Question 4 asked readers how often they encounter ethical dilemmas in their practice. Of the 640 participants who answered the question, 34% reported facing ethics issues once or twice a week, 43% once or twice a month, and 23% hardly ever. Question 6 asked readers about their level of comfort and preparedness when faced with ethical dilemmas in daily practice. The responses are an encouraging sign that psychiatrists recognize and reflect on ethical problems in the profession. Of the 633 participants who responded, 29.4% felt they had adequate skills and knowledge to analyze and resolve ethical dilemmas; a robust 47.2% said they occasionally needed ethical consultation but knew where to find such assistance; 23.4% said they occasionally needed help, but did not know who to turn to for an ethics consult.
Question 7 asked to what extent participants would benefit from expert ethics consultation. Of the 644 respondents, 4.1% replied they would never benefit from consultation and 9.8% said they would often benefit. Many (35.7%) said they seldom needed an ethics consult and 50.4% said they could occasionally use a consultation.
In our next survey, we plan to add a question further delineating the ethics resources and type of consultations psychiatrists turn to for guidance.
The current ethical climate
Question 5—the focus of this article—asked readers whether the ethical issues in psychiatry are becoming more difficult or have not changed in the past decade. Most of the 624 respondents (59.1%) found that the ethical issues had not changed in the past decade. The 40.9% of respondents who believed the ethical climate is more challenging were asked to give their opinion regarding the reasons for the difference. The 208 clinicians who took the time to give us their individual perspectives represent a microcosm of the moral distress and the moral seriousness of contemporary psychiatric culture.
It is impossible to do justice to the richness and diversity of commentary, but we can glean some broad and overarching themes. The first is that the context in which psychiatrists are embedded is itself more complicated today than it was 10 years ago. As a psychiatrist put it: “The world is an increasingly complex place. Changes in society, technology, medicine add complexity. Psychiatrists should be increasingly active participants.” Several psychiatrists wrote that psychiatry in the 21st century “has many gray areas where there is nothing to follow” and “values are becoming broader and our ideology is no longer black and white.”
The information technology revolution was identified more often than any other cultural development as dramatically changing psychiatric practice—chiefly in 2 main areas. The first area is how electronic means of communication, such as email and electronic medical records, generate unprecedented confidentiality and privacy concerns. The second area is that the Internet has enabled patients to become educated and empowered as never before, which psychiatrists saw as a double-edged sword. In the words of one clinician: “Patients have now a lot of information available from sources like the Web, and this issue makes some of them more inquisitive about the diagnosis and treatment they get. This means they have more information but this information is not always accurate.”
The shrinking availability of care and expanding demands for treatment were another frequently cited source of ethical problems. “Resource constraints increasingly pose difficult problems of care and safety versus autonomy and patient choice. Referring patients is problematic in a broken, unfunded system.”
Conflicts of interest
The struggle of clinicians trying to do what is right and best for patients in the face of a growing cadre of stakeholders with a panoply of often competing agendas was evident. “Government, JCAHO [Joint Commission on the Accreditation of Healthcare Organizations], and insurance mandates are driving up costs and limiting treatment options. The dilemma is whether to treat the bureaucracy or the patient.” Multiple respondents commented on how politics, the power of the state, regulations, law, and business motives threaten the moral primacy of the good of the patient and the integrity of the psychiatrist. “Some of the ethical dilemmas have been created by the business model of medicine. Do you put the patient’s interest over institution protocol? Other times personal agendas of administrators are carried out at the expense and indifference to patients.”
Many clinicians remarked that for-profit health care dominates in an era of scarce government resources and creates conditions ripe for moral compromise. “Systems-based and financial issues have removed the patient to a no. 2 at best focus in many areas of care. With systems’ needs and economics taking the first or second pressure in clinical settings. Cheap, available is replacing tailored and appropriate for the individual.” The Health Insurance Portability and Accountability Act (HIPAA) and the patient rights movement were some of the most frequently cited changes that have intensified the historic tension between patient welfare and the approaches of law and medicine toward mental illness.
Some of the most poignant responses were from forensic psychiatrists confronting a clash between ethical obligations and legal mandates: “I deal with forensic issues and the courts have become overly aggressive and less attentive to patient rights when patients encounter legal issues.”