What’s Ethical? Psychiatric Practice -...
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Transcript of What’s Ethical? Psychiatric Practice -...
What’s Ethical?Ethics inPsychiatricPracticeLaura Roberts, MDMedical Collegeof Wisconsin
Laura Roberts, MDDisclosures
Research/Grants: NIMH, NHGRI, AHWEndowment
Speakers Bureau: None Consultant: None Stockholder: None Other Financial Interest: Owner, Terra Nova
Learning Systems, which receives funding fromthe NIH
Advisory Board: Board of Directors, APPI
LearningObjectiveDemonstratecompetency inapplying ethical skillsto clinical care ofpatients with mentalillness
Outline
Professionalism andethics
Key ethics skills for thepractice of psychiatry
Safeguard examples:confidentiality,therapeutic boundaries,informed consent
Professionalism
Use of specializedknowledge andexpertise in serving adistinct role or purposein society
Obligation to adhere toethical standards andto assure the ethicalconduct of colleagues
Ethics
Ethics is a scholarly discipline thatexamines, evaluates, and seeks to moredeeply understand moral aspects (the rightand wrong) of human nature and action
Bioethics is the application of this field tothe work of medicine and biological science
The ability to identify the ethical featuresand tensions in a patient’s care
Key Ethics Skills in thePractice of Psychiatry
AltruismAutonomyBeneficenceCompassionFidelity
Honesty IntegrityJusticeNonmaleficenceRespect for persons
Case Illustration #1
A psychiatrist advocates for insurance“parity” for mental illnesses, stating thatmental illnesses are prevalent, severe, andstigmatized, and a major public healthconcern. He argues that mental illnesses donot receive the insurance benefits thatphysical conditionsreceive in our society.
Key Ethics Skills inPsychiatric Practice
The ability to anticipate and work well inethically risky or problematic situations
The ability to gather information and toseek consultation and additionalexpertise in order to clarify and resolvethe conflict
The ability to build additional ethicalsafeguards into the patient care situation
Hierarchy ofissues to beconsidered priorto making aclinical ethicsdecision
Jonsen AR, et al. Clinical Ethics: A Practical Approach to Ethical Decisions in ClinicalMedicine, 5th Edition. New York: McGraw-Hill, Medical Publishing Division, 2002.
Ethics Decision Making
Clinical IndicationsHow serious is the patient’s illness?Is there a need for medical intervention?What is the optimal standard of care for this patient?
Preferences of PatientWhat preferences are expressed by the patient?Is the patient capable of making this clinical decision?What factors may be impinging on the expressed preferencesof the patient?
Quality of LifeWhat is the patient’s quality of life, given his or her illness process?What impact will clinical intervention have on the patient’s quality of life?
External ConsiderationsWhat external factors exist that may affect the patient’s care (e.g., legal issues,limited programs)?
Case Illustration #2
A 36-year-old patient with chronic paranoidschizophrenia and type II diabetes declines hismonthly depot antipsychotic medications– He then stops taking his diabetes medications
Over the next several weeks, he is hospitalizedthree times with diabetic ketoacidosis
On the fourth hospitalization, the patient is placedon a medical hold and transferred to thepsychiatric unit– Emergency clinical care is initiated
Safeguard ExampleConfidentiality
The ethical obligation to not reveal thepersonal information (history, findings,observations) of a patient withoutpermission
A privilege, not a right
Case Illustration #3
A psychiatrist has carefully cultivated atherapeutic relationship with a paranoidpatient who has a history of violence
The patient slaps his 8-year-old daughter infront of the psychiatrist, just prior to a familyevaluation session– The child has many visible bruises
The psychiatrist intervenes and contactsthe local child protective services agency
“…the edge or limit of appropriate behavior…in the clinical setting”
Imperative to set aside one’s own“interests” (e.g., for self-gratification)in the service of the patient’swell-being
Examples of worrisome signals– Touching– Favors– Gifts– “Exceptions”– Self-disclosure
Safeguard ExampleTherapeutic Boundaries
Ethical RisksBoundary Crossings and Violations
Boundary crossings are behaviors withinthe therapeutic relationship that push thelimits of acceptable professional conductbut may serve to advance the treatment
Boundary violations, on the other hand, arebehaviors that go beyond the parameters ofappropriate conduct and have clearpotential for exploiting the patient
Case Illustration #4
A psychiatrist attends a neighborhoodpicnic and is approached by anacquaintance with a high-ranking role in thecommunity
The neighbor says that she is depressed,occasionally has thoughts that life is nolonger “worth it,” and wonders if she coulddrop by the psychiatrist’s home every weekor so to see the psychiatrist “off the record”
InformationDialogue/process
RationaleRisks/benefits and
likelihoodAlternatives
Future choicesDecisional Capacity
CommunicationUnderstanding
ReasoningAppreciation
VoluntarismDevelopmentalIllness-related
Psychological/culturalContextual factors
Informed ConsentTherapeutic relationship
Nature of decision
Safeguard ExampleInformed Consent
Case Illustration #5
A person diagnosed with schizophreniaunderstands the risks, benefits, andalternatives to an antipsychotic regimenthat his psychiatrist recommends
He says “that sounds great for otherpeople, but…I don’t have schizophrenia”
Resources
Roberts LW, Hoop J. Professionalism andEthics: Q & A Self-Study Guide for MentalHealth Professionals, APPI, 2008.
Roberts LW, Dyer A. A Concise Guide toEthics in Mental Health Care. APPI, 2004.
Geppert CA, Roberts LW. The Book ofEthics: Expert Guidance for Professionalswho treat Addiction. Hazeldon, 2008.
an educational series offered byCME Outfitters, LLC
This CME/CE activity isco-sponsored by
What’s Ethical: Ethics in Psychiatric Practice Laura Roberts, MD Jonsen AR, Siegler M, Winslade WJ: Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, 5th Edition. New York, NY; McGraw-Hill, Medical Publishing Division: 2002.
