Clinicians who work with children face particular ethical issues, but they are not exempted from the general ethical considerations that face all mental health clinicians.
Almost always, psychiatric treatment for minors is initiated not by the patient, but through the pressure of others. In most instances, the pressure is from parents, physicians, school personnel and/or legal authorities. Since child psychiatric patients are especially vulnerable to coercion by others, their clinicians must be particularly careful to know their own ethical responsibilities and their patients' rights.
Many practitioners remember the Accreditation Council for Graduate Medical Education residents' required lectures and seminars on ethics as dull, irrelevant or skipped. Learned physicians (Brewin, 1993) have questioned the usefulness of teaching ethics, at least of an "academic" type, rather than the more clinically based type. I agree, but I believe the quite common negative response of residents' exposure to ethics is not due mainly to poor teaching. I believe it is because ethics, once acknowledged, demand complicated, uncomfortable thinking. It is much easier to only think of other peoples' ethics, not our own.
Most ethical issues are complex and subject to multiple interpretations, perspectives and reactions. Seldom are there obvious, easy solutions. Ethical considerations are often a balance between gray concepts. Unethical decisions can occur when one "good" impinges too much on or denies another "good." For example, a young teen-age patient smokes marijuana. You believe she is not using it in a way that puts her in immediate physical danger, but it is against the law. You discuss with the patient the fact that she seems to recklessly put herself in danger of being arrested. She does not change her behavior. Circumstances should dictate whether informing the parents would help or hurt the best interests of the child. The impact of the decision on the patient-doctor relationship may be crucial.
AACAP Code of Ethics
The American Academy of Child and Adolescent Psychiatry (AACAP) published a Code of Ethics with 17 ethical principles in 1980. Highlights are in the Table. A handful of points made in the code and several ethical aspects of research are covered elsewhere in this section.
The clinician's overriding commitment must be to the patient. More often than with adults, fees are not paid by the patient. The primary commitment cannot be to the payer, parents, authorities or oneself. The clinician's task is to not only avoid harming the child, but to also effect the best or ultimate good for the patient, all things considered. No one would disagree with this seemingly simple precept, but the devil then comes in the details. Both "ultimate good" and "all things considered" are cotton candy terms--luscious looking, but mainly air.
As stated in the code's preamble:
The issues of consent, confidentiality, professional responsibility, authority, and behavior must be viewed within the context of development and the overlapping and potentially conflicting rights of the child or adolescent, of the parents, and of society.
AACAP (1980), Code of Ethics. Washington, D.C.: AACAP.
AACAP (1996), Annotations to AACAP ethical code. AACAP News, pp17-20.
Brewin TB (1993), How much ethics is needed to make a good doctor? Lancet 341(3):161-163.
Hoagwood K, Olin SS (2002), The NIMH blueprint for change report: research priorities in child and adolescent mental health. J Am Acad Child Adolesc Psychiatry 41(7):760-767.
Kaiser Family Foundation (2002), National Survey of Physicians Part II: Doctors and Prescription Drugs. Menlo Park, Calif.: The Kaiser Family Foundation.
Lasser KE, Allen PD, Woolhandler SJ et al. (2002), Timing of new black box warnings and withdrawals for prescription medications. JAMA 287(17):2215-2220.
Rosenthal MB, Berndt ER, Donohue JM et al. (2002), Promotion of prescription drugs to consumers. N Engl J Med 346(7):498-505.
Wazana A (2000), Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA 283(3):373-380.
Zimmerman A, Armstrong D (2002), Useof pharmacies by drug makers to pushpills raises privacy issues. The Wall Street Journal. May 1, p1.