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|Year : 2016
: 58 | Issue : 6 | Page
|Ethics and medical practice: Why psychiatry is unique
Navneet Sidhu, Jagannathan Srinivasraghavan
MD, DLFAPA Past President, Illinois Psychiatric Society & Professor Emeritus of Psychiatry, Southern Illinois University School of Medicine & Consultant Forensic Psychiatrist, Carbondale, IL 62902, USA
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|Date of Web Publication||27-Dec-2016|
|How to cite this article:|
Sidhu N, Srinivasraghavan J. Ethics and medical practice: Why psychiatry is unique. Indian J Psychiatry 2016;58, Suppl S2:199-202
Since ancient times, societies have held physicians to high standards of ethics owing to the caring nature of the medical profession as well as the vulnerability of people in their care. While we are all familiar with the Hippocratic oath, the Formula Comitis Archiatrorum, written in the 5 th century, is considered by some to be the earliest known code of medical ethics. Modern day medical ethics can be traced to Thomas Percival, an English physician and philosopher who wrote Medical Ethics, or a Code of Institutes and Precepts, Adapted to the Professional Conduct of Physicians and Surgeons in 1803  . His ideas such as conduct of physicians towards patients and inter-professional relationships have been a dominant influence in development of the field. Medical Ethics served as a key source for the American Medical Association (AMA) code, which the association adopted in 1847  . In it's current form, the AMA code of Medical Ethics stresses principles such as professionalism, respect for human dignity and rights, medical knowledge, privacy and access to medical care for all people, and the importance of focusing on patients' best interests  . In the United States, organizations such as the American Psychiatric Association (APA) and American Psychological Association have also laid out guidelines that inform psychiatric and psychological practice , . Srinivasaraghavan et al.  have discussed the unique nature of psychiatry, the presence of stigma in mental illness, the socio-economic disadvantages often present in the mentally ill population and the need for psychiatric ethics to go beyond the ethical standards of General medicine. In this paper, we want to highlight how the everyday practice of psychiatry demands high moral and ethical standards of its' practitioners and is unique in its challenges and ethical dilemmas.
| I. Privacy and Confidentiality|| |
Physicians of all specialties owe complete confidentiality to their patients in most circumstances. The effectiveness of the patient- physician relationship and therapeutic alliance relies heavily on this obligation. It is unethical and illegal to share information discussed within the confines of the medical office, without the explicit and informed permission of the patient. In psychiatry, we often hear our patients' innermost fears, worries, fantasies and desires. To a psychiatrist, patients' often expose their vulnerabilities and discuss concerns that could expose them to the prevalent stigma in society. Were a physician not bound by the promise of confidentiality, the therapeutic relationship would be hindered, and treatment would be impeded. Consider the example of a woman telling her psychiatrist of marital discord in her relationship, or a man talking about sexual dysfunction in treatment. Or the case of an employer calling the psychiatrist about the mental health of employee. It is obvious that if such information were to become known outside the confines of therapy, the consequences could be potentially disastrous. In the United States, the Health Insurance Portability and Accountability Act (HIPAA)  of 1996 places civil and criminal penalties on health care providers and entities that disclose protected information to unauthorized individuals or sources.
So when can a psychiatrist share information? Organizations like APA have recognized the limits of this confidentiality in the legal setting. For example, if a physician is required by the law to produce medical records, confidentiality is waived. In such situations, the limits of confidentiality should be explained to the patient. Following the landmark United States case  involving the killing of a university student, Tatiana Tarasoff by another student in 1969, many U.S states  have enacted duty to warn and duty to protect mandates which require a psychiatrist or therapist to reveal information to police or potential victims about dangerous patients in the interest of public safety.
Mandatory reporting of child abuse is another example where confidentiality is violated in order to protect societal interests  . Similarly, in situations where a physician feels that a patient is in danger of hurting himself or herself, confidentiality can be breached while attempting to ensure safety  . In such situations, a psychiatrist may exercise the doctrine of parens patriae (i.e., the state as parent) to engage family, police or law enforcement and involuntarily commit a patient to prevent them from self harm. Such conflicts, where individual autonomy and rights are seconded to safety are unique to psychiatry. The premise here is that the patient is incapable of making decisions for themselves, i.e., the patient lacks capacity, due to mental illness.
In the US, while medical insurance companies can request mental health records for the purposes of billing and payment, psychotherapy notes, also sometimes referred to as "process notes," are subject to higher levels of confidentiality. HIPAA provides this special layer of confidentiality  when the professional keeps these notes separate from the patient record, and the information contained is not necessary for general health care operations purposes. Process notes are afforded this protection because they may contain information of a highly sensitive and personal nature.
| II. Maintaining Boundaries|| |
Gutheil and Simon  have defined a boundary ͻas the edge of appropriate or professional behavior, transgression of which involves the therapist stepping out of the clinical role." The principles of beneficence (taking actions that promote the best interest of the patient) and non-maleficence (do no harm) defined as core principles by Beauchamp and Childress  , are often the underlying concerns in boundary dilemmas. Therefore, an awareness of boundaries in a therapeutic relationship between a patient and a psychiatrist is crucial. Gutheil and Gabbard (1998)  divided boundary dilemmas into two groups: Boundary violations and boundary crossings (See table)  . Boundary violations are behaviors that are always harmful to patients. These may include role, time, space, and place of therapy; money; gifts, services, business relationships and related matters; language; clothing; self-disclosure; and physical contact (Gutheil and Gabbard, 1993)  . For example, a psychiatrist who receives stock tips, or receives expensive gifts from patients is clearly violating professional boundaries by taking advantage of the patient. Many authors have called sexual contact between the therapist and the patient as the ultimate boundary violation. Gutheil and others , have discussed the special vulnerability of borderline and psychotic patients and how a sexual relationship with the treatment provider can be extremely harmful. Boundary violations by the provider often occur when the healthcare professional displaces or confuses his or her own needs with the patient's needs. , More often than not, such violations begin small and develop gradually. , For example, a physician may begin scheduling a patient as the last appointment of the day or have social contact with them before a sexual relationship develops.
The second group of boundary dilemmas is called 'boundary crossings'. The major difference here is that some authors contend that these too are 'transgressions,' but transgressions that may have positive outcomes (Gutheil and Gabbard, 1998)  . For example, while an expensive gift is a clear violation, accepting a hand made gift may enhance the therapeutic relationship and can help advance the patients' best interests. Martinez has proposed a graded-risk model  to understand boundary crossing that emphasizes an ethical 'process approach.' Martinez et al.  propose that each type of boundary crossing should consider potential harm and benefit to the client and the client-professional relationship, the presence or absence of coercive or exploitative elements, professional's motives and aspirations to professional ideals; and the context (including cultural values).
The APA notes that boundaries are required to ensure that the psychiatrist does not take advantage of a patient and that psychiatrists must avoid patient interactions that are aimed at gratifying the psychiatrist's needs and impulses, and must not use their position to influence the patient in a manner that may undermine or threaten treatment goals.
Data from Gutheil TG, Brodsky A. Preventing boundary violations in clinical practice. New York: Guilford Press; 2008.
| III. Individual and cultural sensitivity|| |
The Principlist approach described by Beauchamp and Childress  has been the dominant ideology in resolving ethical concerns in medical bioethics since the 70's. These include the principles of autonomy (respect the views, choices, and actions of others), beneficence (acting to benefit others), non-maleficence (avoiding harm) and justice (treat people fairly) that are drawn upon "common morality." These principles are at times inadequate in addressing ethical dilemmas. For example, telling a terminally ill patient about the death of her son may uphold the principles of autonomy, truth telling and justice but may be directly opposed to beneficence and non-maleficence. Over the last three decades, a narrative ethics approach has become popular. Authors such as Charron,  have focused on the need for health care practitioners to be mindful and attentive with their patients while simultaneously being aware of their own positionality and internal monologue. In order to manage the unique issues and challenges of each patient and to develop therapeutic goals, a psychiatrist must understand her patient as an individual. The same principles apply in obtaining informed consent from a patient for treatment. In the US, while the law guides us that patients have the right to knowledge about their treatment under "reasonable practitioner" or "reasonable person" standards, mental health practitioners must ascertain patients' capacity to give informed consent. Such situations highlight how psychiatry requires a far greater depth of understanding of the patient than simply following ICD or DSM criteria.
Psychiatry is clearly not an exact science where a laboratory or test value could indicate the problem. Ethicist Joan McCarthy suggests that every moral situation is unique and unrepeatable and its meaning cannot be fully captured by appealing to law like universal principles  . Under this approach we must strive to develop a narrative of the individual patient that incorporates his or her personal experiences and cultural beliefs, the telling and retelling of the individual's story. For example, a patient who believes in holistic treatment approaches may not comply with your prescribed treatment. In the above example of the terminally ill patient, the physician who incorporates the narrative ethics approach would consider the patient's own values, morality and personal beliefs.
| IV. Professionalism|| |
Wynia et al.  have called professionalism a " structurally stabilizing, morally protective force in society." According to the American Board of Medical Specialties,  professionalism is defined as, "…a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to diverse patient populations." Medical professionalism, pledges its members to a dynamic process of personal development, life-long-learning and professional formation, including participation in a social enterprise that continually seeks to express expertise and caring in its work. Candilis and Martinez , have called for a Robust Professionalism that incorporates compassion at its core. This model recognizes the formative influence of personal values, the salience of personal identity in one's work, and the connection of personal and professional identities. The APA recommends that the psychiatrist exhibit honesty and integrity in her interactions with the patient. As with other medical specialties, the psychiatrist must be honest and give complete information to her patients in order to facilitate understanding and education.
The power differential that exists in all medical specialties between the physician and the patient is even more pronounced in mental health treatment. The special insights that psychiatrists and psychologists have into human behavior have been used for torture and enhanced interrogation in many countries. Authors such as Sagan and Jonsen (1976)  observed, because the medical skills used for healing can be maliciously perverted "with devastating effects on the spirit and the body", it is "incumbent upon the medical profession and upon all of its practitioners to protest in effective ways against torture as an instrument of political control".
In the US, Behavioral Science Consultation Teams (BSCT or "biscuit" teams) were developed to advise military interrogators. , Using both psychiatrists and psychologists, BSCT teams employed mental health professionals outside their traditional roles, famously advising interrogators about one detainee›s fear of the dark and about another›s close relationship with his mother. , The American Psychological Association was among the first to denounce the use APA's Council of Representatives voted almost unanimously to prohibit psychologists from participating in national security interrogations  .
| Conclusion|| |
We see that even within medicine, mental health practitioners are faced with ethical dilemmas that are unique and challenging. Only when a patient's mental health is incapacitated, can rights such personal freedom be challenged. The patient's disclosure of personal information puts information in the hands of the mental health practitioner that may be highly sensitive. Thus, patients often find themselves in vulnerable positions in such situations where the power differential is marked that can result in boundary violations. Compassion is an integral part of professionalism, along with transparency, honesty, listening to the patient, developing an understanding of the uniqueness of the patient and their story and respecting the basic human rights of the patient. A psychiatrist or therapist must always endeavor to act in a manner that upholds the highest values of his/her profession and value the trust put in his/her by the patient.
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Conflicts of interest
There are no conflicts of interest.
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Source of Support: None, Conflict of Interest: None