of their patients as they bear the burdens of disease and its repercussions. In all of this, people with mental illness trust their caregivers not only to do what is best as healers but also to value and respect them as human beings. Being worthy of that trust requires that psychiatrists develop and work to maintain a deep capacity for self-reflection and sensitivity to the ethical nuances of their work (Roberts and Dyer 2004; Roberts et al. 2002).

The high value of ethics to psychiatry also stems from the unique place of psychiatry within medicine. As specialist physicians trained in human behavior, psychiatrists are asked to bring expertise to complex situations that require an understanding of ethics, medicine, and psychology and of psychosocial aspects of daily life. Psychiatrists are thus often called upon to help clarify and resolve ethical dilemmas that arise in the care of medical patients, to join ethics committees, and to reflect publicly on ethical questions confronted by society. For all these reasons, cultivating an understanding of ethics is vital to providing competent psychiatric care and to fulfilling psychiatrists' distinct duties and roles.

Ethical behavior, moreover, is fundamental to medical professionalism, which in turn is grounded in service to others in society. The "litmus test" of professionalism is the willing acceptance by the professional of an ethical obligation to place the interests of the patient and of society before his or her own (Roberts and Dyer 2004). Awareness of one's ethical duties, therefore, is strongly linked to the development of professionalism. For psychiatrists, cultivation of the knowledge, skills, and professional attitudes relevant to ethical behavior, analysis, and problem solving are critical parts of postgraduate training (Roberts et al. 2004). Moreover, special privileges and obligations accompanying their positions in medicine and society make ethics education a crucial component of lifelong learning for psychiatrists (Chen 2003; Gabbard and Crisp-Han 2010; Rosenstein et al. 2001; Schwartz et al. 2009).

Essential Ethical Skills of Psychiatrists

Psychiatrists whose work embodies the highest ethical standards tend to rely on a set of core "ethics skills" that are learned during or before medical training and are continually practiced and refined during the psychiatrist's career (Table 7-1) (Roberts and Dyer 2004; Roberts et al. 2002). Acquiring these skills in support of professional conduct in psychiatry is itself a developmental process, with certain predictable issues and milestones that occur in relation to the nature of psychiatrists' work and the roles with which they are entrusted (Farm et al. 2003; Hoop 2004; Roberts et al. 2002).

The first of these core skills is the ability to identify ethical issues as they arise. For some, this will be an intuitive insight (e.g., the internal sense that "something is not right"), and for others it will be derived more logically (e.g., the foreknowledge that involuntary treatment or the care of "VIP" patients poses specific ethical problems). The ability to recognize ethical issues requires some familiarity with key ethics concepts and the emerging interdisciplinary field of bioethics (Table 7-2). As a corollary, this ability presupposes the psychiatrist's capacity to observe and translate complex phenomena into patterns, using the common language of the profession (e.g., conflicts between autonomy, beneficence, and justice when a person with mental illness threatens the life of a specific individual and is thus held for an evaluation against his or her preferences).

The second skill is the ability to understand how the psychiatrist's personal values, beliefs, and sense of self may affect his or her care of patients. Just as psychiatrists must be able to recognize and deal with countertransference in the therapeutic setting, they must also be able to understand how their own personalities and experiences may influence their ethical judgment. For instance, a psychiatrist who is emotionally invested in his or her ability to "do good" as a healer should recognize that this may subtly influence his or her judgment when evaluating the decisional capacity of patients who refuse medically necessary treatments. A psychiatrist with a strong commitment to personal self-care and athleticism may have difficulty accepting patients who do not share this commitment and engage voluntarily in high-risk behaviors. The ability to appreciate this aspect of the doctor-patient relationship is important for safeguarding the ethical decision making of the professional who seeks to help serve the well-being and aims of the patient.

Another key ethics skill is an awareness of the limits of one's medical knowledge and expertise and a willingness to practice within those limits. Providing competent care within the scope of one's expertise fulfills both the positive ethical duty of doing good and the obligation to "do no harm." In some real-world situations, however, psychiatrists may at times feel compelled to perform services outside their area of expertise. Such circumstances are often encountered in geographically isolated communities, where clinicians may be faced with the dilemma of providing care for which they lack adequate training or being unable to treat all of the patients who need help (Roberts and Dyer 2004). In such settings, clinicians may feel ethically justified in choosing to do their best in the clinical situation while simultaneously trying to resolve the underlying problem (American Psychiatric Association 2009). A rural psychiatrist may expand his or her areas of competence, for instance, by obtaining consultation by telephone.

The fourth skill is the ability to recognize high-risk situations in which ethical problems are likely to arise. Ethical high-risk situations may be obvious, such as in circumstances in which a psychiatrist must step out of the usual treatment relationship to protect the patient or others from harm. These situations include involuntary treatment and hospitalization, reporting child or elder abuse, or informing a third party of a patient's intention to inflict harm. Other ethical high-risk situations may be harder to recognize—for example, providing clinical care to people with whom one has other relationships (e.g., relatives or friends)—but may create vulnerability to poor decision making and ethical mistakes.

The fifth skill is the willingness to seek information and consultation when faced with an ethically or clinically difficult situation and the ability to make use of the guidance offered by these sources. Just as psychiatrists should tackle clinically difficult cases by reviewing the psychiatric literature and consulting with more experienced colleagues, they should clarify and solve ethically difficult situations by referring to ethics codes and guidelines and consulting with colleagues and ethics committees.

The final essential ethics skill for psychiatrists that we wish to highlight here is the ability to build appropriate ethical safeguards into one's work. For example, psychiatrists who treat children and adolescents are wise to routinely inform new patients and their parents—at the onset of treatment—about the limits of confidentiality and the physician's legal mandate to report child abuse (Belitz 2004). An illustration of this skill is the early career psychiatrist who arranges to continue routine mentoring sessions as he gets his practice established. Another illustration is the later career psychiatrist who joins a peer-supervision group to improve her ability to care for a new patient population.

Practical Ethical Problem Solving

Many clinicians use an eclectic approach to ethical problem solving that intuitively makes use of both inductive and deductive reasoning. Such an approach does not typically yield one "right" answer but rather an array of possible and ethically justifiable approaches that may be acceptable in the current situation. In the clinical setting, a widely used approach to ethical problem solving is the "four-topics method" described by Jonsen et al. (2006). This method entails gathering and evaluating information about 1) clinical indications, 2) patient preferences, 3) patient quality of life, and 4) contextual or external influences on the ethical decision-making process.

Many ethical dilemmas in clinical care involve a conflict between the first two topics of the four-topics model: clinical indications and patient preference. These dilemmas include situations in which a depressed cancer patient refuses life-prolonging chemotherapy or a young person undergoing a "first break" is brought to a hospital for treatment against his or her will. In each situation, the preferences of a patient are at odds with what is medically beneficial, creating a conflict for the physicians between their duties of beneficence and respecting patient autonomy. To work through such dilemmas, it is critical to clarify what is clinically necessary and to fully and thoughtfully explore the patient's preferences. Why does the patient refuse treatment? Does the patient have the cognitive and emotional capacity to make this decision at this time? What is the full range of options that are medically beneficial? How urgent is the clinical situation, and is time available for discussion, collaboration, and perhaps compromise? If the patient does not have decision-making capacity, the dilemma is at least temporarily resolved by identifying an appropriate alternative decision maker. If the patient does have the ability to provide informed consent—involving capacity for decision making and for voluntarism—then, under most foreseeable circumstances, his or her preferences must be followed. By engaging the patient in a conversation in which the physician describes the full range of treatment options and demonstrates sensitivity to the reasons for the patient's refusal, the physician frequently may craft a solution that the patient can willingly accept and the physician can justify as medically beneficial.

Key Ethical Issues in Psychiatry

Ethical decision making can be extremely challenging in the field of psychiatry because of the complexities of the doctor-patient relationship, the need for careful attention to ethical safeguards when working with people with disorders and treatments that affect mental processes, and the legally authorized power of psychiatrists to use involuntary treatment and hospitalization in some circumstances. For instance, maintaining treatment boundaries is important for all clinicians, but it is especially so in the intimacy of the psychotherapeutic relationship. Similarly, the concept of doctor-patient confidentiality is an important safeguard in all. of medicine but is particularly relevant to patients with illnesses that are stigmatized and for whom treatment may involve revealing deeply private, often "shaming," information. As another example, the process of informed consent for treatment may require more careful efforts in psychiatry because of the possibilities that patients with severe and persistent mental illness may suffer episodic, fluctuating, and/or progressive impairments of decisional capacity (Carpenter et al. 2000; Kovnick et al. 2003; Moser et al. 2002; Palmer et al. 2005). Finally, all physicians have an obligation to use their power ethically, but only psychiatrists must routinely and appropriately use legal power to impose involuntary treatment and hospitalization. These and other key ethical issues in psychiatry are discussed in more detail later.

Maintaining Therapeutic Boundaries

The intimate nature of the psychotherapeutic relationship requires psychiatrists to establish and adhere to appropriate professional boundaries, which have been defined as the "edge or limit of appropriate behavior by the psychiatrist in the clinical setting" (Gabbard 2009a). Therapeutic boundaries are important in any type of clinical work, but they have been most thoroughly defined in the context of psychoanalysis and psychodynamic therapy (Gabbard 2009a; Gabbard and Lester 2003). These boundaries include temporal and spatial limits: ^therapeutic encounters typically occur at the physician's office during business hours, except in crisis situations. Limits are also observed in the nature of the relationship, which involves the psychiatrist being paid for services and acting as a fiduciary, a professional who is worthy of the patient's trust. Nontherapeutic encounters, including business arrangements, social relationships, and sexual activity, are forbidden. Within the therapeutic relationship, limits are also observed. The patient is encouraged to share intimate feelings, thoughts, and memories, whereas the physician generally avoids self-disclosure and adopts a posture of neutrality. Physical contact other than handshakes is avoided.

Boundary violations are actions by the psychiatrist that are outside normal professional limits and have the potential to harm patients. The most widely studied boundary violation is sexual contact. Although sexual and romantic entanglements between psychiatrists and patients were not uncommon in the early days of psychiatry (Gabbard and Lester 2003), the damage such relationships may cause has become increasingly clear over the past several decades (Epstein 1994). Sexual contact between patients and physicians has been prohibited by the American Psychiatric Association (APA) since 1973 (American Psychiatric Association 2001), and it is illegal in many states (Milne 2002). A review of qualitative and quantitative studies of therapists who had sexual relations with their patients suggests that risk factors for such behavior include inadequate training, isolation from colleagues, and narcissistic pathology (Epstein 1994). Sexual contact with former patients is also understood as inherently exploitative, because transference feelings do not disappear when treatment ends (American Psychiatric Association 2001). In addition, sexual or romantic involvement with key third parties to a treatment, such as the parent or spouse of a patient, threatens the therapeutic relationship and presents a conflict of interest that should be avoided (American Psychiatric Association 2009).

Nonsexual boundary violations have been less well studied than sexual violations. These transgressions include seeing patients outside normal office hours and in nonclinical locations, engaging in social or business relationships with patients, accepting gifts from them, and nonsexual physical contact (Epstein 1994; Gabbard 2009a). Any of these violations carries the potential to exploit the patient or harm the treatment relationship and should therefore be avoided.

The term boundary crossing has been used to describe a subtle, nonsexual transgression that is helpful to the patient because it advances the treatment (Gutheil and Gabbard 1993, 1998). As an example of a boundary crossing, Gabbard (2009a) describes a guarded, paranoid patient who offers her psychiatrist a cookie. By accepting this token gift graciously, the psychiatrist helps the patient feel more relaxed in the treatment setting and more willing to discuss her symptoms. Boundary crossings such as this are common and not unethical, but differentiating crossings from actual boundary violations may be difficult in the course of treatment.

According to accepted ethical standards in medicine, physicians are "free to choose whom to serve" (American Medical Association 2009; American Psychiatric Association 2009). Once an ongoing doctor-patient relationship has been established, however, the physician may not ethically abandon the patient. As a practical matter, this means that psychiatrists must arrange for clinical coverage when on vacation and must give adequate notice to patients when closing their practices (American Psychiatric Association 2009). It is not considered patient abandonment to transfer a patient's care to another physician if the treating psychiatrist is not able to provide necessary care and if the situation is not an emergency. This may occur because the treating doctor is not trained in the therapeutic modality that the patient needs or because, despite diligent work, it has not been possible to form a therapeutic alliance. Nevertheless, psychiatrists must be aware that a covert, even unconscious, form of patient abandonment may occur when countertransference issues or burnout cause a psychiatrist to subtly encourage a difficult patient to leave treatment. Self-reflective clinicians who recognize this pattern benefit their patients by seeking consultation or supervision (Roberts and Dyer 2004).

Social Media

An emerging area of ethical significance for psychiatrists (and all medical professionals) is the maintenance of ethics and professionalism in the digital age. The Internet, E-mail, blogs, social networking, and other online media pose a number of new ethical challenges (Mostaghimi and Crotty 2011). There are obvious hazards in posting online content about oneself or others that may affect individual patients' as well as societal perceptions of the professionalism of psychiatrists. Both intentional and unintentional online disclosures of patient information (including photographs) have been documented in recent studies (Lagu et al. 2008), and unprofessional content posted on social networking sites by medical trainees has been documented (Chretien et al. 2009; Thompson et al. 2008). It has been suggested that physicians who are members of the "digital generation"—those who grew up in the Internet and social media era—are more accustomed to online disclosure about themselves and others and therefore may not recognize potential pit-falls, but there is scant evidence to support this claim. Moreover, older physicians who may be less digitally fluent and less savvy about privacy and other settings of social media sites (e.g., Facebook) may be at greater risk of inadvertently revealing more about themselves compared with those who grew up having to manage their online lives as a matter of course.

Clearly, all psychiatrists need to make conscientious and informed choices about whether, how, what, and how much to interact and disclose online. Given that the majority of psychiatry trainees, and an increasing number of physicians, have social media accounts, outright rejection of sites such as Face-book and Twitter is not feasible. Moreover, these sites now play integral and positive roles for many physicians as facilitators of social interaction—which may be an important protective factor against burnout. Furthermore, if they act carefully and proactively, psychiatrists can maintain appropriate boundaries, ethics, and professionalism online. Suggested guidelines center around basic issues of trust, privacy, professional standards of conduct, and awareness of potential implications of all digital content and interactions (Gabbard et al. 2011). Simply put, online expression should be viewed as "the new millennium's elevator: a public forum where you have little to no control over who hears what you say, even if the material is not intended for the public" (Mostaghimi and Crotty 2011, p. 561).

Informed Consent and Decision-Making Capacity

Informed consent is the process by which individuals make free, knowledgeable decisions about whether to accept a proposed plan for assessment and/or treatment. Informed consent is thus a cornerstone of ethical practice. Although informed consent is a legal requirement, its philosophical basis is found in our societal and cultural respect for individual persons and affirmation of individuals' freedom of self-determination. An adequate process of informed consent therefore reflects and promotes the ethical principle of autonomy.

Yet promoting autonomy without incorporating other ethical principles fails to create an environment for true informed consent that enhances a patient's meaningful decision making. The principle of beneficence is therefore also crucial in this context. This requires the clinician to thoroughly appraise the degree to which the consent process meets the patient's needs for information and for the opportunity to make a choice consistent with his or her authentic preferences and values (Roberts 2002b).

Viewing informed consent as more than a legal requirement also helps frame it as part of an overall therapeutic relationship and as an opportunity for respectful dialogue, which in turn may enhance the relationship and patient care. The informed consent process should consist of repeated opportunities, over time, to gather relevant clinical information and discuss and clarify patients' (and, when appropriate, families' or caregivers') values, preferences, informational needs, and decisional abilities and decision-making processes.

The phrase "decision-making capacity" differs from the term "competency" in that competency to perform a specific function or for a particular life domain is a legal determination made through a judicial or other legal process. Legal jurisdictions have differing standards for establishing competency (Appelbaum and Grisso 1995a, 1995b, 1995c). Decisional capacity, on the other hand, refers to a determination made by a clinical professional. Psychiatrists are often called upon to make determinations of the decisional capacity of nonpsychiatric patients. A detailed understanding of the concept of decisional capacity is therefore important for all psychiatrists and especially crucial for those who perform consultation-liaison work and those involved in the care of patients with disorders characterized by cognitive impairment. Moreover, being able to explain and teach standards and strategies for assessing capacity to nonpsychiatric colleagues is a critical skill, because many clinicians have not been adequately trained to do even basic screening for capacity.

The use of surrogate consent, as well as the use of involuntary or court-man-dated treatment, is predicated, in part, on the absence of intact decision-making capacity, and thus careful assessment of these component abilities is key in evaluating the appropriateness of seeking involuntary treatment for any patient. A patient who refuses treatment but whose understanding, appreciation, reasoning, and indication of a choice are adequate has the right to refuse treatment. On the other hand, an ill individual may thoroughly understand the medical facts presented by the clinicians but erroneously believe that those facts do not apply to his or her situation, thereby showing a lack of appreciation. For example, a man with a gangrenous foot may fully understand the facts about gangrene and its treatment, but he may refuse treatment because he believes that his foot is completely healthy.

It is important to remember that even patients who accept recommended treatment may do so while lacking adequate capacity for that decision. Thus, although most consultation requests involve patient refusal of recommended treatment, there may be good reasons to carefully assess and document incapacity (or fluctuating capacity, as is frequently seen in hospitalized patients who develop delirium), and seek consent from a surrogate decision maker, even in cases where a patient is accepting treatment. For example, a geriatric patient with psychotic depression was unable to care for herself at home due to somatic delusions that led to significant weight loss. Although willing to undergo electroconvulsive therapy "because it will help with the stomach pains," she was unable to articulate an understanding of the risks, benefits, or alternatives to such treatment. In this case, a surrogate decision maker was needed to provide consent for the treatment in order to ensure that the informed consent process respected the patient's diminished autonomy.

Although there is no clear index for deciding how stringent the standard for consent should be, a general rule of thumb is to use a "sliding scale" approach (Drane 1984). Decisions involving higher risks or greater risk-benefit ratios generally require a more stringent standard for decisional capacity, whereas more routine, lower-risk decisions generally require a less rigorous standard for decisional capacity. For example, the standard for understanding the procedure, risks, benefits, and alternatives related to an invasive treatment (such as deep brain stimulation) should be substantially higher than that for accepting a relatively low-risk treatment such as selective serotonin reuptake inhibitor treatment of unipolar depression.

Crucially, a judgment of capacity is independent of the patient's diagnosis and the severity of the illness. This is a key point to reemphasize to nonpsychiatric colleagues, who may assume that patients with psychiatric disorders de facto lack capacity. However, patients with schizophrenia, bipolar disorder, mania, severe depression, or any other mental illness may possess or lack decisional capacity to accept or refuse a variety of procedures and treatments, ranging from phlebotomy to pharmacotherapy to electroconvulsive treatment. Although the disease process, age, and cognitive functioning may substantially impair patients' abilities to make a fully informed, meaningful choice about treatment, empirical evidence suggests that many people with severe mental illness may commonly have adequate abilities to make treatment decisions (Lapid et al. 2003). Thus, each patient must be carefully assessed to determine a patient's capacity to make a specific decision at the time of assessment. There is often a need to reassess capacity, which is best viewed not as a static trait but rather as one that fluctuates over time.

In cases in which an individual is deemed to lack decisional ability, a surrogate or alternative decision maker is asked to make choices on behalf of that person. Psychiatric advance directives may be useful for persons with mental illnesses that cause fluctuating or progressive impairment. For example, a patient with a history of recurrent psychosis may create an advance directive requesting hospitalization and involuntary medication treatment if he or she becomes incapable of making decisions during a future relapse. Psychiatric advance directives are potentially a means for patients with severe and relapsing mental illnesses to maintain control over their treatment during periods of incapacity. However, advance directives are used only when patients lack decisional capacity, and patients can change their advance directives at any time.

Ethical Use of Power

The relationship between physician and patient is inherently one of inequity. Relative to the population at large, the psychiatrist holds a position of power because of his or her education and socioeconomic standing, because of his or her role as healer and keeper of confidences, and because he or she has been granted special powers by the state—the ability to involuntarily hospitalize patients and to stand as a gatekeeper to health care services such as prescribed medication. Conversely, individuals who seek psychiatric care are relatively disempowered compared with the general population. Psychiatric disorders may impair one's abilities to reason, feel, and behave in an effective manner. Most individuals enter psychiatric treatment at a time of great personal vulnerability, and treatments such as psychoanalysis encourage further regression as a step toward eventual healing. Such a highly unequal power relationship can leave the weaker party less able to identify and advocate for his or her interests and thus more vulnerable to exploitation.

The most egregious ethical violations in the history of psychiatry have been blatant abuses of power. Some have involved individual sociopathic practitioners who exploit their patients for financial gain, sexual gratification, or sadistic pleasure (Gabbard and Lester 2003). Others have involved entire communities of psychiatrists who have allowed their skills and legal powers to be misused to harm patients. In Nazi Germany, psychiatrists killed thousands of patients in mental hospitals in the name of eugenic goals (Gottesman and Bertelsen 1996). Also in the previous century, psychiatrists in the Soviet Union diagnosed political dissidents as having dubious "mental disorders" and subjected them to unnecessary treatments, including long-term involuntary hospitalization (Bloch and Reddaway 1984). Similar accusations have more recently been made against psychiatrists in other countries (e.g., Kahn 2006).

Psychiatrists, like other physicians, are entrusted with the responsibility of judging when involuntary treatment may be necessary to protect the health and safety of a person affected by mental illness. Many important ethical issues surround this use of power by well-meaning and thoughtful clinicians, for example, via involuntary hospitalization, outpatient commitment, or involuntary medication treatment—steps that are sometimes necessary in the care of patients whose mental illness makes them a danger to themselves or others. Involuntary treatment is a clear example of conflicting ethical principles: the obligation to respect patient autonomy and the obligation of beneficence (see Table 7-2). Choosing not to override a patient's treatment refusal would demonstrate respect for patient autonomy, but blind adherence to a patient's wishes about treatment may not be ethically justifiable and may, in fact, cause harm. The suicidal patient who refuses hospitalization, the patient who expresses homicidal ideas, or the patient whose mental illness seriously jeopardizes his or her safety are all examples of patients for whom involuntary treatment may be necessary and justifiable.

In the outpatient setting, involuntary treatment poses distinct challenges. Deinstitutionalization and a fragmented mental health care system have led to a crisis of lack of access to quality, continuous care. As a result, individuals with mental illnesses living in the community appear to frequently "fall through cracks" in the system (U.S. Department of Health and Human Services 1999); some of these individuals' safety may be in jeopardy for reasons of lack of access or nonadherence to treatment.

Confidentiality

Respect for the privacy of patients' personal information has been an established ethical duty of physicians for millennia; Hippocrates stated the ethical duty of confidentiality as follows: "What I may see or hear in the course of treatment ... in regard to the life of men ... I will keep to myself, holding such things to be shameful to be spoken about" (Hippocratic Writings, "The Oath" 2012). Patients entrust their physicians with the most intimate details of their lives, often telling their doctors things they have never told—or would never tell—anyone else. Effective treatment, and in particular effective psychotherapy, would not be possible if patients did not feel free to disclose intensely personal information under the assumption of confidentiality.

From the standpoint of United States law, doctor-patient confidentiality is a legal privilege granted to patients. The privilege requires physicians to keep patient information private unless the doctor is legally compelled to make a disclosure or the patient waives the privilege. Although this may sound straightforward, in practice there are many gray areas in which a physician's legal and ethical duties may conflict. In remote rural settings, where clinicians and their patients are also neighbors, friends, and relatives, confidentiality poses extraordinary challenges (Roberts et al. 1999). This is true in other small communities and organizations in which individuals have multiple and overlapping roles (Roberts 2004). With the Health Insurance Portability and Accountability Act of 1996, specific protections for personal health information, including a higher level of protection for psychotherapy notes, were also enacted (U.S. Department of Health and Human Services 1996).

There is a broad recognition of several limits on confidentiality. When patients consent to specific, limited disclosures of their information (e.g., for third-party payment or for a court proceeding), disclosure may occur. In these instances, the amount of information to be revealed should be the minimum amount necessary for the specific situation—that is, a rigorously upheld "need to know" approach should be taken. Patients should be informed of limits to confidentiality when entering treatment (although there is disagreement about how best to enact this duty). Patients should not be asked to sign a blanket waiver of general consent to disclosure, because many patients would not want all of their personal mental health information being disclosed to a third-party payer, for example (Mosher and Swire 2002).

There are other instances when a nonconsenting patient may have the privilege of confidentiality suspended based on the physician's overriding duties to others. These situations typically involve child or elder abuse or threatened violence. The notion that psychiatrists have a "duty to protect" members of the public from the violent intentions of their patients was demonstrated by the legal case Tarasoff v. Regents of the University of California (see Chapter 6, "Clinical Issues in Psychiatry and the Law").

In general, however, patients should reasonably be able to expect that the information they tell their psychiatrist or other mental health professional will be kept confidential and that disclosure will not occur without their consent. Unfortunately, several studies have shown that many patients are not informed about specific safeguards for their confidentiality and do not seek treatment out of fear about lack of confidentiality (Roberts and Dyer 2004).

In an emerging era of electronic health records, digitized medical information, and a push toward national health identifiers (Flynn et al. 2003; Griener 2005), it remains unclear whether, to what degree, and how special privacy protections for mental health treatment will continue to be guarded. Ensuring privacy of genetic and genomic data stored electronically is another evolving issue that promises to raise new challenges related to confidentiality in psychiatric care (Hoge and Appelbaum 2012; Sax and Schmidt 2005). Thus, the ethical obligation of confidentiality will continue to be a topic of concern and should be a matter of heightened attention on the part of psychiatrists as health information technology evolves.

A number of hospitals, clinics, and organizations have developed approaches to handling mental health and other sensitive information in the medical record, such as a "lockbox" or "break the glass" approach that requires special access for those viewing mental health records. However, even marking an electronic progress note as "sensitive" will, in most cases, still allow numerous providers access to that record. Moreover, patients now have unprecedented access to their own medical charts, test results, and diagnoses as documented by providers through electronic medical record (EMR) systems. One patient was enraged to find that "marijuana abuse" was listed as one of her diagnoses when she accessed her own chart through an EMR. The psychiatrist in this case had likely erred by not discussing the EMR and what she would be documenting in it with the patient ahead of time. As this example illustrates, providers who document in EMR systems should understand who will have access to the patient's mental health records and strive to include medically necessary information while limiting content that is not relevant to the overall medical care of the patient. Drawing this line is not always easy, however. For example, some psychiatrists may routinely document their observations of patients' personality traits as relevant to providers who interact with the patient, but this terminology might be misinterpreted, mishandled, or inappropriately disclosed in ways that could be harmful to the patient, the therapeutic alliance, and the patient's overall medical care. The emerging era of EMRs essentially requires psychiatrists to consider more carefully what should and should not be entered into the medical record and to use appropriate language that enhances health care provider communication and fosters optimal medical care. It is safe to say that the ethical and practical implications of these systems will continue to manifest themselves over time, with both positive and negative examples, but that the underlying ethical principles that guide psychiatric treatment also need to form the basis of the use of EMRs.

Managing Dual Roles and Conflicts of Interest

By virtue of their skills and training, psychiatrists are naturally invited to participate in a variety of roles in the medical community and in society. Psychiatrists are educators of medical students and residents, administrators of academic programs and health care systems, clinical researchers and basic scientists, and consultants to industry. Because the ethical duties required by one role may not align precisely with the duties of another role, psychiatrists in multiple roles often face ethical binds. The conflicts of interest that arise are not necessarily unethical, but they must be managed in a way that allows the psychiatrist to fulfill professionalism expectations and maintain a fiduciary relationship with patients. There are many strategies for helping to ensure that role conflicts do not distort the judgment of professionals, such as disclosure and documentation, focused supervision and oversight committees, retrospective review, and other safeguards (Roberts and Dyer 2004).

Financial conflicts of interest pertaining to patient care represent a significant threat to the integrity of the profession of medicine. Among the most obviously unacceptable conflicts of interest are those in which physicians have a clear-cut financial arrangement that could adversely influence how they treat patients. For example, fee-splitting arrangements in which a psychiatrist is paid to refer patients to a consultant are unethical because the payment may compromise the psychiatrist's judgment about the clinical merits of the referral. Similarly, accepting bonuses from hospitals for referring patients suggests that the physician's professional judgment may be co-opted. Physicians who work for managed care organizations may also face a financial conflict of interest, particularly with plans that provide incentives to encourage physicians to order less-expensive treatments and tests. Guidelines for ethical practice in organized settings established by the APA in 1997 require that managed-care psychiatrists disclose such incentives to patients (American Psychiatric Association 2001).

Currently, various organizations within medicine differ in their approaches and guidelines for dealing with relationships with industry (American Medical Association 1998; Institute of Medicine 2009), and this topic continues to be hotly contested in psychiatry. A meta-analysis of 29 studies on physician-pharmaceutical company interactions demonstrated that physicians' attitudes toward a medication and/or their prescribing practices are influenced by having personal contact with pharmaceutical sales representatives, attending sales presentations, attending continuing medical education conferences sponsored by pharmaceutical companies, and using industry funding for travel and housing expenses to attend professional meetings (Wazana 2000). At a minimum, psychiatrists should learn and work within the guidelines specified by their own organizations and work environments. Academic departments of psychiatry and psychiatric residency training programs increasingly play an important role in educating physicians about the ethical issues involved in relationships with the pharmaceutical industry (Christensen and Tueth 1998).

Another type of conflict of interest arises for psychiatrists who have additional professional duties that may not be fully congruent with the role of physician. Such conflicts are sometimes referred to as "dual agency" situations. An extreme example is the forensic psychiatrist who may be asked to evaluate a death-row inmate to determine whether he or she is "sane enough" to be executed (Gutheil 2009). In this instance, the forensic psychiatrist's first duty is to veracity—telling the truth—in the service of society above all other interests, including those of the individual who is being evaluated.

Ethical binds occur with many other types of dual roles, although they are less dramatic. Research psychiatrists who provide clinical care for their study volunteers may struggle to maintain the integrity of the doctor-patient relationship in the face of the demands of the research protocol (Joffe and Miller 2008). Similarly, medical trainees, supervisors, and administrative psychiatrists may find that their roles as students, teachers, and managers challenge their ability to put the needs of patients first (Hoop 2004; Roberts and Dyer 2004). In public health settings, for example, psychiatrists may find it challenging to balance fidelity to individual patients with the legitimate need to be good stewards of social resources and to distribute them fairly (Sabin 1994). Managing these multiple roles requires physicians to recognize the potential for ethical binds, institute safeguards when possible, and fully inform patients (Roberts and Dyer 2004).

Ethical Interactions With Colleagues and Trainees

As members of a profession, psychiatrists are expected to behave ethically toward their colleagues individually and collectively. The American Medical Association's Principles of Medical Ethics explicitly states that physicians should "deal honestly" with colleagues, "respect the rights" of colleagues, and "strive to expose those physicians deficient in character or competence, or who engage in fraud or deception" (American Psychiatric Association 2010) (Table 7-4). Although the first two statements in the ethics code encourage collegial behavior, the third suggests the importance of self-governance in the medical professions and the need to report colleague misconduct and impairment.

Intervening and reporting colleague misconduct or impairment are some of the most difficult ethical imperatives of the conscientious psychiatrist. When colleagues bring legitimate cases of physician misconduct to light, they are fulfilling the ideals of beneficence and nonmaleficence by protecting the physician's current and future patients. Nevertheless, a number of psychological barriers to reporting colleague impairment have been identified, including overidentification with the impaired physician, collusion with the colleague's denial and minimization, and a tendency to overvalue confidentiality and protecting the colleague's reputation and career at the expense of safety (Roberts and Miller 2004).

To help psychiatrists overcome their reluctance to report a colleague's improper behavior, Overstreet (2001) suggested a useful four-step procedure for working through the issue. First, the psychiatrist should become informed about the reporting requirements of his or her state. In some localities, physicians may suffer legal penalties if they fail to report physician impairment. Second, the psychiatrist should seek to more fully understand the situation, including how his or her own feelings may complicate the ability both to observe the colleague's behavior objectively and to report it. Third, all the options that fulfill the duty to "strive to expose" the misconduct should be considered. Just as there is a range of physician misbehaviors, there can be a range of appropriate responses. These may include speaking privately with the colleague about one's concerns, informing the colleague's supervisor or administrative chief, filing an ethics complaint with the district APA branch, and/or notifying the state licensing board. Finally, the physician should choose the most appropriate option or options as a first step, knowing that others are available should the situation persist (Overstreet 2001).

It is important to note that a reporting physician is not expected to make a definitive judgment about whether or not a colleague is practicing competently. Worrisome professional behavior should instead be investigated by appropriate professional bodies such as the APA (2010) and state licensing boards. Furthermore, as a practical matter, an impaired physician may in fact be greatly helped by the impetus to accept treatment. To that end, many states have enacted laws regarding physician impairment based on model legislation proposed by the American Medical Association Council on Mental Health. These statutes are designed to encourage appropriate treatment and rehabilitation rather than approaches that may be seen as merely punitive (Roberts and Dyer 2004).

The ethical obligations of psychiatric faculty toward trainees involve many of the same requirements as relations with colleagues, plus the added obligations of a "fiduciary-like" relationship with trainees (Mohamed et al. 2005). The connection between an attending physician and a resident or medical student has some similarities to the doctor-patient relationship, although the two are, of course, not identical. In both, there is a power differential, the possibility of transference feelings, and in some cases the potential for the weaker party to be exploited. The propriety of sexual relationships between supervising physicians and trainees therefore has become increasingly controversial due to the potential negative impact on the trainee, the patients whose care is being supervised, and the training program as a whole (American Psychiatric Association 2010).

Source. American Psychiatric Association: The Principles of Medical Ethics With Annotations Applicable to Psychiatry, 2010 Edition. Washington, DC, American Psychiatric Association, 2010 (available at: www.psychiatry.org/practice/ethics/resources-standards).

Medical school and residency training also give rise to specific ethical issues because of the need for trainees to provide care that is beyond their current level of expertise. The third-year medical student who performs a lumbar puncture for the first time, the new intern responsible for evaluating the suicide risk of a patient in an emergency department, the inexperienced resident with a severely regressed therapy patient—all must provide medical care outside their current zone of competence in order to learn skills that will benefit future patients. The process requires treating patients as a means to an end—a violation of the principle of respect for persons—and yet the thorough training of psychiatrists is clearly beneficent from a public health standpoint. Handling this ethical dilemma requires the informed consent of patients as willing participants in the educational setting as well as safeguards to ensure that trainees practice only marginally beyond their current capabilities and with adequate supervision (Fry 1991; Hoop 2004; Roberts and Dyer 2004; Vinicky et al. 1991).

Future Directions

For the past several decades, major topics of ethical reflection in psychiatry have included traditional topics such as boundary issues in psychotherapy, informed consent, confidentiality, role conflicts, and involuntary treatment. More recently, several new avenues for ethical inquiry have opened as new diagnostic and therapeutic modalities have been invented. First, technological advances, as in medicine as a whole, continue to create new and unforeseen ethical challenges. For example, scientific research in genetics, neuroimaging, and molecular and cellular neuroscience holds the potential to produce new technologies for diagnosing predisposition to diverse neuropsychiatric conditions. Both the risks and the benefits of such diagnostic testing could be substantial, and empirical and conceptual ethics research is needed to guide its proper use. Another example is the adaptation of invasive treatments (including surgical interventions) for psychiatric disorders such as severe depression or obsessive-compulsive disorder. Issues pertaining to patient selection, informed consent for both research and treatment options, and maintenance of an ongoing therapeutic relationship with such patients are just beginning to be discerned.

A second trend in psychiatry with important ethical implications is financial. In community settings in the United States, low Medicare and Medicaid reimbursement rates for psychiatric procedures coupled with reductions in funding for the uninsured are placing extreme pressures on psychiatrists to provide ethical, clinically appropriate care to large inpatient caseloads within 15-minute, or even 10-minute, outpatient appointments (Gabbard 2009b). In academic settings, financial difficulties have been in part responsible for a heavy reliance on industry to subsidize psychiatric education and clinical research. Psychiatrists who serve as faculty members, administrators, researchers, and/or journal editors and who also have financial ties to private companies must successfully and openly manage this potential conflict of interest or risk damaging the already-fragile public trust in the field of psychiatry.

Clinical psychiatry, in sum, is ethically laden, and ethically rich, work. In the professional life of a psychiatrist, ethics helps inform and shape day-to-day choices—not only the decisions surrounding clearly problematic situations such as involuntary treatment but also the routine decisions of clinical practice. In this work, service to the well-being and interests of patients must take precedence over other concerns, and adherence to ethical standards of the field is essential; these are the requirements of professionalism. Through each of these actions, and through our ongoing attempts to become more discerning, more self-aware, and more respectful, we embody ethics for our patients and as an expression of our profession.

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Table 7-2. Glossary of ethics terms
Term	Definition
Altruism	The virtue of acting for the good of another person rather than for oneself.
Autonomy	The principle honoring the individual's capacity to make decisions for him- or herself and to act on the basis of such decisions.
Beneficence	The principle of engaging in actions to bring about good for others.
Compassion	The virtue of recognizing the experience of another person and acting with kindness and regard for his or her welfare.
Confidentiality	The professional obligation of physicians not to disclose information or observations related to patients without their permission.
Fidelity	The virtue of promise keeping.
Honesty	The virtue of truthfulness.
Integrity	The virtue of coherence and adherence to professionalism in intention and action.
Justice	The principle of fairness in the distribution of benefits and burdens.
Nonmaleficence	The principle of avoiding harm toward others.
Respect	The virtue of fully regarding and according intrinsic value to someone or something.