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Introduction: The Brave New World of Psychiatric Ethics

Introduction: The Brave New World of Psychiatric Ethics

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A quarter of a century ago, psychiatric ethics was a far narrower realm of discourse. Ethics education—whether in residency or practice—was mostly confined to the forensic psychiatric issues of inpatient psychia try, such as involuntary commitment and competency determinations, and the psychoanalytic sphere of concern focused on boundary crossings and violations of the psychotherapeutic frame.

The universe of psychiatric ethics has dramatically expanded as evinced in the list of potential topics the editorial staff considered for this special report (Table). The order of the list does not indicate priority or importance, which is what made it so difficult to select the most appetizing topics from this rich conceptual menu. We hope during the course of the year to be able to offer up some of these fascinating subjects in print, on our Web site, and through our expert commentator blogs. A number of the issues on the list not covered in the special report were the subject of empirical ethics in the 2011 and 2013 Psychiatric Times Ethics Surveys: results of which will also be featured in various formats in the future.

A quick glance at this expansive but far from comprehensive list of psychiatric ethics questions shows that the impact of law on psychiatry remains, as does the centrality of the physician-patient relationship. Yet this post-modern synopsis also reflects a more pervasive influence of the technological imperative, the business of medicine, the politics of being a physician, and an increasingly multicultural and aging democracy than it would 2 decades ago. The electronic information revolution in medicine and psychiatry rivals that of the scientific revolution of the 17th century and has affected almost every subject in this special report—an unprecedented phenomenon in the history of psychiatric ethics.

End-of-life ethics was long dominated by internal medicine, but Richard Martinez, MD, MH, and Casey Frank, JD, MPH, give us an impressive summary of important legal and public policy developments in the area of end-of-life bioethics where psychiatry’s presence and gifts are coming to fruition. We are excited that the substantive quality of this review enables it to serve as this month’s CME article.

Against the backdrop of media psychiatry, cable television therapy, psychiatric blogs, and tweets about more things than Horatio ever dreamed of in his psychiatric residency, Richard A. Friedman, MD, examines the so-called “Goldwater Rule.” As a caution and caveat to free talking, he provides an excellent rule of thumb for those embarking on public commentary: play the role for which psychiatric professionals are well cast—that of educator of the public—and eschew the risky business of opining about the private lives of the rich and famous.

Brian K. Clinton, MD, PhD, looks at one of the most controversial developments in contemporary psychiatry: the full and real-time access of patients to their psychiatric records. Whether we think patients should read their charts, they are already doing so—another example of the democratization of psychiatric ethics. The author provides practical tools for the navigation of what is inarguably a sea change in psychiatric thinking about disclosure and reassurance that transparency in documentation does not have to be traumatic for the patient or the practitioner.

Jennifer H. Radden, PhD, reminds us of the philosophical birth of psychiatry with a presentation of Aristotelian virtue theory for the 21st-century psychiatrist. Virtue theory offers a value-based aspiration to ideals approach to psychiatric ethics to balance the rules-based ethics of an increasingly commercialized and regulated health care system

One area of regulation that psychiatrists, like their medical and surgical colleagues, will now be forced to master is coding and billing. DSM-V, HCA, ICD-11, and the new CPT codes, while frustrating to many in the short term, in the long haul will move us toward parity with the rest of medicine. Mark S. Komrad, MD, leads us through the maze of documentation details without losing the center of what we do—care for patients.

Many of the ethical dilemmas explored in these articles chart new territory in the moral imagination. The complexity and pluralism of the cultural context in which psychiatry is now embedded cast doubt on the survival of the cornerstone of psychiatry: the private psychiatric psychotherapist. Public skepticism now rivals that of the enlightenment period: neuroscience, research trials, and alternative and complementary medicine are deconstructing the psychopharmacological dominion of biological psychiatry.

Amidst this doubt and chaos, the authors of these articles provide guidance and hope that psychiatry can reinvent itself as it has so many times before to not only endure but to evolve to a new joining of our humanistic past and scientific present to create a renaissance psychiatrist of the future. So let us boldly go together where psychiatric ethics has never gone before!

Disclosures

Dr Geppert is Chief of Consultation Psychiatry and Ethics at the New Mexico Veterans Affairs Health Care System in Albuquerque. She is also Professor in the Department of Psychiatry and Director of Ethics Education at the New Mexico School of Medicine. She serves on the Editorial Board of Psychiatric Times.

 
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