Trying to fit everything you need to know about professional ethics in one article is a nearly impossible task. But somebody’s got to do it—or at least attempt it! For this article, I’ve drawn heavily on several sources, including the APA’s ethics web page (http://bit. ly/codbbT) and the textbook Clinical Handbook of Psychiatry and the Law (Gutheil T and Appelbaum P 4th ed. Philadelphia: Lipincott, Williams and Wilkins; 2006). I encourage you to read these resources on your own, as they contain much more detail than a newsletter article allows.
In some ways, psychiatric ethics are easy to remember, because they amount to a list of common sense rules. The devil is in the details of applying these rules to the wide variety of clinical circumstances that we encounter. We covered some of this material in TCPR November 2007, but the emphasis in that issue was on forensics and avoiding malpractice. While there is much overlap, in this issue we focus on ethics. The following are what I consider to be the major issues in psychiatric ethics.
The essence of confidentiality is the right to privacy. If a patient has told you something in private, you are not allowed to share this with others, except in the following circumstances:
A. Your patient signs a consent form explicitly allowing you to talk to others about him or her. This is the essence of the HIPAA form that most of us are required to ask patients to read and sign. Contrary to popular belief, HIPAA does not make medical information more private. Instead, it provides standardized rules for sharing confidential medical information. Generally, parties you are allowed to share information with include insurance companies and any other health care practitioners involved in your patient’s care. (You can download useful HIPAA forms from www.thecarlatreport.com/category/topics/ hipaa.)
B. Your patient is suicidal or is not able to take care of his or her basic needs.
C. Your patient is threatening to harm somebody. In such cases, you are both ethically and legally required to take some action to prevent such harm. This might involve admitting your patient for intensive treatment, calling the police, or notifying the identified victim. The well-known Tarasoff decision does not require that you warn the potential victim—only that you take “reasonable” action to protect him or her. Exactly what action this entails remains your judgment call.
The key ethical principle is that you must never exploit the doctor-patient relationship for some type of personal benefit, whether the benefit is sexual, financial, social, etc. Peter Gruenberg offers another way of phrasing this: “The overarching principle is that we must have only one kind of relationship with a patient—that is, a doctor-patient relationship” (from Ethics Primer of the American Psychiatric Association, 2001).
A. Social relationships with patients. Having social relationships with either current or former patients is generally considered unethical, but there is a spectrum of inappropriateness here. For example, having sex with a current patient is clearly unethical because it entails an extreme exploitation of a patient for personal gratification. On the other hand, playing golf with a former patient who you saw years ago for a few psychopharm visits may sometimes be okay, as long as you do not use your therapeutic knowledge of his or her vulnerabilities to win. To avoid any boundary breaches, it’s best to play it safe and to limit all your personal relationships to the vast majority of people out there who are not your current or former patients.
B. Relationships with key third parties. Social relationships with key third parties of a patient, such as relatives or case workers, is discouraged. Such relationships might impair objective therapeutic decisions about your patient’s care, and also confer the risk that you will share confidential information with your new “friends.”
C. Accepting gifts. Accepting small gifts from patients (as opposed to drug reps), like candies, a book, or a gift certificate, is deemed acceptable, especially if they occur in the context of a gift-giving season. Accepting very expensive gifts risks making you feel indebted to your patient, potentially impacting your medical decision making. As with all ethical principles, each situation is a judgment call.
Your Duties to Your Patients, or, “Going the Extra Mile”
The underlying principle is that you have a duty to make sure your patients are cared for. While this may sound painfully obvious, many perplexing situations arise that relate to this principle.
A. Deciding which patients to accept into your practice. You have no ethical or legal duty to care for a person until you formally accept him or her into your practice. Generally, you are free to accept patients based on whatever criteria you choose—often, this is based on financial issues, such as whether the patient has insurance that reimburses adequately for visits. This is reasonable. But is it ethical to use other criteria too, such as choosing only “interesting” or “intelligent” patients? A good rule of thumb is to ask yourself if you would feel comfortable disclosing to peers or to patients what your reasons are for deciding whom to see. If you think the reaction would be highly negative, you may be on ethically shaky ground.
B. Avoiding negligence in care. This is the issue that most frequently comes up in malpractice suits against psychiatrists, and includes negligent failure to prevent suicide, missing a diagnosis, or misusing medication or psychotherapy. You can avoid these problems by reminding yourself that it is your duty to go the extra mile for your patients. If you are concerned about suicidality, you’ll need to carve out extra time to discuss the patient’s mental state with relevant friends or family. If you are unsure of whether you are dealing with bipolar disorder vs. depression, you should schedule extra diagnostic sessions or refer the patient to a consultant. If you feel that you are flailing about in your prescribing decisions for a treatment-resistant patient, you’ll need to spend extra time reviewing the chart, doing literature searches, and consulting with colleagues.
C. Discharging patients appropriately. There are many reasons to discharge patients, including their failure to pay bills, lack of cooperation with your treatment recommendations (eg, the patient continues to use street drugs despite your advice), or such poor chemistry between the two of you that effective treatment has become impossible. In all of these cases, you must document your reasonable efforts to remedy the problem, and if you discharge the patient, you should include in the chart a letter sent to the patient in which you announce the discharge and list various referrals. If you discharge a patient without doing these things, you might be accused of abandonment, which can lead to a lawsuit if the patient does poorly. The rules vary by state, so make sure you know what’s expected of you in the state in which you practice.
The ethical thing to do is to inform patients of the risks of treatment so that they can make informed decisions. This means discussing the most prominent side effects of pharmacological treatments, as well as the risks to the patient of declining treatment. We sometimes avoid revealing uncommon but serious side effects in a well-intentioned effort to convince patients to accept a medication that we think will be helpful. But these days, between TV commercials, the Internet, and the pharmacist, patients are likely to find out about all side effects eventually, and it’s best they learn about them from a reliable source—you.
The two legal and ethical principles to keep in mind here are: 1. The government has the responsibility to keep its citizens safe, and therefore issues “police powers” to certain professions. 2. The government also must protect people who cannot protect themselves, a power known legally as “parens patriae,” which translates to “parents of the nation.” These two principles allow you to commit patients involuntarily because of risk of harm to self, to others, or inability to take care of oneself. Keeping these principles in mind can also help when you are trying to explain to a patient why you feel he or she requires commitment. “I am going to require that you be hospitalized now, even though I realize you are not happy about this. As your doctor, it’s my duty to protect you from yourself. I believe that the best way to protect you right now is through a hospitalization.” Your patient might remain angry, but you will have done the right thing, both ethically and legally.