Ethics And Psychiatry Research Paper

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Ethics concerns what is right and what is wrong. It is often used synonymously with morality, but sometimes a distinction is made between ethics, the systematic approach to understanding right and wrong, and morality, the forces which govern right conduct. Ethics is central to human experience, and plays a vital role in the profession of psychiatry. In a time of cultural change, the appeal to ethics can help to resolve conflicts of both civic life and self-understanding. Often ethical principles are used in an attempt to find a common ground or a ‘higher ground’ for resolving disputes or to find a basis for acting in a dilemma.

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Ethical codes and traditions are important in defining the norms of professional conduct and even what it means to be a profession. Insofar as ethics deals with intellectual attempts to understand right and wrong (reason) as well as the affective impact of struggling with moral issues (emotion), psychiatric thinking offers an important perspective on ethics. This research paper deals with both ethics in psychiatry and psychiatry’s contributions to ethics.

1. Types Of Ethical Theories

There is in ethics a constant tension between rulebased (deontological) approaches and approaches which appeal to principle (teleological). Deontological ethical theories maintain that there are rules of action with moral validity independent of the consequences that require adherence, such as keeping a promise, maintaining justice, or following a commandment of God or the state. Teleological ethical theories are based on the principle of utility (utilitarianism) or beneficence, which proposes that the ultimate moral standard is the general happiness of all people concerned, or the greatest net balance of good over evil (‘the greatest good for the greatest number’). Situation ethics represents another form of ethical reasoning, called the consequentialist approach, in which an action is judged to be morally right or wrong by assessing the consequences of the action. Much of clinical medicine is consequentialist in that the goodness of actions is judged by their outcomes.

2. Ethics Of Virtue And Character

Both teleological and deontological approaches to ethics have one serious shortcoming. They depend on the activities of the rational mind of a motivated moral agent to apprehend right and wrong. Moral philosophers and psychiatrists alike appreciate that not everyone is motivated to be moral; that even good people sometimes do bad things; and that people are capable of rationalizing self-interest (Hauerwas 1977, 1981, Pincoffs 1971, 1980).

A delineation of obligations, however essential, is not the whole picture of ethics. Virtue, character and integrity are every bit as important in understanding right conduct. For the professions especially, integrity in concrete situations is the hallmark of virtuous life.

3. A Brief History Of Medical Ethics

The ethical traditions of the medical profession originate in the fourth century BC with the Oath of Hippocrates. This oath, sworn by healer–craftsmen, has come to symbolize the ethical ideals of the medical profession. In the nineteenth century, first the British Medical Association, and subsequently the American Medical Association (AMA) and professional organizations in other countries began to adopt formal codes of ethics modeled on the principles of the Hippocratic Oath.

By the mid-1960s, the values underlying the doctor–patient relationship began to change. The most notable factor was the emergence of new technologies, which began to change the way we thought about medicine and even what it meant to be human: genetic engineering, organ transplantation, advanced life support, safe abortion and birth control, and medical and surgical treatments based on clinical research. No longer was medical care primarily palliative. No longer could it be assumed that the patient would necessarily want what the doctor might offer (Dyer 1997a, 1997b).

Also in this era, several social movements began to change the way society thought about assumed relationships, with an increased emphasis on the right of the autonomous person to self-determination. Informed consent and autonomy came to be the keys to medical ethics and medical decision-making. Medical ethics in this era became bioethics as it came to be realized that the decisions in medicine were decisions in which society had a stake.

By the 1970s, economics increasingly became a part of thinking about ethics. Allocation of resources became a concern, and the question was often asked, ‘Could health costs be contained without rationing care?’ The principle of justice eventually superseded beneficence and autonomy in ethical discourse, with an emphasis on fair distribution of medical resources.

3.1 The Ethics Of Advertising

Most physicians are not inclined to seek patients though advertising. Healthcare organizations, however, may make their appeal through advertising, especially in a market-driven healthcare economy. The 1957 version of the AMA Principles prohibited ‘solicitation’ of patients, by which was meant ‘obtaining patients by deception’, or making false claims (AMA 1957). After the Supreme Court decision Federal Trade Commission (FTC) vs. AMA (Greenhouse 1982), professional organizations such as the AMA can no longer formally constrain physicians from advertising.

Advertising has two basic goals: (a) dissemination of information and (b) product differentiation. For physicians, providing information about services offered and fees charged is consistent with patient benefit, but attempts to differentiate the product are suspect. Licensing, accrediting and credentialing organizations assume the role of maintaining standards. Beyond the activities of individual practitioners, the larger ethical question for advertising is truthfulness. Notable is the advertising of unhealthy products such as tobacco products and alcohol. Much advertising is antithetical to professional goals of patient benefit (Dyer 1995, 1997a, 1997b).

4. The Place Of Ethics In The Definition Of A Profession

What differentiates a profession from a trade? What makes medicine a profession? The emphasis on the commerce of technology in medicine in recent years may obscure the centrality of an ethical attitude toward the patient, which has traditionally been considered to be the defining feature of a professional life.

A profession may be defined by (a) its knowledge, technology and expertise, or (b) its ethics or values. The habits of modern thought might lead us to believe that this is an either–or choice. Clearly for psychiatry, as for most of medicine, allopathic technologies such as drugs and procedures have become important and perhaps even central in some people’s minds. The recent primary care thrust has reopened consideration of a more holistic approach to healing, including talking. Ethics is more fundamental to professional definition than technology. Technology is useful as long as it serves ethical ends but not as an end in itself. Knowledge, technology and expertise are not commodities to be bartered in the marketplace, but skills which may be used to ethical ends under the purview of professional values.

5. The Hippocratic Oath And The Hippocratic Tradition

The Hippocratic Oath is a remarkable document, not so much because it answers the ethical questions posed by modern medicine, but because it frames those questions. It articulates principles, notably the principle of patient benefit, which is often helpful to physicians in sorting out where their allegiances lie. Taken together with its corollary, the principle of nonmaleficence (Primum non nocere, first do no harm), the principle of beneficence puts the patient at the center of ethical decision-making. The Hippocratic Oath provides an ethical perspective that calls into questions many of the assumptions of modern culture and transcends the pressures of political expediency.

5.1 The Contemporary Relevance Of The Hippocratic Oath

A reading of the Hippocratic Oath reveals many phrases which responsible physicians might not want to follow literally. Medicine was delineated as a higher calling, a covenant with the gods. The Oath provided a relationship with a like-minded family of individuals who shared certain values and self-understanding. It defined the physician’s life in a beneficial relationship to those served. Its paternalism was questioned when society emphasized individualistic autonomy, but the Oath’s emphasis on justice foreshadowed a larger concern for community interests.

The Hippocratic tradition has at various times and places served as an ethical reference external to immediate expediency, by which physicians may gauge their behavior and to which they can appeal (or by which they may be judged by their colleagues). For example, the World Psychiatric Association censured the practices of psychiatrists in the former Soviet Union and other eastern European countries for the detention of political dissidents. Such mislabeling with psychiatric diagnoses is called the political abuse of psychiatry, for the profession is used for ends other than patient benefit (Bloch 1991, Bloch and Reddaway 1977). Such extreme abuses make a case, which is not always appreciated, for professions being autonomous organizations self-regulated by a code of ethics rather than serving the interests of society which may be politically conflicted. The Hippocratic Oath is an everpresent reminder that acting in the interest of someone other than the patient creates a conflict, a conflict which is often experienced internally by the physician.

5.2 Honor In Medicine

The Hippocratic Oath speaks of honor, holiness and purity. The good name and respect of both the practitioner and the profession are to be earned through consistent application of the ethical principles, and the code provides guidance. Good conduct becomes ‘characteristic’ of the professional, and a code of conduct organizes one’s thinking about good conduct both symbolically and in very practical matters.

5.3 The Fiduciary Principle

The doctor–patient relationship is spoken of sacredly as a fiduciary relationship, a relationship based on trust. That trust must be earned, at the least by the hard work required to acquire the skills necessary to apply the art. But it must also be earned by the consistent application of attentive response to the patient’s needs, what we call ‘responsibility’. Unlike law or business, where the trustee may act for the client, in medicine the physician must act with the patient and with the patient’s consent, implying a partnership. That action may be paternalistic, but if that concern verges on control, the modern patient may well lose trust and confidence.

5.4 Hippocratic Oath For Psychiatrists

Maurice Levine (1972) articulated a Hippocratic Oath for psychiatrists with some unique insights about the values of this profession. His code articulates the importance of self-knowledge or at least self-awareness and constant self-scrutiny. He stresses the need to recognize in ourselves the feelings that patients can stir up, particularly seductive patients, and the importance of getting consultation (or supervision) not just in training but whenever it might be necessary. This is a useful reminder at times when many treatments are briefer and more biological, because many of the complaints of unethical conduct received by the American Psychiatric Association (APA) come from patients whose doctors did not sufficiently deal with their own feelings and acted out in treatment situations. Self-reflection is an important ethical tradition, not only in psychiatric and psychoanalytic circles, but throughout Western culture dating back to the Socratic admonition to ‘Know thyself.’

6. Contemporary Codes Of Ethics (AMA And APA)

When the AMA was founded in 1847, it adopted a code based largely on the Hippocratic principles of beneficence and honor. This code (The Principles of Medical Ethics) has been revised every few decades (most recently in 1957 and 1980). When the APA adopted its first code in 1973, it decided to use the AMA Principles With Annotations Especially Applicable to Psychiatry. The principles should be read teleologically, not deontologically as a list of rules. The requirement of honorable behavior of the physician goes to the physician’s character and virtue and cannot be reduced to a list of rules. The physician must understand the principles in terms of a higher calling and act in accord with the dictates of conscience.

The APA (1995) may impose four possible sanctions for misconduct by a psychiatrist: admonishment (informal warning); reprimand (formal censure); suspension (not to exceed five years); and expulsion. In this sense, this code is minimalist but essential, serving as a tool for professional discipline. A psychiatrist should know what is specified in the code because he or she might be subject to sanctions. The modern physician should also understand the principles that underlie the code in order to be able to act in situations which have not been explicitly spelled out. The following discussions illustrate the constant tension between rule and principle and the importance of the physician striving for virtuous action.

6.1 Sexual Misconduct And Boundary Violations

Sexual contact with a patient is unethical. This is one of the least ambiguous sections of the ethical code. It is a tradition that goes back to the Oath of Hippocrates, which speaks of such conduct as ‘mischief’. It is important for psychiatrists because the intimacy of the treatment activates strong feelings and fantasies in the doctor–patient relationship, the discussion of which may be essential to healing. In psychiatry especially, the nature of such feelings the patient may have for the doctor (transferences, i.e., derived from significant relationships in the past and activated in the treatment) and feelings the doctor may have for the patient (countertransferences) receive close scrutiny. They are no less important for other physicians, other therapists, or other professionals. It is sometimes argued that the reason sexual contact is proscribed is because of the power differential, an argument which applies equally to employers and employees, supervisors and supervisees, teachers and students. Most basically, the importance of trust in the therapeutic relationship requires forbearance. As a rule, sexual contact with a patient is proscribed.

Those more legalistically inclined might wonder if erotic feelings might be acted on if the professional relationship were terminated. Transferences endure over time, so the interests of the patient–client could never be served by crossing this boundary. The most recent version of the APA Annotations Applicable to Psychiatry spells this out: ‘Sexual activity with a current or former patient is unethical.’ Other examples of boundary violations, which rest on similar considerations, are business relations with a patient, using the professional relationship for other contacts, or profiting from information gained from the therapeutic relationship.

6.2 The Boundary Between Ethics And Law

Ethics and the law share a similar concern for right and wrong. But the ethical requirements of professionals do not coincide identically with the requirements of all citizens. The Oath of Hippocrates held physicians to a standard that was not required of all citizens. The AMA Principles and APA Annotations recognize this tension and expect physicians to ‘respect the law’ and ‘seek changes in those requirements which are contrary to the best interests of the patient.’ Civil disobedience against unjust laws is a respected ethical tradition. A physician is a citizen whose professional role requires adherence to principles such as patientbenefit above all.

6.3 Confidentiality

Confidentiality, understood as secrecy, in the doctor–patient relationship is one of the most fundamental principles of professional ethics. Confidentiality has its roots in the confidence or trust that is placed in the physician and on which the treatment depends. It has become increasingly difficult to safeguard confidentiality. Insurance companies, managed care organizations, other providers, courts and sometimes families claim a right to know what is going on in patients’ treatments. The possibility of misuse of information from insurance data banks is a large issue. Confidentiality is one of the most fragile tenets in the contemporary era.

At times, principles may conflict. For example, the Tarasoff decision obligates a psychotherapist who has knowledge that a patient may intend harm to a third party to notify that third party of the potential risk. Mandatory reporting of suspected child abuse is another example in which the interest of the state in protecting children legally supersedes the physician’s duty to maintain secrecy. In a larger context the erosion of confidentiality threatens to undermine the possibility of a kind of therapy that requires developing openness to another person confident that what is disclosed is only for the patient’s benefit.

6.4 The ‘False Memory’ Controversy

Much conflict has developed around the issue of therapists directing therapy to recover memories of childhood sexual abuse, which may not have occurred. In particular, there have been instances reported in which therapists used suggestive methods such as hypnosis in order to recover memories of past sexual abuse that were believed to be repressed. Alleged perpetrators of such abuse have been prosecuted and even jailed. Therapists’ zeal about these issues may lead to unethical behavior, even with good intentions, with destructive results for their patients and families (Chodoff 1999).

6.5 The Double Agent Problem

Double agents work both sides. There are situations in which the physician works for someone other than the patient, and there may be a conflict between the patient and the physician’s employer resulting in a divided allegiance and compromised confidentiality. The classic case of this is the physician working for the military, trying to get soldiers back into combat. This is ethically analogous to treating the psychotic prisoner incompetent to face execution. The student health psychiatrist doing an evaluation for the dean or the psychiatrist doing a pre-arraignment examination have loyalties that go beyond the patient’s best interest and which require at the least disclosure of the purpose of the examination and how the information will be used. Increasingly physicians working for corporations, managed care organizations and government hospitals have interests which radically transform the nature of the relationship between doctor and patient.

6.6 Fees, Billing, And Reimbursement

The financial arrangements for medical service strike at the heart of the ethical issues in how medicine is valued. Inevitably there must be some sort of exchange for the services rendered, and inescapably there must be some sort of feelings about the monetary transaction. In the dyadic doctor–patient relationship that is a very direct transaction, though it may be buffered by insurance companies, billing and collection processes. Patient benefit and fee-for-service have traditionally gone hand in hand, and the fee (alongside honor and duty, of course) has helped focus the physician’s attention on whose benefit should receive attention. One of the general criticisms often leveled against traditional (Hippocratic) medical ethics is that it does not deal with the physician’s larger obligations to society and particularly to the distribution of medical services.

One financial arrangement in particular that sometimes questioned is the practice of charging for missed sessions. The APA Annotations has specifically addressed this and has said, ‘It is ethical for the psychiatrist to make a charge for a missed appointment when this falls within the terms of the specific contractual agreement with the patient’ (Sect. 2, paragraph 6). The idea of patients having responsibility for the treatment and ultimately for their health and wellbeing is not something usually considered in medical ethics, but it goes beyond the idea of medicine as technology that the doctor delivers and stresses the patient’s investment and commitment to the healing process.

Another financial arrangement that is addressed throughout the AMA Opinions and APA Annotations is fee-splitting. Physicians should receive remuneration for the work they do, and they should obtain patients by referral based on the quality of their work and the reputation they earn in the eyes of satisfied patients and other physicians. Any incentive such as splitting the fee with a referring physician is considered unethical. It offers a temptation to place monetary gain above the best interest of the patient.

6.7 Informed Consent

An issue that has been receiving increasing attention recently is the importance of preserving patient autonomy and control in the context of medical decision-making and participation in research. Recent debate has occurred around the issue of whether patients with psychiatric illnesses are competent to give consent in such situations. The danger in such debate is that psychiatric patients can be further stigmatized with policies that are overprotective and confuse psychopathology with a generalized lack of competence. Efforts to educate patients regarding the nature of medical decisions and research projects should protect their rights by helping them to make decisions for themselves (Appelbaum 1998).

7. The Ethics Of Managed Care

The current revolution in healthcare financing challenges many traditional assumptions of medical ethics. The most fundamental change is the departure from a dyadic doctor–patient relationship. Doctors in the new environment are being transformed into ‘providers,’ patients into ‘consumers,’ and any number of ‘third parties’ claim an interest in what goes on in that relationship.

In the economic model of marketplace transactions, much more is at stake than how the payment is to be allotted. The metaphor of healthcare as an industry radically transforms the healing process to physiological interventions that take place in a delimited period of time. Physicians become technicians, and patients become recipients of technology, with both likely to be strangers to one another. Medicine is transformed from a human service into a commodity.

In the interest of efficiency or economy these transformations might seem warranted, but the practices we are currently witnessing in the name of managed care must themselves be subjected to ethical scrutiny. Certainly much of what is going on is not ethically justifiable, nor does it serve the ends it was purported to serve. The transformation of medicine from a profession to a trade by the Federal Trade Commission was justified as a cost-saving measure on the grounds that increasing consumer choice (through advertising) would lower costs. The value placed on autonomy set the stage for a transformation in which consumers have very little choice about the healthcare they receive. Healthcare has become an investment opportunity where vast amounts of money have been siphoned away from service delivery into the pockets of executives and shareholders of mega-corporations. The market solution has been a nonsolution to this point in that it has only succeeded in lowering costs without adequately addressing quality of service or the distribution and allocation of services.

The ethical physician is inevitably in tension with a system designed to limit or deny the care given to his or her patients. While recognizing that resources are finite, the ethical physician must struggle to do the best possible for individual patients without compromising integrity. Many of the practices of managed care are fraudulently unethical, such as gag rules prohibiting physicians from discussing treatment options with their patients. Such policies do not enhance consumer choice, but diminish patient autonomy and oppose informed consent, placing the physician in the position of a double agent without the possibility of disclosure. Many practices of managed care are more subtly unethical, such as misleading advertising or incomplete disclosure. Some practices, such as limiting who may serve on panels, may be in restraint of trade. They are certainly not pro-competitive. Managed care is an ethically unstable response to the healthcare financing dilemma and must be subjected to thoroughgoing ethical evaluation. A just society must demand accountability for its citizens.

8. Conclusion

Looking back to the longstanding traditions of medical ethics, we are now in a position to better appreciate the place of the Hippocratic Oath in contemporary medicine. Though it is sometimes criticized for being anachronistic, its true value is apparent. The Hippocratic tradition in medicine provides a perspective of enduring values by which the shortcomings of modern economic expediency may be judged.


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