ETHICS IN PSYCHIATRY : FROM THE THE AMERICAN PSYCHIATRIC ASSOCIATION

Proposed Changes to APA Guidelines

Principles of ethics and professionalism in psychiatry

Section 1. Introduction

Mental illness affects millions of persons throughout the world, regardless of age, gender, class, or nationality. One in five people will suffer a significant episode of mental illness over the course of their lives, with neuropsychiatric disorders comprising the leading cause of disease burden in countries with established market economies and the third leading cause of disease burden across the globe. The immense suffering associated with mental illness is greatly increased by stigma, societal disadvantage, and coexisting conditions.

Psychiatrists are physicians with specialized knowledge of mental illness and its treatment. Psychiatrists share the same ethical ideals as all physicians and are committed to compassion, fidelity, beneficence, trustworthiness, fairness, integrity, scientific and clinical excellence, social responsibility, and respect for persons. Psychiatrists endeavor to embody these principles in their diverse roles as diagnosticians, treating physicians, therapists, teachers, scientists, consultants, and colleagues.

The daily work of psychiatrists poses distinct ethical challenges. Mental illnesses directly affect thoughts, feelings, intentions, behaviors, and relationships – those attributes that help define people as individuals and as persons. The therapeutic alliance between psychiatrists and patients struggling with mental illness thus has a special ethical nature. Moreover, because of their unique clinical expertise psychiatrists are entrusted with a heightened professional obligation: to prevent patients from causing harm to themselves or others. Psychiatrists may consequently be required to treat patients against their wishes and breach the usual expectations of confidentiality. Psychiatrists may also be called upon to assume duties of importance to society, such as legal or organizational consultation, that are beyond the scope of usual clinical activities. These features of psychiatric practice may therefore create greater asymmetry in interpersonal power than in other professional relationships and introduce ethical issues of broad social relevance. For all these reasons, psychiatrists are called upon to be especially attentive to the ethical aspects of their work and to act with great professionalism.

Psychiatrists are entrusted to serve in a special role in the lives of ill persons and in society as a whole. Psychiatrists’ ability to serve in this special role is predicated on the fulfillment of the ethical principles that ground the field. This is the cardinal feature of a profession: professionals apply specialized knowledge in the service of others, and are part of a distinct group that affirms a code of ethics and engages in self-governance. Members of the profession, by definition, must exercise strong self-discipline and accept responsibility for their actions. They must seek to adhere to a specific set of standards. As a consequence, there are many who have a stake in the ethical commitments and conduct of psychiatric practitioners. This is most apparent for patients and their families, but it is also true for colleagues, students, members of the profession of medicine as a whole, and society at large. All count on the profession’s integrity in embodying the principles of ethical practice.

Ethical conduct by psychiatrists goes beyond mere knowledge of ethics principles. It also requires certain moral skills and habits. These assure that ethically sound judgment and the actions that follow fall within accepted ethical bounds. Examples of skills of importance to the ethical practice of psychiatry include: 1) the ability to recognize ethical aspects of a professional situation; 2) the ability to reflect on one’s role, motives, potential “blind spots”, and competing or conflicting interests; 3) the ability to seek out, critically appraise, and make use of additional knowledge and valuable resources, e.g., clinical, ethical, or legal information; 4) the ability to apply a formal decisionmaking model in evaluating the ethical aspects of a professional situation and in identifying possible courses of action; and 5) the ability to create appropriate safeguards in an ethically complex situation. Routine behaviors or habits of the ethical practitioner include obtaining additional data, seeking appropriate consultation or supervision, maintaining clear professional boundaries, and separating roles that may pose conflicts. Together these skills and habits support ethical decision-making and minimize the likelihood of ethical breaches.

A statement of ethics principles affirmed by the profession is an important resource for aligning ethical knowledge with professional behavior. Such a document can provide guiding principles to assist practitioners in identifying and resolving ethical dilemmas. Ethics principles can also help define the boundaries of acceptable behavior, proscribing certain behaviors while supporting and encouraging others. Consequently, ethical principles are valuable in assessing the professional conduct of colleagues. Ethics principles are likewise an important tool for the educators who introduce students to the ethical foundations of the field.

To help fulfill these aims, this document has been organized into five sections.

Section 1 introduces the scope, spirit, and structure of the document.

Section 2 presents the Principles of Medical Ethics of the American Medical Association. These nine principles serve as the foundation for ethics and professionalism in the field of medicine, including the specialty of psychiatry. The American Psychiatric Association conforms to these AMA principles in its Constitution and Bylaws.

Section 3 articulates ethics principles as applied to the morally complex aspects of psychiatric work. These aspects of professional practice are organized into four domains: the ethical basis of the physician-patient relationship; ethically important practices in psychiatric care; the ethical basis of relationships with colleagues; and other ethically important topics in psychiatric practice. Each domain covers several topics, such as dual agency, honesty and trust, confidentiality, informed consent, conflict of interest, small community issues, among others. For each topic, we provide a description of important ethics concepts, and seek to demonstrate their special relevance to psychiatric practice.

Section 4 provides a discussion of the uses of the document to educational, clinical, professional compliance, and related areas.

Section 5 outlines selected additional resources that may be of value to readers.

This document differs in two respects from prior APA codes of professional ethics (the Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry). It is oriented toward educational more than regulatory purposes. It is for this reason that the document gives attention to the philosophical basis of ethical psychiatric practice, the concepts and terms of importance to ethics and professionalism, and the skills and habits of ethical professionals. Moreover, the document seeks to encompass more completely the multiplicity of roles and activities of psychiatrists, the diverse populations they serve, and the array of settings in which they work. It is our hope that this document will become a valuable resource for our profession.

Section 2. Principles of Medical Ethics of the American Medical Association

Preamble. The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. As a member of this profession, a physician must recognize responsibility to patients first and foremost, as well as to society, to other health professionals, and to self. The following Principles adopted by the American Medical Association are not laws, but standards of conduct which define the essentials of honorable behavior for the physician.

I. A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.

II. A physician will uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.

III. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements, which are contrary to the best interests of the patient.

IV. A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law.

V. A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.

VI. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.

VII. A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.

VIII. A physician shall, while caring for a patient, regard responsibility to the patient as paramount.

SURELY THIS MEANS THAT 'SAFEGUARDING' CHILDREN IS PARAMOUNT TO ANY PROFESSIONAL AS CONSTANTLY STATED BY DIRECTORS FO CHILDRENS' SERVICES. CAN GIVING THEM HARMFUL 'DRUG COCKTAILS' CONSTITUTE SAFEGUARDING THE CHILD?

IX. A physician shall support access to medical care for all people. Adopted June 1957; revised June 1980; revised June 2001

Section 3. Ethical principles in the professional practices of psychiatrists

In this section, we illustrate how ethical principles find expression in the professional practice of psychiatrists in their various roles and activities. We have focused on four domains:

3.1 The ethical basis of the physician-patient relationship

3.2 Ethically important practices in psychiatric care

3.3 The ethical basis of relationships with colleagues

3.4 Other ethically important topics in psychiatric practice

Each domain has several topics that correspond to everyday practice issues. In section 3.2, for example, this document addresses the topics of confidentiality, honesty and trust, non-participation in fraud, informed consent, decisionmaking capacity, involuntary psychiatric treatment, and therapeutic boundary-keeping. Within each topic, we define relevant ethics concepts and explain how they relate to the professional activities of psychiatrists. We also provide examples and, when appropriate, exceptions or special applications of these ideas within the profession of psychiatry.

This document highlights domains and topics that have apparent significance and salience in the practice of psychiatry at the present time. We could not address the full universe of ethically important issues in our field, and we could not anticipate the issues that will accompany future innovation and change in psychiatry. We have thus selected the domains and topics that will, we hope, help clarify and illuminate the fundamental ethical commitments of our profession.

We believe that ethical conduct is informed by knowledge of ethical principles and expectations but is best assured through the acquisition of ethically important skills and behaviors. These skills and behaviors – the “habits” of an ethical professional – will allow a psychiatrist to respond to complex and novel situations with an understanding of their ethical implications and the ethically-sound decisions that may be undertaken.

Practice Domain 3.1

The ethical and professional basis of the physician-patient relationship

Topic 3.1.1 The physician-patient relationship

The physician-patient relationship is the foundation of medicine. It is at the heart of psychiatric practice. Many ethical principles have bearing on this relationship, including respect for persons, beneficence, autonomy, honesty, confidentiality, and fidelity. The physician-patient relationship generally begins when a physician has a face-to-face interaction with a patient in which the physician is entrusted with the responsibility of applying his or her knowledge and clinical skills on behalf of the health and well-being of the patient. In our society, the relationship has been conceptualized as a consensual agreement between two autonomous individuals who are free to enter, sustain, or discontinue the relationship unconstrained by discrimination, coercion, or fear of physician abandonment.

In psychiatric practice, as in other areas of medicine, however, the patient may seek care because of distress from significant mental and physical symptoms. This need for clinical care, especially in cases of severe illness, creates an asymmetry or disparity in the relationship: patients are relatively less empowered than physicians. This disparity creates a special ethical obligation for physicians who must place the unique needs of the patient above their own professional or personal interests. Physicians, furthermore, must be vigilant for situations that can reasonably be expected to cause physical, sexual, psychological, or financial harm to the patient. For psychiatrists, ethical obligations to the patient arise from a special sensitivity to the trust and dependence created, in part, by the communication of highly personal information.

At times, the nature and specific obligations of the physician-patient relationship can vary because of a patient’s age or cognitive capacity. For example, when the patient is a child, the process of informed consent will typically extend to the child’s parent or guardian. Similarly, when a seriously ill patient’s cognitive capacity is compromised, the process of informed consent may include the next of kin or a legally recognized substitute decision-maker.

Third party obligations and the clinical context may also influence the ethical expectations of the physician-patient relationship. For instance, a psychiatrist providing psychoanalytic treatment to a long-term patient should not, under ordinary circumstances, disclose key aspects of the treatment to anyone else. On the other hand, a psychiatrist who serves as a consultant in providing a psychosomatic medicine evaluation undertakes different clinical duties, will have different responsibilities in the patient’s care, and may have different ethical obligations in comparison with the long-time psychotherapist. The consulting physician retains the fundamental responsibility to serve the well-being and interests of the patient, but will naturally share clinical information, diagnostic impression, and treatment plan recommendations with appropriate clinical staff members. Similarly, in forensic, employment, or military settings, the physician’s obligation to preserve a patient’s confidentiality may be limited or redefined because of obligations to a third party.

Because of the complex variations in physician-patient relationships, the reasonably anticipated duties and limits of these different relationships should, when possible, be discussed with the patient. For example, in treating an adolescent in psychotherapy, it will be important to talk with him or her about the kinds of issues that can be “kept private” in their discussions, and which kinds of issues require informing others (e.g., parents, state officials, referral physicians, clinical staff, etc). In a health care system where patients are transferred from one physician to another (e.g., from an inpatient “hospitalist” to an outpatient psychiatrist), the patient should receive appropriate clinical information, such as the reasons for subsequent treatment, the consequences of foregoing treatment and the reasons for transitioning the patient’s care to another clinician.

Topic 3.1.2 Professional competence

Competent care of the patient is the cornerstone of ethical psychiatric practice and is the primary basis of patient trust. Professional competence is the ability to apply the accepted standards of clinical practice to patient care. It is an absolute requirement of ethical psychiatric practice.

In a rapidly evolving and diverse field such as psychiatry, competent practice is influenced by advances in behavioral and biological sciences and by complex social and economic contexts of practice. Obtaining, maintaining, and practicing within the bounds of professional competence consequently requires attention throughout a psychiatrist’s career; life-long learning must be a habit of professional competence.

From an ethical perspective, it is expected that psychiatrists will maintain a sufficient level of professional competence through continuing education, supervision, consultation, or study. It is also expected that psychiatrists will practice within the bounds of their competence. This is predicated on their training, education, professional experience, supervised experience, or consultation. It is further expected that psychiatrists will make referrals or delegate care only to persons who are, in the psychiatrist’s best judgment, competent to deliver the necessary treatment. Finally, it is expected that psychiatrists will obtain the relevant education, training, and supervised experience to implement new treatments with proven effectiveness or treat conditions that are new to their practice.

In an underserved context, if a patient care situation falls outside of a psychiatrist’s usual scope of practice and areas of professional competence, he or she may justifiably provide care if: a) the psychiatrist has closely related training and experience; b) the psychiatrist possesses the most readily available expertise; and c) the patient’s clinical needs warrant evaluation and intervention (e.g., because of severity, urgency).

Topic 3.1.3 Dual agency and overlapping roles

The terms “dual agency”, “dual roles”, “overlapping roles”, and “double agency” refer to the competing allegiances and obligations a psychiatrist may have in an interaction with a patient. Because of their special expertise, psychiatrists sometimes use their training to serve specific social institutions (e.g., employers, the judicial system, the military). Under a variety of circumstances, a psychiatrist may have competing duties to an institution and an individual patient, for instance, or to two patients or two institutions.

Specific examples of dual roles that may give rise to role conflicts include the obligation to assure security in the correctional setting and the provision of an adequate fighting force in the military. In these circumstances the traditional patient-physician relationship is in tension with allegiance to a social institution and concerns of social order, stewardship of community resources, or justice. In these situations, the psychiatrist must always uphold the ethical principle of respect for persons, but honesty (e.g., through accurate and truthful documentation of the findings of an evaluation) may be the greater obligation than beneficence, which typically shapes physician-patient interactions. In other words, psychiatrists may be unable to serve patients exclusively because of appropriate ethical obligations to community safety, social order, or other fundamental societal interests.

A vital ethical skill for psychiatrists who serve in various roles is to recognize the different professional obligations that exist in dual or overlapping role situations. Sometimes it is possible, and advisable, to try to reduce or completely eliminate dual roles. In a correctional setting, for instance, separating the role of clinician from the role of institutional or administrative representative permits the caregiving psychiatrist to safeguard the relationship with the patient. This approach recognizes the differing obligations imposed by the two roles and the confusion that may occur for both the patient and the social institution.

Treating psychiatrists should also generally avoid serving as expert witnesses for their patients or performing evaluations of their own patients for legal purposes. This form of dual agency can damage the therapeutic relationship and confound the accuracy and utility of the evaluation. However, there may sometimes be difficulty in separating psychiatrists’ functions within a complex set of interactions. In Worker’s Compensation, guardianship, or civil commitment hearings, for example, it may not be realistic or even possible (because of legal requirements) to achieve the formal separation of roles. Recognizing the vulnerability of the individual in conflict with a social institution, a permissible alternative to complete role separation is maintaining primary, although not total, allegiance to the individual. Such an approach would allow recognizable thresholds for breaking confidentiality similar to the responsibility for reporting harm to self or others.

When dual or overlapping roles cannot be minimized (e.g., clinical research situations, employee health centers, correctional settings, school-based mental health programs) it is especially important to inform the patient about the role issues and conflicting ethical obligations. Informed consent “cautions” or “warnings” about overlapping roles should be commonplace in these settings.. Attention should be paid to subtle changes in the patient's view of the relationship; cautions and reminders should be repeated if potentially harmful self-disclosures are anticipated. Further, psychiatrists reporting to social institutions must also make clear whether they have personally interviewed an evaluee or formed an opinion based on other data. Language must be clear on any limitations of the professional opinion, using terms and phrasing that describe the appropriate level of uncertainty (e.g., “the records support the presence of…, reports are consistent with.., the data appears to….” etc.) Through such efforts, institutions and patients -- or individuals undergoing evaluations -- are reminded that the psychiatrist fulfills two roles, and that disclosures may be used in ways that are not therapeutic.

There is one role that, despite its basis in medical knowledge, is absolutely prohibited in all fields of medicine. Physicians may not ethically participate in any manner that supports, facilitates, or enacts human torture or the development and monitoring of interrogation techniques that involve torture.

Practice Domain 3.2

Central ethical and professional practices in psychiatric care

Topic 3.2.1 Confidentiality

Confidentiality is the obligation not to reveal a patient’s personal information without his or her explicit permission. Information may be derived either from the patient’s direct disclosure or the physician’s observations. The special nature of confidentiality derives from a long and cherished history that predates modern medicine and privacy laws, and is part of the foundation of the physician-patient relationship. It is important to distinguish between the ethical duty to keep confidences (an obligation created by and owed to the patient) from the legal duty that governs the handling of private medical information (an obligation created by the state). Recognizing this difference maintains the psychiatrist’s focus on the patient’s interest rather than on mere compliance with privacy regulations.

Respecting patients’ confidentiality is especially important for psychiatrists because patients entrust them with highly personal and often sensitive information. Patients’ willingness to make painful, stigmatizing, or embarrassing disclosures depends on their trust in the physician-patient relationship and its expectation of confidentiality. Beyond this therapeutic rationale, there are ethical duties that arise from principles of fidelity (i.e., promise-keeping), beneficence (i.e., doing good, seeking benefit), and non-maleficence (i.e., avoiding harm).

The exchange of patient information with families and others should occur with the patient’s explicit informed consent (or with implied consent in emergencies, see section 3.2.4) and when it is consistent with the psychiatrist’s best clinical judgment. The psychiatrist’s goal when involving families in a patient’s treatment is to facilitate the coordination of care, the gathering of data, and the management of expectations. Although family members may have been excluded from treatment discussions in the past, evolved conceptualizations of patient autonomy now recognize the importance of the patient’s relationships more fully. Thus, the absolute--even routine -- exclusion of families and significant others may not be ethically or clinically justified.

Explicit permission is important for the ethical disclosure of patient information by psychiatrists to family members, teachers, or others. However, psychiatrists may accept or receive information under many circumstances. Psychiatrists should be sensitive to the feelings this kind of information disclosure may raise for patients and maintain communication with them when it occurs.

Several important considerations guide the confidentiality of medical information:

i. Patients should be told of the limits to confidentiality at the beginning of the physician-patient relationship and as events arise that create potential revelations.

ii. Disclosure of confidential information should occur only if informed consent has been given by the patient or if it is necessary to protect the patient or third parties from imminent harm, in a manner consistent with relevant legal statutes.

iii. Disclosure of patient information should always be limited to the requirements of the situation. This limitation is particularly relevant when state or federal privacy rules provide a lower standard of protection.

iv. In their progress notes, psychiatrists should record only the information necessary for continued patient care.

v. Psychotherapy notes may afford further, although not absolute, protection of patient information when kept separate from other components of the medical record. Psychotherapy process comments, therapist formulations and hypotheses, details of patient’s dreams and wishes, and intimate personal details of patients or related individuals should be recorded in these psychotherapy notes rather than the medical record.

vi. Electronic patient records require appropriate, additional safeguards and precautions. (See also Professional Use of the Internet, Topic 3.4.6).

Topic 3.2.2 Honesty and Trust

Honesty and trust are elemental values of a profession. Honesty entails the “positive” duty to tell the truth as well as the “negative” duty not to lie or intentionally mislead someone. Derived from core principles of trustworthiness, integrity, and respect for persons, honesty and trust are fundamental expectations for the patient seeking psychiatric care.

Discussions and interactions in psychiatric practice often deal with highly sensitive and personal information. Psychiatrists may be occasionally tempted to skirt or “soften” the truth in order to avoid harm to a patient. In general, omission (intentional failure to disclose) and evasion (avoidance of telling the truth) will undermine a trusting and constructive relationship between physician and patient and is not appropriate. In addition, releasing inaccurate or misleading clinical information to insurers or employers is a specific example of dishonesty and may constitute fraud. Such behavior undermines trust in the profession as a whole and in third-party interactions in particular. At the same time, out of respect for patient privacy, the ethical physician should reveal only the minimum information necessary for third party review.

Protecting patients from harmful disclosures (i.e., withholding information), as in very acute situations, in therapy with fragile or minor patients, or in end-of-life decision-making -- when deemed essential -- must occur with the strictest concern for patient values and autonomy. This protective measure should be temporary, and ideally will occur with prior discussions with appropriate persons who are in accord with such an approach.

Topic 3.2.3 Non-participation in fraud

Fraud is an action that is intended to deceive, and ordinarily arises in the context of behavior that seeks to secure unfair or unlawful gain. It is illegal, which violates a fundamental ethical principle for the profession of medicine (see Section 2). Moreover, because honest dealings are essential to the physician-patient relationship, any act of deception or misrepresentation compromises the psychiatrist’s ability to provide care.

Psychiatrists communicate with numerous agencies and individuals during patient treatment. They are responsible for the usual physicianly contact with funding and reimbursement agencies, families, employers, and other third parties. However, because of their expertise in human behavior, psychiatrists are often asked, formally and informally, for information justifying or excusing patient actions. This offers numerous opportunities for ethical mis-steps.

Ideally, principles of trustworthiness and integrity will over-ride inappropriate attempts to benefit an individual patient or psychiatrist. Deceptive conduct of any kind cannot be generalized as a model for others, and, when it becomes known, undermines patient trust in the profession as a whole.

Specific examples of fraud in psychiatric practice include making false or intentionally misleading statements to patients, falsifying medical records, research, or reports, submitting false bills or claims for service, lying about credentials or qualifications, supporting inappropriate exemptions from work or school, practicing outside one’s area of professional competence or beyond one’s authorized scope, providing unnecessary treatment, and taking credit for another’s work. Further illustrations of overt (and legally actionable) dishonesty include writing a prescription for a patient in a family member’s name, or writing prescriptions for a larger number of pills than necessary in order to reduce insurance co-payments. These actions are not ethically acceptable in the practice of psychiatry.

Topic 3.2.4 Informed Consent

Informed consent is an ethically and legally important process that involves information-sharing (e.g., about the nature of an illness and a recommended treatment) and knowledgeable and authentic decision-making about the individual’s health (e.g., by a patient or authorized surrogate). Informed consent for assessment or treatment is obtained if adequate information is disclosed, the patient is capable to make a decision, and does so voluntarily.

The doctrine of informed consent has evolved largely since the 1950’s. The legal standard for information disclosure, for example, continues to evolve and still varies by jurisdiction. Many states apply the “professional standard,” in which the amount and content of disclosure is determined by what most physicians traditionally disclose. Another standard, more consistent with an increasing emphasis on patient autonomy, is the “reasonable person standard.” This standard requires that physicians disclose what a reasonable person would want to know. Typically these standards include an accurate description of the proposed treatment, its potential risks and benefits, any relevant alternatives and their risks and benefits, and the risks and benefits of no treatment at all.

The field of psychiatry as a whole is attentive to the use of language and the interpersonal aspects of obtaining informed consent. The manner in which information is presented, the choice of facts that are included or omitted, and the selection of alternatives that are offered have distinct effects on patient choices. Distorting influences on the consent process may consequently arise from the simplest patient interactions. These include telephone conversations, cross-coverage, and curbside encounters in the clinical setting. Even language used in informal interactions with patients can carry the weight of professional opinion and is colored by the vulnerabilities of knowledge and power inherent to the patient role. When seeking consent, psychiatrists thus must be careful not to influence the patient unduly.

Adults are presumed capable of making their own decisions, with the clinical and legal burden of proof falling on those who wish to prove otherwise. Assessments of decision-making capacity should follow clinical models of assessment and the legal standards of the jurisdiction. (See also Decision-making Capacity, Section 3.2e)

Physicians maintain the highest standards of informed consent when they become familiar with, and endeavor to honor, the specific authentic and enduring personal values of their individual patients. The requirement of voluntariness in informed consent thus affirms the autonomous and values-shaped decisionmaking of the individual and it prohibits coercive pressures in the consent process. In the practice of psychiatry, these issues may be particularly salient because some symptoms of certain mental illnesses (e.g., amotivation, alexithymia, a sense of diminished self-worth, negative cognitive distortions) can prevent an individual from discerning, expressing, and enacting his or her specific authentic and enduring personal values in some circumstances. Furthermore, the experience of dependence, societal marginalization, and insufficient access to clinical care may create a situation of desperation that may interfere with voluntary decisionmaking. It is important to note that these vulnerabilities need not confer incapacity. Nonetheless, they should be explored in order to optimize a patient’s decision-making. This is particularly important in psychiatry where, even if patients are decisionally capable, both internal and external factors (e.g., the patient’s illness, stigma, lack of resources) can make them vulnerable to coercive influences.

Important exceptions to informed consent exist:

i. Genuine emergencies do not require informed consent. Emergency care occurs in the framework of implied or presumed consent. That is, in emergency situations in which reasonable persons would want the intervention it is ethical to proceed as if consent exists.

ii. Care for children or incompetent patients requires consent from parents or legally recognized surrogates. Assent of incompetent individuals (i.e., acquiescence as opposed to informed consent) is obtained whenever possible.

iii. Patients may also waive their right to informed consent. This exception, however, presumes competence to do so.

iv. Finally, the doctrine of therapeutic privilege allows a physician to withhold information if it is truly damaging to the patient. But such an exception should be rare. Withholding information about side effects, for example, in the hope of increasing compliance is not acceptable.

Because the concepts of autonomy and informed consent have a legal basis, they may cast the clinical situation in an adversarial light. This view is antithetical to ethical practice. Although the ultimate choice to consent is made by an individual patient, autonomous choice does not take place in a vacuum; it must be nurtured by continued dialogue. Ultimately, the ideal understanding of informed consent is clinical, an important reminder of respect for the strengths of patients and the need for transparent, collaborative, and enduring alliances. Psychiatrists who strive to develop these relationships with their patients will easily exceed the requirements of ethics and law.

Topic 3.2.5 Decision-making capacity

Decision-making capacity is the ability of an individual to reach an informed, reasoned, and free choice, when making a specific decision. Among patients and research participants, capacity is a consideration in psychiatric and non-psychiatric conditions that affect mentation, cognition, or emotional regulation.

Common assessment standards expressed in ethics and law include evidencing a choice, understanding relevant information, manipulating information rationally, and appreciating the situation and its consequences. Elements of each standard are often necessary to a competent decision and apply to the specific task at hand.

Psychiatrists in particular have special preparation with respect to the mental status examination and certain cognitive evaluation procedures. Rather than screen all individuals, psychiatrists may use capacity assessments in a targeted fashion when patient decisions or discussions raise concerns. Psychiatrists may be asked to perform capacity assessments when patients or research participants exhibit cognitive deficits, appear to lose decision-making capacity, or manifest atypical behaviors and decisions. Although any physician may conduct the assessment, psychiatrists are specially trained to identify the vulnerabilities of persons with mental retardation, delirium, or hopeless outlook as well as to identify cognitive strengths of even severely ill persons. Psychiatrists recognize that deficits in decision-making capacity may be overcome by targeted educational and clinical interventions. These often include part-by-part and repeated information disclosures, or use of a single trusted clinician to communicate information. Interventions to reduce anxiety, diminish psychotic symptoms, or reduce sedating side effects are equally valuable in overcoming incapacity. Other interventions may include videotape, written, or group education sessions.

Psychiatrists may apply assessment standards on a “sliding scale”, with more stringent assessments and higher thresholds of capacity required for decisions that are more consequential, complex, or risky. When incapacity persists surrogate decision makers may be invoked in accordance with local law. Surrogate decision-makers themselves should also be held to appropriate standards of decision-making capacity.

Capacity assessment is particularly relevant for determining the wishes of patients who want treatment or research procedures after they become incapacitated. In such circumstances capacity assessment tools or independent interviewers may be helpful in maintaining standards of surrogate decision-making and adherence to patient wishes. Reminding patients of their earlier preferences can also serve to enhance their decision-making. These techniques, however, do not, overcome the clinician or investigator’s primary obligation to provide appropriate information and assessment.

Topic 3.2.6 Involuntary psychiatric treatment

Involuntary psychiatric treatment most commonly comprises psychiatric hospitalization or court-ordered outpatient treatment. Mandated treatment generally uses the state’s enforcement apparatus to place individuals into medical care, and is justified by the doctrines of police power and of parens patriae (i.e., the state as “parent”).

For psychiatrists, mandated treatment creates inherent ethical tensions. It requires great sensitivity to principles of respect for persons and social responsibility because psychiatrists are contributing to decisions directly controlling patient choices. This kind of power -- in which a patient’s personal freedoms are limited and treatment decisions are being made -- is generally exercised by careful balancing of principles that value both the individual and the community.

Involuntary hospitalization is usually justified by patients’ imminent dangerousness to themselves or others, or their inability to meet basic needs. To meet these criteria, dangerousness must be likely in the near future, and related to a major mental illness. In acknowledgement of the seriousness of depriving a patient of freedom, involuntary commitment usually requires judicial review, access to legal counsel, and consideration of the least restrictive alternative to hospitalization.

Separate authorization is often required for treatment with psychiatric medications. In collaboration with the patient (and/or surrogate decision-makers) ethical psychiatrists discuss those treatments that are most likely to restore the patient’s freedom – if necessary, in incremental fashion. This requires sensitivity to the coercive nature of commitment, the informed consent process, and the patient’s decision-making capacity. When there is a treatment refusal, and efforts to engage in collaborative decision-making have been insufficient to prevent harm, administrative or legal appeals may be available to review treatment and may require a showing of impaired capacity.

Historically, prior to the ascendancy of dangerousness-based statutes in the 1970s, treatability was the most common legal criterion for involuntary psychiatric hospitalization. The APA has taken a view that combines the two. The APA’s model law for civil commitment embodies a standard that adds treatment rationales to commitments using dangerousness criteria. The APA’s model law requires that:

i. the person is suffering from a severe mental disorder; and

ii. there is reasonable prospect that his disorder is treatable at or through the facility to which he is to be committed and such commitment would be consistent with the least restrictive alternative principle; and

iii. the person either refuses or is unable to consent to voluntary admission for treatment; and

iv. the person lacks capacity to make an informed decision concerning treatment; and

v. as the result of the severe disorder, the person is a) likely to cause harm to himself or to suffer substantial mental or physical deterioration, or b) likely to cause harm to others.

Another common form of involuntary care is mandatory outpatient treatment. Although many states retain the same criteria for outpatient commitment as inpatient commitment, the focus is increasingly on repeated deteriorations that require hospitalization. The likelihood of continued deterioration without intervention, a treatment plan that holds the prospect of stabilization, and involvement of the community treatment team are important ethical requirements.

Outpatient commitment should be informed by concern for patient values, past clinical history, and decision-making capacity. Specific procedures that address non-adherence to recommended treatment should be clear to patients and clinicians, from mandated emergency evaluations to court hearings.

Expectations for taking psychotropic medications should be clearly stated in a formal treatment plan. Forced medication, however, remains a matter of some legal controversy. The ethical problem, as in inpatient settings, remains one of creating a class of persons for whom psychiatrists are required to care, yet who they are unable to treat.

Ethical obligations to patients committed in the community may require psychiatrists to advocate for greater resources, community-based services, and parity with other forms of medical care. Active outreach and intensive service coordination are among the means for meeting these obligations and ending the suffering of people living with mental illness who may not receive adequate care without such intensive efforts.

Psychiatric commitment of children by parents or guardians requires even greater attention to the effects of confinement and loss of liberty. In such cases psychiatrists endeavor to assure a balance between the fewest obstacles to treatment and the greatest protections from unnecessary institutionalization. The ethical ideal is one of the child’s best interest, appropriate high quality care, and psychiatric participation.

Topic 3.2.7 Therapeutic Boundary-keeping

Boundaries may be described as defining the limits of a profession. They connote a professional distance and respect that ensure an atmosphere of safety and predictability. Appropriate therapeutic boundaries are also necessary for therapeutic efficacy. Psychiatrists are trained to examine and appreciate the significant psychological and social overtones of the treatment relationship. Their expertise consequently gives rise to specific rules that govern the bounds of ethical practice.

Physicians must never exploit or otherwise take advantage of patients. The unique position of power afforded by the psychotherapeutic relationship can be used in ways that are unrelated to treatment. Physicians must therefore limit the relationship with patients to the therapeutic context. This boundary requires that physicians avoid patient interactions that are aimed at gratifying the physician's needs and impulses.

Professional boundaries limit both sexual and non-sexual behavior. Even the possibility of a future sexual or romantic relationship may contaminate current therapy. Thus sexual activity, not only with current but also with former patients, is unethical. Likewise, any occasion in which the physician interacts with a current or former patient in ways that may be a prelude to an intimate, non-professional relationship (e.g. as a date, intimate friend etc.) should be avoided.

Inappropriate physical contact is perhaps the most obvious form of boundary violation, but other behaviors can transgress, undermine or cross therapeutic boundaries. These cause harm by exploiting the patient's dependence on the physician or by exploiting the inherent power differential between them.

Examples of non-therapeutic interactions within the treatment relationship that should be avoided include, but are not limited to: financial and business dealings, employer-employee relationships, or trustee and guardianship roles. These boundary violations, as with inappropriate physical contact, have the potential to compromise the physician's exclusive focus on the patient's well-being, to impair the physician's judgment, and to diminish the effectiveness of care.

The rules guiding professional boundaries are context-sensitive. For example, social or business interactions with a patient may be unavoidable in a rural setting. Because of this, it is important to distinguish boundary violations from boundary crossings. Boundary violations are transgressions that are immediately harmful, are likely to cause future harm, or are exploitive of the patient. Boundary crossings are deviations from customary behavior, but do not harm the patient, and may allow for flexibility within the therapy.

Psychiatrists recognize that not all therapeutic boundary issues may be resolved satisfactorily. Although psychiatrists are encouraged to address boundary issues with the patient in therapy and to seek consultation with colleagues, certain problems may only be resolved by termination of the therapeutic relationship. These include instances when the physician’s subjective reaction to the patient interferes with therapy or the patient’s intentional intrusion into the physician’s personal life makes it difficult to assure intact treatment boundaries.

Specific applications of boundaries in psychotherapy include:

i. Time and Place – The therapeutic relationship is bounded by constraints on the appointment itself. A set time to begin and end a session should be agreed upon and adhered to. Although variations may, on occasion, be helpful (e.g. visiting a patient with a severe physical illness at home) psychiatric sessions should take place in dedicated office space.

ii. Money – Psychiatric fees exemplify the business nature of the therapeutic relationship.

Reduced, waived, or unpaid fees should be considered carefully and discussed with the patient because they may adversely affect therapy. In most health care systems such as academic medical centers, practices that may be identified as non-equitable may place psychiatrists’ institutions at risk for violations of federal regulations. Barter (i.e., allowing the patient to trade or work for the therapist in order to pay for treatment) is at best confusing and ill-advised. Barter in some jurisdictions is illegal.

iii. Gifts – Small gifts from patients, especially small handmade gifts, are acceptable. Their meaning and symbolism are appropriate for discussion in therapy. Psychiatrists must also be aware that the meaning of gifts varies across cultures. Large personal gifts should be avoided. Philanthropic donations to finance or support a psychiatrist’s position or research (e.g., an endowed chair) should be channeled through proper administrative venues. The appropriateness of accepting such gifts should be determined in consultation with colleagues or ethics committees. Thus acceptance of philanthropic gifts, in psychiatry as in other fields of medicine, may be ethically acceptable if there is sufficient role separation and if appropriate safeguards are in place to prevent exploitation of the patient. The restrictions on receiving gifts from industry (e.g. pharmaceutical companies), are well defined in the AMA Council on Ethical and Judicial Affairs (CEJA) code. In general, gifts from industry should benefit patients, relate to the physician’s work, and be of minimal value. (See also Financial Conflicts of Interest, 3.4d).

iv. Self-disclosure – Self-disclosure from the therapist is not, in general, conducive to the therapeutic relationship and should be avoided. Therapists should not burden patients with their own personal issues, and they should not use the opportunity of the therapeutic relationship to influence the patient in any way not directly relevant to the treatment goals. Exploring common interests such as sports and movies, while likely boundary crossings, may on occasion be useful in the therapeutic process. The disclosures required by general standards of truth and honesty are expected (e.g., fees, vacation schedules, conflicts of interest, etc.) (See also Honesty and Trust, 3.2b).

v. Physical contact – Sexual activity with current and former patients is unethical. Non-sexual physical contact, other than a handshake, is best avoided. Patients may interpret touch differently than the psychiatrist intends. Therapy with children does allow contact appropriate to the patient’s development and clinical condition (e.g., a hug).

vi. Language choice – Boundary violations may stem from the therapist’s choice of language. The title or name the therapist and patient call each other is an important and sensitive issue that should be discussed in therapy. Use of the patient’s first name, for example, may imply an intimacy that is not intended, and may add to the power difference, especially if the therapist is referred to as “Doctor.” By the same token, the use of last names may be experienced as distant and aloof. The choice of language by the psychiatrist should be motivated by therapeutic aims. The use of expletives and off-color language may be experienced as verbal assault and should be avoided.

vii. Appearance – One’s manner of dress also requires professional boundaries. Psychiatrists should follow common professional office standards and avoid dressing provocatively.

viii. Influence – The psychiatrist’s influence in the professional relationship should be closely monitored. Psychiatrists should not use their unique position of power in the therapeutic relationship to influence the patient in any way unrelated to treatment, (e.g., by focusing on political views, direct solicitation of donations to a hospital, or recruitment to a personal cause or organization).

ix. Behavior with family and other patient intimates – Personal relationships between the therapist and the patient’s family (or individuals intimately associated with the patient) should be avoided during the course of therapy and usually even after it ends.

Practice Domain 3.3

The ethical and professional basis of the relationship with colleagues

Topic 3.3.1 Seeking professional consultation

An important aspect of psychiatric practice is the ability to recognize when one needs consultation. Professional competence itself entails recognizing the limits of one’s clinical skills. Consultation in the analysis of ethical dilemmas is encouraged as well.

Psychiatrists treat difficult illnesses, and psychiatric illnesses are influenced by complex social and cultural contexts, co-morbid conditions, and stigma. Because of this complexity, psychiatrists should carefully consider the need for consultation when patients are not doing well.

If psychiatrists receive referrals for conditions that are outside their expertise and more competent psychiatrists are available, they should make the referral to the more competent clinician. However, psychiatrists should not delegate care that requires the exercise of professional medical judgment to non-physicians.

Psychiatrists should agree to patient requests for consultation (or to the requests of family/guardian for minor or incompetent patients). Psychiatrists may suggest a choice among consultants, but the patient or family should make the final decision. If psychiatrists disapprove of the professional qualifications of the consultant, or have a difference of opinion with the findings, they may withdraw from the case after suitable notice.

Topic 3.3.2 Relations with non-psychiatrists/collaboration on multidisciplinary teams

The primary goal in multidisciplinary treatment, as in all psychiatry, is the highest standard of care. This derives from recognizable ethical standards of beneficence and fidelity to patients, and draws on the expertise and ethics of professionals who are similarly devoted to mental health. The treatment of patients, especially those who are chronically ill, is enhanced by multidisciplinary coordination (e.g., with psychology, social work, and nursing).

When psychiatrists assume a collaborative role with other mental health clinicians, however, they must assure that they are fully engaged and not merely used as “figureheads”. Decision-making in collaborative treatment approaches must occur in a manner that enhances the care of the patient.

One type of collaboration occurs with independent practitioners. For instance, a psychiatrist in private practice may treat a patient with medication, while an independent psychologist or social worker provides psychotherapy. Although the practitioners work independently, they coordinate their care and assume shared responsibility for the patient. The psychiatrist and the collaborating clinician must communicate with their common patient the unique roles of each clinician. For example, it should be clear which clinician is to be called when the patient becomes suicidal..

In some multidisciplinary teams, the psychiatrist is the only physician involved in the patient’s care and thereby bears special ethical and legal responsibilities. Because of the specialized knowledge and level of accountability of physicians, psychiatrists should not accede to a decision which may be detrimental to sound principles of psychiatric patient care.

Topic 3.3.3 Responsibilities in teaching and in supervising psychiatrists-in-training

The training of the next generation of psychiatrists is an important duty based in scientific and clinical excellence, social responsibility, and respect for persons. Psychiatrists should strive to take part in the training of young psychiatrists, as well as in the education of new physicians on the psychiatric aspects of medicine.

As teachers and supervisors, psychiatrists must model not only clinical expertise but also a high standard of professional ethics. Psychiatrists should remain committed to fostering a positive, respectful learning environment for trainees. Psychiatrists must be mindful of the asymmetry in power between themselves and their trainees; this asymmetry places important fiduciary responsibilities on the teacher (for example, avoidance of sexual involvement with trainees) that take into account the vulnerabilities of trainees and their development as professionals.

Topic 3.3.4 Responding to the unethical conduct of colleagues

All physicians have an obligation to recognize and report the unethical behavior of colleagues. Unethical conduct includes a variety of behaviors that violate professional standards. These may include exploitation of a patient, dishonesty, fraud, or behavior meant to demean or humiliate others.

The duty to report unethical conduct is an essential part of a profession’s self-regulation. It is the members of a profession who are in the best position to recognize unethical behavior from their colleagues. When unethical psychiatrists continue to practice, they not only harm patients, but also damage the profession as a whole. They also harm future patients who may become reluctant to seek care.

Physicians who engage in unethical behavior may be unaware of the ethical standards they are expected to observe. Alternatively, they may engage in unethical conduct because they believe the rules do not apply to their situation or believe they are “an exception”. Finally, misconduct may occur because physicians intentionally choose not to abide by the rules and expectations of the profession. Irrespective of the reasons behind misconduct, however, psychiatrists have ethical obligations to learn and follow their profession’s standards. Colleagues are obliged to follow the reporting requirements of their jurisdiction. In some instances reporting is mandated by law.

In the clinical setting in particular there should be special protections (e.g., opportunities for consultation, supervision) against any behavior that could reasonably be expected to exploit a patient.

Unethical behavior which does not fit into the category of impairment or incompetence should be reported in the following manner:

i. Unethical conduct which threatens patient safety or welfare should be reported to the appropriate authority of the clinical setting, (e.g., to the chief of a particular service, or the hospital chief of staff).

ii. Unethical behavior which violates the provisions of the state licensing board should be reported to the state licensing board.

iii. Unethical behavior which violates criminal statutes should be reported to the appropriate law enforcement authorities.

iv. Examples of unethical conduct which do not fall into the previous three categories, or which has not been addressed specifically by other institutional policies, should be reported to the local district branch of the APA, or to the county medical society.

Topic 3.3.5 Responding to impaired colleagues

Impairment among psychiatrists arises from physical, mental, or substance-related disorders that compromise their professional competence. An impaired physician not only fails the ethical duty of providing professionally competent care, but also risks direct harm to patients. The effect of impairment is also heightened because psychiatrists often work with seriously ill persons who may not recognize impaired behavior. Some patients may consequently be unable to advocate for themselves or seek alternative treatment.

Moreover, an impaired physician fails the community of psychiatrists and its standards. Because psychiatrists are uniquely trained to identify impairment from mental illness or substance abuse, they have a special ethical responsibility to monitor their own health. Psychiatrists also have an ethical obligation to be familiar with the relevant legal and institutional policies that address physician impairment. It is likewise important to be aware of the resources that can assist impaired colleagues. When psychiatrists observe evidence of impairment, they share in the obligation of all physicians to abide by the law and to assure patient safety by reporting it.

Domain 3.4

Other ethically important topics in psychiatric practice

Topic 3.4.1 Working within organized systems of care

Managed care systems include those that prospectively, concurrently, or retrospectively review treatment in order to contain costs. Such systems may emphasize preventive or primary care services, require specific approvals for specialty procedures or referral, encourage use of specific treatment guidelines, or create economies of scale to streamline care within large systems.

The fundamental tension of psychiatrists working in this setting is addressed by maintaining the primacy of patient benefit while recognizing the importance of resource stewardship. Psychiatrists practicing within such systems must be honest about treatment restrictions, assure reasonable access to care within the system, and help identify alternatives available outside it.

Use of appropriate standards of care and evidence-based practices, when available, are part of this obligation and support efforts to maintain the primacy of patient care. In the roles of policy-maker, administrator, or reviewer, psychiatrists must live up to the general standards of fairness in the profession and to clinical standards of care. Persistent concern for patient welfare must remain the paramount principle in decisionmaking. Fiduciary obligations to use resources wisely and assure access to care should be guided by rationally synthesized, evidence-based practices and transparent communication to enrollees regarding what is covered and what is not.

In keeping with the professional principles of fairness, respect for persons, and fidelity, psychiatrists ensure that significant injustices of benefit coverage or availability are remedied by identifiable and accessible appeal mechanisms. This includes advocacy for parity of care and non-discrimination for psychiatric and other medical conditions.

Because patients do not necessarily yield any of their expectations of privacy in the managed care setting, both psychiatrists and reviewers retain strong obligations to maintain the confidentiality of the medical record.

Psychiatrists should keep themselves abreast of specific cost-containment strategies that are unethical, including gag clauses, hold harmless clauses, proprietary definitions that restrict care, and other emerging practices.

Topic 3.4.2 Clinically Innovative Practices

Evidence-based practice is a cornerstone of professional competence. However, clinical decision-making in situations where there is not yet an established literature is not uncommon. In such situations, patient care should still be guided by informed clinical judgments drawing on sound theoretical reasoning, the best available research, and mainstream clinical experience. When usual treatments have failed, psychiatrists retain the authority to offer non-standard or novel interventions using a shared decision-making approach grounded in the patient’s informed consent and a thorough discussion of how the treatment is being chosen and the uncertainties surrounding it.

The advancement of psychiatric diagnosis and treatment requires formal research but it can often be sparked by the clinical innovation that precedes it. Clinical innovation, however, must be clearly distinguished from human research in its theoretical and practical foundations, and should not be confused with scientific inquiry that seeks to produce generalizable knowledge. The reader is referred to the APA Task Force Report on Research Ethics for elucidation of the principles and recommendations offered for psychiatric research.

Topic 3.4.3 Psychiatric issues in end-of-life care

End-of-life care is a collaborative decision-making process that should begin early in the physician-patient relationship. Preparation for conditions that may require palliative care, withholding or withdrawal of treatment, or general trade-offs of longevity for quality of life involves familiarity with patient values and exploration of common scenarios that arise in the medical setting.

Psychiatrists can have a critical role to play in end-of-life discussions because of their experience in dealing with sensitive and difficult discussions with patients. Psychiatrists can also identify and treat common neuropsychiatric symptoms at the end of life. Finally, psychiatrists may be well-positioned to address the psychological suffering that accompany the stigmatization and marginalization of those nearing the end of life.

Appropriate approaches to end-of-life care often combine treatment–specific information with values histories. Such approaches allow physicians to balance information regarding end-of-life care with accurate knowledge of patient sensibilities. Patients must be provided sufficient information for making decisions and their wishes documented and monitored over time. Ongoing discussions with care-givers can be an invaluable source of information. Use of the full range of tools for improving end-of-life care – including advance directives, treatment vignettes, and values histories – can begin to overcome the barriers to treatment faced by persons requiring end-of-life care.

Where there is doubt regarding the authenticity or stability of decisions, psychiatrists have special expertise in focused capacity assessments. In addition, specific assurances that patients will not be abandoned can overcome feelings of hopelessness. Information on the likely course of an illness and means for managing symptoms can also bring hope. Improved communication is critical for addressing common feelings of dread and despair, identifying and treating depression, addressing medication side effects or related neuropsychiatric symptoms, and supporting families in resisting psychosocial stressors.

Topic 3.4.4 Financial Conflicts of Interest in Relations with Pharmaceutical Manufacturers

The practice of psychiatry and the roles assumed by psychiatrists may bring competing values into conflict (See Section 3.1.3, “Dual agency and overlapping roles”). The mere existence of a conflict of interest is common, expected, and does not by itself imply any wrongdoing or compromise in the integrity of the professional. Whether and how a conflict of interest is recognized and addressed, however, does raise important ethical questions. Failure to recognize and actively manage conflicts of interest does constitute a serious compromise of professional integrity. Without active efforts, conflicts of interest may create pressures that may shape physician decisions or actions in ways that are detrimental to patients and to the profession.

The APA endorses the codes of conduct outlined in recent documents of the American Medical Association (see Section 5). The ethics of managing financial conflicts of interest must go beyond the mere following of rules and instead embrace their spirit.

It is also possible, and indeed quite common, for an activity primarily intended for marketing to meet the minimal regulatory requirements of “education,” thus escaping FDA scrutiny. The FDA sets minimal standards because it expects objective, independent physicians—motivated by the welfare of their patients and an allegiance to academic integrity—to exercise their own scrutiny. Therefore integrity and true professional self-regulation require that the standards be set at a higher level than mere regulatory compliance. Such integrity cannot be externally imposed; it should be the aspiration of individual practitioners as well as of professional societies.

Some useful questions for self-appraisal of conflicts of interest include: What would my patients think about this arrangement? What would the public think? How would I feel if the relationship were disclosed by the media? What is the purpose of the industry offer? What would I think if my own physician accepted this offer?

Finally, it is important to recall that disclosure does not eliminate a conflict. It only shifts the responsibility for managing negative consequences to the recipient of the disclosure. Routine disclosures of broad conflicts of interest have a de-sensitizing effect that diminishes the gravity of the profession’s ethical responsibility. Routine disclosures may consequently lull the profession into failing to recognize real conflicts when they arise.

Financial conflicts of interest (especially in interactions with the pharmaceutical industry) pose a danger to the practitioner’s independence. Rules, although important, serve only as minimal standards of conduct. Disclosure, a common institutional rule, merely shifts the responsibility for the conflict to others without addressing the potential dangers to integrity and objectivity. Therefore, avoiding persistent conflicts of interest remains an important ethical obligation for the psychiatric practitioner.

Topic 3.4.5 Ethical issues in small communities

Small communities pose special ethical challenges to psychiatrists because of the interdependence of the members in the community. Many small communities face great limitations of health care resources, and heightened barriers to care arising from weather, geography, or lack of transportation. Psychiatrists who serve small communities treat patients who may be long-time neighbors, members of their extended family, local officials, or civic leaders. Consequently, the ethical standard of separating personal and professional relationships may be difficult to achieve.

Psychiatrists in small communities may experience greater difficulty in protecting the health information of their patients. When patients describe their own health-related experiences, they may indirectly disclose information about family or community members who may be well-known to the clinician. The consequences of confidentiality breaches may be serious and enduring, particularly given the stigma associated with mental illness. Certain communities may also require sensitivity to cultural practices that are unique to the group. Practices, rituals, and conceptualizations of fundamental medical principles (e.g., familial rather than individual consent) may require psychiatrists to obtain consultation or education on their role in these interactions. Respecting values that may be prioritized differently can be useful in improving the relationship with the patient as well as the entire community. Finally, small community physicians may themselves be isolated, experiencing fewer opportunities for supervision, consultation, expert review, and continuing education.

These features of small communities may therefore create situations where patient needs cannot be met completely. In psychiatric emergencies in remote and frontier areas, for example, it may not be possible to refer the patient to another clinician in a timely manner or to provide the consultation or referral available in urban areas. Some of these concerns are also relevant for the occupational health psychiatrist who cares for members of a circumscribed workplace community or to the student health psychiatrist who cares for members of a college or medical school community.

Psychiatrists in small communities may consequently provide care of broader scope than psychiatrists in larger communities, and may find it necessary to provide care where professional and personal roles overlap. Psychiatrists in these communities should make special efforts and adopt specific practices to assure that their patients are provided appropriate care to the full extent possible. Examples of such practices include additional training for staff on the importance of confidentiality protections, development of reciprocal referrals and ethics consultation resources in neighboring communities, and additional efforts to obtain supervision, consultation, expert review, and continuing education.

Topic 3.4.6 Professional Use of the Internet

Use of electronic media to improve knowledge, communication, patient assessment and care brings great power to the practicing psychiatrist. The greater reach of communication and access, however, brings greater responsibility for patient safety as well. Because psychiatry depends so heavily on the written and spoken word – perhaps more so than other specialties – it is tempting to use electronic media to facilitate communication. This potential benefit, however, must be sought carefully and guarded from a number of potential pitfalls.

It is important to recognize the clinical limitations of electronic communication. Face-to-face evaluation and an ongoing physician-patient relationship cannot be replaced by electronic media. Failure to recognize this limit may create unanticipated consequences for psychiatrists who may extend their practice beyond recognizable limitations. However, there may be circumstances in which the use of two-way audio-visual “telepsychiatry” is the only method that permits patients in remote areas access to psychiatrists. The potential threat to patient privacy must also be recognized. Lastly, the Internet makes it possible to propagate misinformation rapidly, widely, and irreversibly. Inaccurate information may consequently have broad adverse consequences. Any public representations of psychiatric practice, including statements on psychiatrists’ websites, must be based on sound scientific information.

The practicing psychiatrist should ensure the confidentiality of medical records. At the same time, it is important to distinguish the mandates of privacy law with the traditional ethical obligations of confidentiality. Even when the standards of privacy law are met, duties arising from professional ethics may remain (see section 3.2.1 on confidentiality).

Topic 3.4.7 Public statements and the media

Public statements to journalists and other members of the media are part of the mission of the profession to provide public education on mental illness. They are important for addressing social stigma and issues of fairness such as the lack of parity between insurance coverage for psychiatric and other medical conditions. In this activity, psychiatrists are governed with particular force by the ethical principles of scientific excellence, trustworthiness, and social responsibility. Without this emphasis the integrity of the professional and the profession are undermined.

From an ethical perspective, psychiatrists are on firmest footing when commenting on mental illness in general, basing their statements on well-established medical literature. This is an important function for a profession that consistently seeks to decrease stigma associated with mental illness and to diminish the adverse impact of misinformation. Thus, when psychiatrists are asked to comment on a specific individual in the public eye, they may, in accordance with their expertise, comment on the general health issue involved.

In general, it is not ethically acceptable to offer professional opinions about specific individuals in public settings without an appropriate examination and an appropriate formal authorization for the public statement. However, these restrictions may not apply to psychiatrists whose intellectual scholarship focuses on studying the relevance of mental illness in the lives and actions of public or historical figures. In these circumstances, this intellectual work must be subject to the scrutiny and standards of the appropriate scholarly field. The psychiatrist must accurately indicate the scope of collateral sources used in the analysis.

Psychiatrists’ use of language in public statements and comments to the media should make clear the limitations of their data or of the certainty of their opinion. Minority or evolving viewpoints should be described appropriately, and psychiatrists should be careful not to represent their views as those of the entire profession.

When referring to specific individuals, as in the presentation of case material for scientific audiences, in teaching settings, at public gatherings, or in interactions with the media, it is essential that the psychiatrist either obtain written permission or vigorously and sufficiently disguise the case material.

Topic 3.4.8 Civil disobedience

Civil disobedience is the nonviolent and principled refusal to obey the dictates of government. Civil disobedience may occur when a psychiatrist’s ethical obligation to a patient conflicts with the law. Such a conflict may occur, for example, when, in the psychiatrist’s opinion, the state’s request for patient information jeopardizes the patient’s well-being. Psychiatrists should clearly state their ethical obligation in such cases, when options within the law have been exhausted. Psychiatrists may consequently agree to comply with the mandate or not. While physicians have an ethical responsibility to respect the law (see Section 2), it is conceivable that a practitioner could violate the law without violating professional ethics. If psychiatrists refuse to comply with the law, however, they should be aware of the legal consequences of their action and obtain legal counsel.

Section 4. Uses of this document

The overarching aim of the Principles of Ethics and Professionalism in Psychiatry is to serve as an informational document for the field. It is relevant to the many types of activities that psychiatrists undertake, the diverse populations they serve, and the array of settings in which they work. This document is clinically-oriented, but has relevance for other psychiatric endeavors such as research, consultation, leadership, and education. Its primary purpose is to help individual psychiatrists gain a sense of the accepted bounds of professional conduct.

Psychiatrists may find it helpful to read the revised Principles in their entirety, gaining an appreciation for the richness of thought and language that frames ethical dilemmas. This approach can offer a basis for understanding how common ethical principles are applied. Since it is impossible to anticipate every ethical dilemma, this kind of reading can provide the reader with a framework that can be applied to novel situations.

This document is also intended as a reference manual. The index allows the reader to locate specific topics of interest. In addition, the resources section provides assistance in identifying critical documents for further reading and study on particular ethical issues.

This document is written as a resource for psychiatrists who serve in many roles. It may be of particular value to individual psychiatric practitioners in their clinical activities. It may also be helpful to teachers and academic psychiatrists as they convey expectations regarding ethical conduct to the next generation of physicians. In addition, as with previous versions of this document, this set of principles can serve to facilitate fair and systematic peer-review when a concern arises about the conduct of a colleague. The document may also be of assistance to administrators and institutional leaders in establishing expectations for the conduct of psychiatrist employees and faculty members.

This document is not a “rule book”. It is a tool, and its value and impact will depend on the ways it is used. It is not intended to cover all ethically important situations and novel ethical questions that psychiatrists may encounter in the course of their careers. Accordingly, it will have limitations. For instance it may not be relevant for the resolution of courtroom disputes which apply legal rather than clinical standards and values, nor is it intended to undermine ethical practitioners serving in communities with scarce mental health resources (e.g., by applying urban standards to rural settings). Furthermore, it cannot fully capture all of the circumstances that alter the ethical nature of a particular decision or action. Indeed, people may do the “right thing” for the “wrong reasons”; or they may do the “wrong thing” for the “right reasons”. Consequently, the ways in which people understand ethical aspects of their work, and the values influencing the ethical commitments of the profession of medicine naturally evolve. Clarifications, reiteration, and re-application of principles to emerging issues are accepted elements of this evolution.

For these reasons, this document emphasizes the importance of ethical skills as well as knowledge of ethical principles and their application to psychiatric practice. It is our hope that this work will help assure greater clarity and rigor in approaching, implementing, and evaluating ethically important decisions and actions. In the end, however, an ethics resource is only as good as the integrity and judgment of those who use it.

Section 5. Additional Resources: Policy statements, ethics guidelines, and related

resource documents of the American Psychiatric Association

American Academy of Psychiatry and the Law, Ethics Guidelines for the Practice of Forensic Psychiatry, 1995, Amer Acad Psychiatry Law, Bloomfield CT

AMA. Opinion of Council on Ethical and Judicial Affairs. E-8.061 Gifts to Physicians From Industry. http://www.ama-assn.org/ama/pub/article/4001-4236.html

AMA CEJA Opinion. E- Addendum II: Council on Ethical and Judicial Affairs Clarification of Gifts to Physicians from Industry (E-8.061) http://www.ama-assn.org/ama/pub/article/4001-4388.html

AMA CEJA Opinion. E-9.9011 Continuing Medical Education. http://www.ama-assn.org/ama/pub/article/4001-4237.html

AMA Council on Ethical and Judicial Affairs, Ethical Issues in Managed Care, JAMA January 25, 1995, 25(4): 330-335

American College of Physicians-American Society of Internal Medicine Position Paper: Physician-Industry Relations. Part I: Individual Physicians. Ann Intern Med 2002; 136: 396-402.

American Psychiatric Association: The Principles of Medical Ethics With Annotations Applicable to Psychiatry, Washington: APA, 2001

American Psychiatric Association. Opinions of the Ethics Committee on The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry 2001 Edition,

APA Research Ethics position piece.

Academy of Psychosomatic Medicine. Position Statement: Psychiatric Aspects of Excellent End of Life Care, 1998-1999.

American Psychiatric Association Commission on AIDS, AIDS policy: Position statement on confidentiality, disclosure, and protection of others. American Journal of Psychiatry 150: 852, 1993

American Psychiatric Association Guidelines for assessing the decisionmaking capacities of potential research subjects with cognitive impairment. American Journal of Psychiatry 1998; 155 (11): 1649-1650.

American Psychiatric Association Guidelines for legislation on the psychiatric hospitalization of adults, 1982.

Ethics Primer, American Psychiatric Association, 2001

Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002; 136(3):243-6

National Alliance for the Mentally Ill, NAMI statement on involuntary outpatient commitment. American Psychologist, 1987. 42: p. 571-584.

National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, The Belmont report: ethical principles and guidelines for the protection of human subjects of research. 1979, Government Printing Office: Washington, DC.

National Institutes of Health, NIH policy and guidelines on the inclusion of children as participants in research involving human subjects. 1998: Bethesda, MD.

National Institutes of Health. in Harm's Way: Suicide in America. 2001.

National Institute of Mental Health Genetics Workgroup: Genetics and mental disorders, National Institute of Mental Health, 1997.

U.S. Department of Health and Human Services, Code of Federal Regulations, Title 45: Public Welfare. Part 46: Protection of Human Subjects Regulation Governing Protections Afforded Children in Research (Subpart D). 1983

U.S. Department of Health and Human Services, Mental Health: A Report of the Surgeon General. 1999: Rockville, MD.

U.S. Department of Health and Human Services, Report of the Surgeon General's Conference on Children's Mental Health: A National Action Agenda. 2000: Washington D.C