Psychiatry and ethics: A whirlwind tour

The following is my article originally published in San Francisco Medicine (Vol. 83 No. 10, December 2010), the monthly journal of the San Francisco Medical Society.  This issue was devoted to “Psychiatry for the Nonpsychiatric Physician.”  Reprinted by permission.

The practice of psychiatry is rife with ethical issues. Some critics, such as author-psychiatrist Thomas Szasz, attack the legitimacy of psychiatry itself, claiming it’s unethical to treat mental distress as though it were a medical disease. Psychiatric diagnosis has been challenged on ethical grounds when used to punish political dissidents in other countries, and here in the U.S. when a criminal defendant is found not guilty by reason of insanity. Involuntary psychiatric hospitalization and treatment looms large as a matter of ethical concern. The “5150” became California law in the 1960s and authorizes civil commitment for up to seventy-two hours when a patient is “dangerous to self or others” due to a psychiatric disorder. It soon became the model for such laws nationally, yet revisions and reformulations are constantly put forward.

While each of these issues is profoundly important, they are not the ethical challenges that most psychiatrists face on a day to day basis. Most of us don’t spend our time questioning whether the field is legitimate in general, nor whether making a diagnosis is an ethical act. Most psychiatrists have outpatient practices and rarely contend with involuntary hospitalization or treatment (although it happens). What are the more common ethical challenges in psychiatry?

Clear and professional boundary keeping is the cornerstone of psychiatric practice, especially for those psychiatrists who conduct psychotherapy. Just as a surgeon drapes the surgical field to assure a clean and well-demarcated work space, the psychiatrist establishes a “frame” of time, place, and purpose with each patient to assure a psychologically clean and well-demarcated space to do psychological work. The best known and probably most important ethical rule in psychiatry is not to exploit patients sexually. (Unlike in other specialties, this also extends to former patients.) Less understood is that this attention to psychological boundaries precludes many other social interactions that seem more innocuous. Unlike other physicians, psychiatrists who utilize psychotherapy cannot attend sporting, dining, or other events, public or private, with patients. Since we use the doctor-patient relationship as the very instrument of care, it cannot be put to other purposes. This illustrates something unique about psychiatry: Ethical and clinical issues often overlap. Clear professional boundaries are both an ethical matter and a clinical matter.

Here is another example. Psychiatrists deal with confidentiality dilemmas all the time. For example, young adult patients often have parents who both pay for the treatment and want to know about it. Yet such patients have ethical and legal rights to confidentiality. Other specialties deal with this as well, although in psychiatric practice the presenting problem may be the parental relationship. Thus, what to tell family members — or what to advise the patient to tell — is a matter of both ethical and clinical significance. The same is true of reporting confidential details to third party payers, magnified here by the social stigma attached to psychiatric disorders.

Many psychiatric problems do not cause immediate distress in the patient, but only in those around him. Typical examples include mania, paranoia, narcissism, sociopathy (antisocial behavior), some eating disorders, and so forth. Since subjective distress does not motivate treatment in such conditions, a large part of psychiatric practice is helping patients appreciate the need for treatment and choose it for themselves. While the ethical issues here are not as stark as plainly forcing treatment, there are still several matters to consider. It may be ethically problematic to try to change a patient for the benefit of others, even if the patient would also benefit in the long run. Most physicians would feel qualms about trying to change anything in a patient without that patient’s conscious assent, yet in psychiatry we often have no option but to proceed when the patient lacks the insight and judgment to assent. As a result, there are ethically problematic pressures to persuade the patient, using emotional appeals and slanted arguments — anything to gain cooperation. Such situations place the psychiatrist, at least temporarily, in an adversarial position with respect to the patient’s subjective desires and constitute a conflict of interest between the patient’s wishes and the psychiatrist’s.

A special case of divided loyalties occurs when a patient seeks psychiatric treatment for a reportable behavior. The state mandates the reporting of suspected child or elder abuse, and certain other behaviors. While there is obvious value in such reporting, unfortunately it can also prevent patients from receiving the very treatment than could curtail such behavior in the future. In some such cases, legal reporting requirements may conflict with ethical practice.

Another common set of ethical issues surrounds the placebo effect. Among the various medical specialties, psychiatry stands out in allying with the placebo effect. In internal medicine, a treatment that makes the patient feel better but leaves the infection or tumor unchanged is a failure, and a dangerously misleading one at that. In contrast, a psychiatric treatment that relieves a patient’s depressed mood or anxiety is a success, regardless of whether it changes the patient biologically.

Usually the patient’s subjective experience is the endpoint. Ethical dilemmas arise when honesty falls prey to the need to instill hope. For example, a depressed patient who has failed five medication trials of adequate dosage and duration presents for a sixth. The patient hopes the sixth medication, possibly a heavily promoted new product, will be the long-awaited miracle cure. The psychiatrist knows this track record bodes poorly but doesn’t want to be pessimistic in front of the patient, as success or failure often hinges on the patient’s expectations. So the sixth medication trial proceeds despite the psychiatrist’s better judgment, and it typically fails. Putting aside the placebo effect, the psychiatrist would advise a different approach — psychotherapy maybe, or perhaps a fresh look at the patient’s work history, coping skills, nutrition, exercise, and social support. None of these, however, are what the patient believes in or wants to hear, and thus potentially effective alternatives aren’t even tried.

Speaking of heavily promoted products, psychiatry has the dubious distinction of prescribing the most expensive drugs in the whole medical armamentarium. According to a recent New York Times article, antipsychotics are the top-selling class of pharmaceuticals in America, with annual revenue of about $14.6 billion. Antipsychotics were formerly a niche product, but recently manufacturers have gained FDA approval for a much wider range of indications. Moreover, most antipsychotic prescriptions are now written off-label (not always, or even primarily, by psychiatrists). The burgeoning use of expensive and potentially hazardous antipsychotic medications for relatively minor indications — insomnia, anxiety, nonpsychotic depression, and so forth — has both clinical and ethical implications. Psychiatrists, and all physicians, should recommend treatments based on risk/benefit considerations, and not on extraneous factors such as lavish marketing, financial ties with industry, and so forth. Such conflicts of interest remain endemic in medicine despite recent voluntary restrictions by the pharmaceutical industry and some professional organizations. Psychiatrists in particular should be acutely aware that such influences can, and do, operate unconsciously and despite one’s best intentions. Yet again and again, prominent psychiatrists appear in news headlines about improper funding by industry and failure to disclose financial conflicts of interest. The field risks trading away its most valuable commodity — trust.

This whirlwind tour of psychiatry and ethics has barely scratched the surface. These are only some of the most common ethical issues in clinical practice; there are many other equally worthy contenders. Nonetheless, it illustrates some of the range of issues faced in the field, the many commonalities with other medical specialties, the great overlap with purely clinical decision-making, and the way psychiatry, more than any other medical specialty, is defined and shaped by the social context in which it is practiced.