Thursday, 20 June 2019

Why Psychiatry Must Go Above and Beyond in Ethics

Psychiatry is among the most unique disciplines in all of medicine. Psychiatrists are not only medical doctors, but they are also mental health specialists who deal as much with the thoughts and emotions as they do the physical body. These added dimensions also mean greater responsibility to medical ethics. Psychiatry jobs – whether they be permanent employment, private practice, or locum tenens – are held to a higher ethical standard.

 

A fascinating paper published in 2016 by the Indian Journal of Psychiatry discussed the higher ethical standards of psychiatry. This post is based on that article. While it will not go into the article in great detail, some of the more salient points deserve further discussion.

 

Patient Expectations of Confidentiality

 

The first thing to recognize is that patients have a reasonable expectation of confidentiality regardless of the treatment being sought. Thus, psychiatrists are not alone in the need to maintain confidentiality. Doctors in every specialty are required by medical standards and the law to protect any and all information furnished by patients. But in psychiatry, those obligations cover more information.

 

For comparative purposes, consider a cardiologist whose access to patient information includes medical history and personal information like name, address, etc. All of that information must be kept confidential. If that same patient were also seeing a psychiatrist, there will be a greater need for confidentiality in the psychiatric office.

 

Why? Because the psychiatrist is privy to information the cardiologist is not. The psychiatrist gets to hear the patient’s inner thoughts and emotions. He might hear stories of marital infidelity, sexual dysfunction. He might hear of unresolved anger. The patient might speak of hearing voices or seeing things.

 

Everything the psychiatrist hears in his office must remain confidential. Without confidentiality there is an immediate breach of trust which could ultimately render any possible treatment ineffective.

 

Professionalism and Boundaries

 

A second area of ethical concern relates to the professionalism of the clinician and how that professionalism affects boundaries. It is generally understood that some types of behaviors are off-limits to psychiatrists when treating patients. All are behaviors that cross the line of medical professionalism; some cross additional lines as well.

 

Unfortunately, violating boundaries makes it nearly impossible for a psychiatrist to continue acting as the patient’s clinician. That psychiatrist must step aside and refer the patient to another psychiatrist for care. Otherwise, continued unprofessional behavior could be harmful to both patient and doctor alike.

 

Working with Patients Individually

 

A third area of ethical concern might very well be the most difficult in all of psychiatry: dealing with patients on an individual basis without violating the principles of autonomy, beneficence, non-malfeasance, and justice. These principles have guided medical ethics for decades, though they do not always serve psychiatry well.

 

One example cited by the referenced paper speaks of telling a terminally ill patient about the death of her son. Offering that knowledge may be in keeping with autonomy and justice, but it would be at odds with beneficence and non-malfeasance.

 

The paper also cites the example of not being able to obtain the necessary information from a patient unable to give informed consent. That patient might also not be well served in knowing everything about his or her condition. If informed consent is not possible, having a reasonable understanding of one’s mental state might also not be possible.

 

Psychiatry could very well be the most challenging discipline in medicine. Beyond the difficulty of treating mental health issues that do not always fit into nice, tidy boxes are a myriad of ethical and moral dilemmas that do not come with easy answers.

 

 

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