Cynthia Geppert, MD, MA, MPH, MSBE, DPS, FAPM

Imagine there's no heaven
It's easy if you try
No hell below us
Above us only sky
Imagine all the people living for today

This iconic song inspired Geppert, Professor of Psychiatry and Director of Ethics Education at the 

University of New Mexico School of Medicine

, to share her thoughts on moral imagination. Dr Geppert is also the Ethics Chair for 

Although many believe these are utopian lyrics, she explains, she sees it as having faith in humanism and an expression of the idealistic belief that the world can be better. Lennon hopes for things—for ideals—that we may or may not agree with and may or may not be possible. Yet, if every person uses this moral imagination to explore a better world, maybe we can make it happen, Geppert notes.

Leveraging cognitive science, Mark Johnson shared introduced the idea of moral imagination in the 

. Here, Geppert challenges us to discern the various possibilities on how we can act, despite the challenges faced by the pandemic—or any hardship. The goal, she explains, is not to retreat into fantasy or escape, but rather to face the terrible realities and set ourselves free through our imaginations. Doing so, she explains, allows us to leverage renewal and empathy as we move forward.

Geppert points to the examples of the good we have seen as a result of the pandemic, and ponders how we might bring those positives forward with us as we re-open and re-emerge into the post-lockdown and quarantine world. For instance, animals have returned to their habitats and exploring areas they had long abandoned in national parks worldwide. Perhaps, she muses, as we move forward, we can find ways to enjoy our natural surroundings without disturbing these animals’ homes. Animal shelters quickly emptied with lockdown. She ponders, is there a way to encourage adoptions and fostering in the future? Pollution has subsided in many areas. Can we can continue to forgo some car and plane trips to minimize the damage to our environment? Recovered patients donated plasma, health care workers put their own well-being aside to care for others, and people have offered to shop for the elderly and the sick. Can we continue to value and foster the acts of 

Geppert reminds us of what a fellow dreamer shared, as he helped eradicate polio, which was once considered impossible: “There is hope in dreams, imagination, and in the courage of those who wish to make those dreams a reality.” And she invites listeners to have the courage to use their imagination to rebuild a better and kinder world with 

You may say I'm a dreamer
But I'm not the only one
I hope some day you'll join us
And the world will be as one.

Videos

Dr Cynthia Geppert invites listeners to have the courage to use their imagination to rebuild a better and kinder world

It’s Time to Use Our Moral Imagination

Slideshows

In psychiatry, hot debates abound if you just look around-and if this Special Report collection is any indication, the result is a balance of opinion and civility made richer by virtue of opposing views.

Psychiatric Questions, Queries, and Quarrels

Perhaps no branch of medicine has been the subject of so much controversy as psychiatry. Almost everything about our profession has been doubted and debated: our assumptions about the nature of psychiatric disorders from psychoanalysis to neuropsychiatry, and our interventions from ECT to CBT. Those who query and quarrel are often from outside the fold of the profession, albeit at times with help from insiders like the late great Thomas Szasz.

 Recently, the most impassioned polemic has frequently come from other mental health disciplines-those closest to us always know our weaknesses best. The intrinsic division within our own house has also been the subject of T. M. Luhrmann’s ethnography of psychiatry.

As of March 2, 28 states and the District of Columbia have approved medical marijuana, and there is an ever-burgeoning list of psychiatric conditions that meet the criteria for state programs-despite the concerns of many psychiatrists about the increased risk of psychosis, especially for those individuals with a diathesis.

 Yet this is also regrettably a topic on which there has been rhetoric that too often obfuscates reason on both sides. Christopher Fichtner, MD, and Howard Moss, MD, may prolong the controversy by providing more of a 

. Medical marijuana as a phenomenon in the culture of medicine has been driven far more by the public and politicians than by practitioners and professionals. Except perhaps for our colleagues with expertise in complementary and alternative medicines, many mainstream psychiatrists are playing scientific catch-up.

No issue in psychiatry has been as contentious and protracted as the arguments and counterarguments over the DSM diagnostic system. In our own social life, most of us have learned that there are subjects where the disagreement is so intense we have to change the subject. This is exactly what we have in the article by Bruce Cuthbert, PhD, on the National Institutes of Mental Health Research Domain Criteria (RDoC). Cuthbert discusses this research-based diagnostic system and offers instructive comparisons and contrasts with DSM. The acronym RDoC is the latest chapter in psychiatry’s ongoing story of the search for a holy grail of biological etiology. Those who think this a quixotic or futile quest may take some solace in that any criteria still leave ample room for the judgment and experience of the practicing clinician.

 redux hones in on one of the most popular targets of the media: that psychiatric disorders are overdiagnosed in an effort to medicalize and medicate normal variants in human behavior. Psychiatric detractors give a variety of rationales-some suggestive of conspiracy theories-for this tendency. Rahil R. Jummami, MD, Emily Hirsch, and Glenn Hirsch, MD, take on one of the most heated topics-the diagnosis and treatment of 

. Mining the epidemiological data field, they draw interesting, and at times opposing, conclusions as befits a Special Report dedicated to dissension. Readers can decide after reading the article whether ADHD is really over-or perhaps even under-diagnosed as well as parse out the logical fallacy that a diagnosis leads ineluctably to medication management.

 is arguably on a subject that is the most oriented toward future debates-physician-assisted suicide (PAS) for patients with mental illness. PAS has been legal and ethical not only in Europe for years but more contemporaneously in our neighbor to the north-Canada. No other issue in our series has aroused such polarized and powerfully held opinions, and this is not surprising given that PAS or PAD (

), depending on your view, goes to the heart of the ethical commitment of psychiatry as a profession of healers of the mind.

 We urge readers to seriously consider the positives and negatives of this momentous change in our evaluation and balancing of the age-old tension in mental health care between compassion and suffering and begin to formulate their own position and justifications for a question that urgently confronts us all.

 ProCon.org. The Leading Source for Pros and Cons of Controversial Issues. 

http://medicalmarijuana.procon.org/view.resource.php?resourceID=000881

 Pies R, Geppert CM. Not just a matter of semantics. 

Articles

An overview of the DSM diagnostic system, the medicalization of normal variants of human behavior, and physician-assisted suicide.

Introduction: More Dives and Intellectual Jujitsu

, to controvert “is to oppose with logical reasoning, to dispute or contradict”; even more literally in the Latin it means, “turned against.” Hence came the disputations of medieval theologians and the point-counterpoint of the 

 of Thomas Aquinas. In this 2-part Special Report on Controversies in Psychiatry, we offer our modern version of such point-counterpoint.

But first a bit of a clarification. Cable television and social media have taken the academic shine off of controversy and sullied it with scandal. True controversies, such as those we will examine in this Report, are substantive clinical issues about which there is real and serious disagreement among experts. Political controversy, as we have sadly seen these past few months, can be a sign that the social body is ailing. But respectful debates about substantive topics are signs of curiosity and imagination signaling health of mind-or in this case the community of minds that is psychiatry.

Gauged by this measure, psychiatry is very well indeed, for the most difficult part of chairing this Special Report was how to choose from the dozens of controversies our outstanding editorial staff developed.

The articles in part I examine some of the most intriguing questions. Strong evidence supports sound arguments on each side of each topic.

The first set of articles addresses assisted outpatient treatment (AOT), a topic that may not seem like a controversy to many of our readers. The authors of the 2 articles suggest that there are salient counter-claims about AOT that strike the fundamental chord of mental health ethics: the conflict between beneficence and autonomy, and between paternalism and liberty that deserves a hearing and thoughtful response.

The second issue addressed is the debate over the use of antidepressants in pregnancy-another contemporary clinical dilemma in which practitioners often fear they have no viable options. Lauren Osborne, MD, Katherine McEvoy, MB ChB, and Jennifer Payne, MD, show that empirical data and shared decision-making offer a number of reasonable strategies.

Neuroscience has more than proved that engaging in challenging mental exercise is key to the longevity and vitality of the life of the mind. So we invite readers to join us in this age-old intellectual jujitsu, which has been an essential part of the training of rabbis and lawyers, philosophers, and-yes-physicians.

Dr. Geppert is Professor of Psychiatry and Director of Ethics Education, University of New Mexico School of Medicine; and Chief, Consultation Psychiatry and Ethics, New Mexico VA Health Care System, Albuquerque, NM.

This special report on controversies in psychiatry examines the pros and cons of assisted outpatient treatment and also antidepressant use in pregnancy.

Introduction: Deep Dives and Intellectual Jujitsu

If we were to conduct a survey of readers’ responses to the quiz that follows, we would likely find a marked generational divide between those who believe that “patient-targeted Googling” is just another form of collateral information and those who think that Googling is just a new type of boundary crossing.

 The etiquette and ethics of the electronic revolution have been styled “digital professionalism,” and it is a field in flux as we see when we analyze the 

The case presented a mid-career psychiatrist, Dr. R, with a predominantly psychotherapy practice who is treating Ms B, a woman in her thirties who purports to have been a famous academic musician until she unjustly lost her career after a student accused her of sexual misconduct. Initially, the psychiatrist believes the patient is suffering from an adjustment disorder, but as the sessions proceed he begins to doubt the patient’s narrative. His best efforts to engage Ms B in more critical reflection on the events, or even offer up more factual details, fail. He entertains the idea of Googling Ms B to find out what really happened-ostensibly to move the stalled therapy forward. But first he seeks advice from his former psychology professor, who assures him that there is nothing unethical about the practice.

The quiz asks you to think about whether you agree with the professor’s advice and how in your own practice you would handle information about a patient obtained from an Internet search.

1. Assume you are the psychology professor. What do you tell Dr. R about the ethics of “Googling” Ms B?

Go ahead and Google; the Internet is public domain.

 This is one of the most common reasons or rationalizations-depending on your perspective-in favor of Googling a patient. It is technically true that the Internet is mostly public domain, but this assumes that the person conducting the search is “the public” with the prevailing mores and morals of their society and not a mental health professional who many ethicists believe should be held to a higher standard of conduct.

 Don’t Google the patient; it’s a violation of HIPAA. 

This is often used to mechanistically intimidate practitioners into not Googling, although the psychiatrist is technically not “exchanging information” in that he is not disclosing any protected health information about the patient. But this reflexive turn to HIPAA shows the ambivalence of many who contemplate Googling, yet who instinctively believe it is intruding on a patient’s privacy or who fear the legal consequences of a violation.

Don’t Google the patient; it is a breach of the patient’s trust in the therapeutic alliance.

 This is the answer of many older psychiatrists as well as those who have strong psychoanalytic training or orientation. How and when the patient reveals her psyche in the therapeutic relationship is at least as significant as what is revealed, and taking such a shortcut betrays not only the patient’s trust but the integrity of the process.

Don’t Google the patient; instead search the major newspapers from the city where Ms B purports the events occurred.

 This raises a fascinating question. How is Googling ethically better or worse than searching the newspapers, the latter inarguably being public domain? Ask yourself if you picked up the morning 

 and found a story about one of your long-term patients: would you read it, or would you first ask the patient for her permission? A survey published this year found that nearly 40% of psychotherapists had searched online for information about a patient, especially when-as in the case of Ms B-they felt they had been deceived. About the same percentage knew or supervised someone who had engaged in patient-targeted Googling.3 Earlier surveys that focused on psychiatrists found similar percentages.

 One study found that 60% of psychiatrists questioned in New York believed that patient-targeted Googling could be constructively utilized in psychiatry.

2. The professor tells Dr. R there is no ethical reason he cannot Google the patient. Dr. R then asks if he should obtain informed consent from the patient to conduct the search.

In question 2, Dr. R is still struggling with the question of confidentiality and so brings up the equally fundamental ethical concept of informed consent and whether he should obtain it before searching.

No, don’t tell her. This undermines the entire psychological purpose of the activity and its ethical justification to find out the truth, so you could help her in therapy.

 This is an odd mixture of motives that are key in determining whether a search is ethical. The professor seems to be saying that the goal of Googling is not just to obtain the information but to use it psychologically to facilitate the therapy. It is this basis in beneficence that could provide the ethical counterweight to the breach of confidentiality.

No, don’t ask her permission, but you can tell Ms B later that you conducted a search to be better able to understand and work with her in therapy. 

This bends the beneficence toward soft paternalism and assumes that the patient will accept that the psychiatrist acted for her “good.” It is easy to see how this strategy, especially for this already embittered patient, might unwittingly have the opposite effect of reinforcing her immature defenses-she will continue to believe that all that has befallen her is the result of undeserved perfidy.

Yes, ask her permission out of respect for her privacy. 

This is a prudent choice and may be what Ms B desires with her insistence that she was such a renowned figure that her reversal of fortune was headline news. The only catch is that the truth the papers printed is far less glamorous than Ms B’s fantasy, and a stark confrontation of this discrepancy would expose the false self she is desperately holding onto in therapy. More simplistically, if she says no, Dr. R will have no information and must also deal with the unpredictable reaction of his patient.

Yes, ask her permission and suggest that you do the search together in your office during a session.

 This best respects the patient’s autonomy and privacy and probably also has the most therapeutic potential to enable Ms B to face the truth of her past. However, like option C, she can obviously refuse the suggestion, leaving the course of therapy even more impeded. Should Dr. R decide to Google Ms B, it is hard to see how he could constructively use the information or preserve the alliance given the way the information was obtained.

3. The professor tells you not only is it ethically permissible to Google Ms B but that you actually have an ethical obligation to conduct the search in order to provide appropriate care. Does Dr. R really have an ethical duty to Google Ms B, and if so, what is its nature?

Question 3 emphasizes the spectrum of ethical views on the subject, even among leading psychiatric ethicists.

Yes, Dr. R has a duty to overcome his own negative counter-transference toward the patient.

 This locates the warrant for Dr. R to work through his own negative emotions toward Ms B to regain the position of therapeutic neutrality he needs to be effective in treating his patient.

No, Dr. R does not have an ethical obligation to Google the patient because doing so is a breach of physician-patient confidentiality.

 This is the most traditional answer at the other end of the continuum: Googling cannot be a professional duty because it directly contravenes the more fundamental obligation to respect patient confidentiality.

No, Dr. R has an obligation to work within the psychodynamic frame to empathically understand and effectively treat the patient.

 This offers a more sophisticated variant of the previous option. It locates the psychiatrist’s primary duty to maintain the boundaries of the therapeutic relationship, within which compassionate listening may enable the patient to find healing.

Yes, if Dr. R does not review information that could potentially prevent harm to the patient, and if she attempts suicide, he will not have done his duty to protect her and could be held legally liable.

 This is the even more extreme version of C and once again emphasizes the diversity of opinion on the practice. A psychiatrist who did not obtain clinically indicated collateral information such as previous treatment records or reports of significant others-with consent outside an emergency situation-would not have met the standard of care.

Since by analogy the Internet is a source of information about the patient, do we not also have a duty to consult it? One thing almost every practitioner along the Googling continuum agrees on is the need for more definitive ethical and legal guidance, and several organizations and experts have proposed professional recommendations.

4. Now that Dr. R has this information, what should he do with it?

In the final question, Dr. R’s clinical reality intrudes on the professor’s pontifications. Dr. R searched the Internet for information about Ms B-and now how does he handle it in therapy? Sound clinical advice is found in a review article by Clinton and colleagues.

Dr. R should tell Ms B that he Googled her and would like to discuss what he found, so they can engage in more productive work about her real problems.

Dr. R should tell Ms B that he Googled her and that she has a right to know what he learned, so she can make an informed decision about whether to continue in therapy.

Both options assume Dr. R did not seek Ms B’s consent before his virtual detective work, and each is an attempt to restore some measure of ethical equilibrium. Option A pleads that he did not seek her consent for her own good, while option B gives Ms B a chance to exercise her own self-determination even if the search is a faitaccompli.

Dr. R should not tell Ms B that he Googled her but should begin shifting the therapeutic approach from adjustment disorder to narcissistic personality disorder.

 Options B and C add a breach of truth-telling to the lack of consent. Most psychiatrists would scrutinize a clinician who changed his diagnostic impressions on the basis of news stories.

Dr. R should not tell Ms B that he Googled her; instead he should say that he had read about her in a newspaper at the time of the incident but recalled the details differently.

 This is prevarication, and the worthwhile therapeutic objective could be more honestly accomplished through Dr. R disclosing his search.

Working through the case scenario, the wisdom of the deontological stance of the American Psychiatric Association (APA) Ethics Committee becomes apparent.

 In its commentary on the Principles of Medical Ethics, the APA opines that what renders a decision to Google a patient ethically justifiable is the motive of the psychiatrist. To Google for the good of the patient may be acceptable, to Google to circumvent the hard work of interviewing, or for voyeuristic breaching of boundaries, or in the case of Dr. R frustration over a thwarted therapy, may well not be ethical. You decide.

Googling a patient is not, in and of itself, unethical. First and foremost, the Googling of a patient should be done only in the interests of promoting patient care and well-being and never to satisfy the curiosity or other needs of the psychiatrist. Also important to consider is how such information will influence treatment, and how the clinician will ultimately use this information. The psychiatrist should ask himself or herself these questions before resorting to a Google search.

Dr. Geppert is Professor of Psychiatry and Director of Ethics Education, University of New Mexico School of Medicine; and Chief, Consultation Psychiatry and Ethics, New Mexico VA Health Care System, Albuquerque, NM. She reports no conflicts of interest concerning the subject matter of this article.

 John NJ, Shelton PG, Lang MC, Ingersoll J. Training psychiatry residents in professionalism in the digital world. 

 Geppert C. To google or not to google? This is the question. 

 Eichenberg C, Herzberg PY. Do therapists google their patients? A survey among psychotherapists.

 Koh S, Cattell GM, Cochran DM, et al. Psychiatrists’ use of electronic communication and social media and a proposed framework for future guidelines.

 Deen SR, Withers A, Hellerstein DJ. Mental health practitioners’ use and attitudes regarding the Internet and social media. 

 Genes N, Appel J. The ethics of physicians’ web searches for patients’ information. 

 Clinton BK, Silverman BC, Brendel DH. Patient-targeted googling: the ethics of searching online for patient information. 

 Ethics Committee of the American Psychiatric Association. 

Opinions of the Ethics Committee on the Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry.

 Arlington, VA: American Psychiatric Association; 2016.

How would you handle information about a patient obtained from an Internet search? Take the quiz.  

To Google or Not to Google? Is “Patient-Targeted” Googling Ethical?

The lady doth protest too much, methinks.

Dr. R is a psychiatrist who has been in private practice for 15 years in a large urban city in the Northeast.

 His practice consists mostly of psychodynamic psychotherapy with some minor medication management. The majority of his patients are self-pay.

Ms. B is an attractive, very intelligent 36-year-old single woman whom Dr. R has been treating for about 6 months for what initially appeared to be an adjustment disorder with depressed mood resulting from an unfortunate career reversal. Most of the sessions have revolved around Ms. B’s feelings of betrayal and embitterment regarding the loss of her academic post in the music department of a large university in the Midwest, where she previously lived. Ms. B insists that a student had falsely accused her of improper sexual advances and that because of department politics, she was forced to resign a year ago. At the time Ms. B says she was a promising concert violinist and music scholar.

Ms. B is distraught that after having graduated from a famous conservatory the only job she has been able to obtain is directing the music program at a local private school. She is enraged that circumstances have reduced her to such a lowly position. Dr. R is well aware of the literature on adjustment disorder and that these patients have an elevated risk of suicide.

The central theme that has emerged in therapy is Ms. B’s loss of reputation and honor and her extreme resentment regarding the unfairness of academia. She vehemently blames the Chair of the department for not defending her against what she perceives as ridiculous allegations from a student who did not get the grade he wanted in her music theory class. She voices revenge fantasies but states that she “would never act on them as I am beyond such primitive reactions; that is why I am in therapy.” As the therapy proceeds, the psychiatrist begins to doubt Ms. B’s account of her recent events and even questions her history as a musician. His psychodynamic formulation is now moving toward a narcissistic personality disorder or even, at times, delusions of grandeur suggesting a bipolar diagnosis.

Repeated efforts using a variety of psychotherapeutic techniques to explore Ms. B’s family of origin or to enable her to describe the emotional effects of the professional upheaval are met with accusations that Dr. R is calling her a liar and a renewed preoccupation-even obsession-with her stolen fame. Ms. B rebuffs any reinterpretation of her experience with the response that “you must have read all about this when I was humiliated in the newspapers; of course it happened exactly as I told you.”

Dr. R is becoming increasingly skeptical of Ms. B’s personal narrative and frustrated with her resistance. He is a regular reader of several major newspapers and a music aficionado yet cannot recall ever reading anything about Ms. B. After much struggling with his own sense of psychoanalytic boundaries, Dr. R finally decides to try to substantiate at least the basic details of Ms. B’s story. He fears that unless he can obtain some reliable independent report about her past he will be unable to constructively help her build a future.

Dr. R believes that the most efficient means of accessing such information would be through the Internet, where he can run a targeted search using the facts as he knows them from the therapy. Dr. R has not kept up much with digital professionalism. He is aware of colleagues who are on Facebook and some who advertise their services on the Internet. He knows that a few even regularly provide psychiatric commentary in blogs. “Googling” a patient does not seem much different from the old-fashioned obtaining of collateral information, but he is unsure of the legal or even ethical ramifications of using the Internet to gather such information. He calls an old friend who was his psychology professor in college and who now teaches ethics at a local college for advice.

Assume you are the psychology professor. What do you tell Dr. R about the ethics of “Googling” Ms. B?

 Go ahead and Google; the Internet is public domain, and there is no ethical or legal problem with accessing the information.

 Do not Google the patient; it is a violation of HIPAA, which protects the electronic exchange of individually identifiable information.

 Don’t Google the patient; it is a breach of the patient’s trust in the therapeutic alliance.

 Don’t Google the patient; instead go to the public library and search the major newspapers from the city where Ms. B purports the events occurred.

2 The professor tells Dr. R there is no ethical reason he cannot Google the patient. Dr. R then asks if he should obtain informed consent from the patient to conduct the search.

 No, don’t tell her. This undermines the entire psychological purpose of the activity and its ethical justification to find out the truth, so you could help her in therapy.

 No, don’t ask her permission, but you can tell Ms. B later that you conducted a search to be better able to understand and work with her in therapy.

 Yes, ask her permission out of respect for her privacy.

3 The professor tells you not only is it ethically permissible to Google Ms. B but that you actually have an ethical obligation to conduct the search in order to provide appropriate care. Does Dr. R really have an ethical duty to Google Ms. B, and if so, what is its nature?

Yes, Dr. R has a duty to overcome his own negative counter-transference toward the patient so that he can form a therapeutic relationship.

 No, Dr. R does not have an ethical obligation to Google the patient because doing so is a breach of physician-patient confidentiality.

 No, Dr. R has an obligation to work within the psychodynamic frame to empathically understand and effectively treat the patient.

 Yes, if Dr. R does not review information accessible to him that could potentially prevent harm to the patient, and if she attempts suicide, he will not have done his duty to protect her and could be held legally liable.

Dr. R decides to Google Ms. B because he fears that unless he knows what really happened to her, her enraged desperation may result in her harming herself or someone else. He finds a few stories in the city newspaper as well as a brief statement from the university about the incident. From these communications, Dr. R learns that Ms. B was not only charged with allegations of sexual impropriety with a student, but the charges were actually substantiated and she was given a choice to resign or to be terminated. She is described as an instructor in the department and a substitute violinist in the local symphony-hardly the irreproachable luminary of classical music she portrayed herself to be in therapy.

4 Now that Dr. R has this information, what should he do with it?

 At the next session, Dr. R should tell Ms. B that he Googled her and would like to discuss what he found so that they can engage in more productive work about her real problems.

 At the next session, Dr. R should tell Ms. B that he Googled her and that she has a right to know what he learned, so she can make an informed decision about whether to continue in therapy.

 At the next session, Dr. R should not tell Ms. B that he Googled her but should begin shifting the therapeutic approach from adjustment disorder to narcissistic personality disorder.

 At the next session, Dr. R should not tell Ms. B that he Googled her; instead he should say that he had read about her in a newspaper at the time of the incident but recalled the details differently and could they discuss the discrepancies as a means of moving her toward insight.

Ethics consultations often involve a number of different and often conflicting ethical concerns and questions. Please vote for your choices-and post your comments below. I’ll offer a discussion of your comments and commentary about the ethical concerns and questions this case raises in a coming issue of Psychiatric Times.

Dr. Geppert is Professor of Psychiatry and Director of Ethics Education, University of New Mexico School of Medicine; and Chief, Consultation Psychiatry and Ethics, New Mexico VA Health Care System, Albuquerque, NM. She reports no conflicts of interest concerning the subject matter of this article. 

“Googling” a patient does not seem much different from the old-fashioned obtaining of collateral information, but the ramifications may be far more than you bargain for.

To Google or Not to Google? This Is the Question

Evaluations of decisional capacity are among the most common-and the most complex-psychiatric consultations. Determination of decisional capacity is fraught with myths that may mislead all physicians. These misunderstandings present clinical pitfalls that can result in serious medical, ethical, legal, and psychosocial challenges. Conversely, the ability to conduct a decision-making capacity assessment with knowledge, skill, empathy, and wisdom is a duty and service of high ethical value and significance. Decisional capacity assessments that psychosomatic medicine psychiatrists perform every day help protect vulnerable individuals from neglect and exploitation, preserve autonomy and self-determination, and help other clinicians and administrators solve complex bioethical and biomedical dilemmas.

These evaluations provide a forum for the entire health care community and its stakeholders to engage in thoughtful deliberations that inform policy development that upholds the highest ethical values of our profession and society regarding medical care and research.

This article will focus on capacity to participate in medical decisions rather than research, but there is considerable overlap in the principles and procedures presented.

Facts and myths about decision-making capacity

One of the most important reasons to tease apart the facts from the myths is that so many of the individuals for whom capacity assessments are requested have psychiatric disorders, such as schizophrenia and dementia (

 with schizophrenia and most patients with mild to moderate dementia are-with psychiatric care, assistance, patience, kindness, and time-able to make many basic medical and dispositional decisions.

Many clinicians, including psychiatrists, may confuse and conflate commitment and capacity, not recognizing that many patients who are committed retain the ability to participate in treatment decisions.

 of over 2500 patients indicate that, contrary to the hypothesis of the research, it was not psychosis that led to incapacity but rather cognitive impairment and substance use.

 The exception is when the psychopathology directly interferes with the patient’s decision-making process as in the frequently encountered case examples in 

The presumption that patients with psychopathology do not have decisional capacity is often grounded in an even more profound misunderstanding of decision-making capacity as monolithic: that decisional incapacity in one area, such as finances, precludes capacity in all areas. Most of us are able to make better decisions in some areas of our lives than in others. Similarly, it is often assumed that capacity is static, when it is really a dynamic, granular ability that is better at some times and worse at others.

 is among the most frequently encountered, yet often unrecognized, conditions that impair the capacity of patients to make decisions in the settings of emergency departments as well as medical, surgical, and intensive care units.

 Because of the intrinsically fluctuating nature of delirium, which typically worsens toward evening, and our obligation to offer the patient an optimal opportunity to perform well on the assessment, it is often best to conduct capacity evaluations in the morning-especially for patients with or at 

Yet this variability is also a positive: it means that we can enhance a patient’s ability through basic interventions we know well as psychiatrists, such as normalizing the sleep-wake cycle; treating anxiety, depression, and psychosis; and providing supportive psychotherapy. Both pharmacological and psychological treatments as well as a variety of cultural adjustments, such as having a trained interpreter and educational modalities (eg, audiovisuals, social supports involving family members), have been shown to improve the ability of patients with physical and psychiatric illnesses to optimize their decisional capacity. Ethically, it is our obligation to try these interventions so that we give the patient the “best chance” to do as well as possible and to assess the patient at the point of his or her highest capacity.

An essential aspect of this “best chance” is that the psychiatrist must define the object of the capacity request. The first thing we teach psychiatric residents who respond to a consultation request for capacity determination is to discuss with the requesting clinician, “Just exactly what is the question?” This helps to begin a dialogue and to elicit the latent as well as the manifest content of the consultation question. A study examined 100 consecutive consultations for capacity evaluations submitted to a 

 service at an academic medical center. The results of this study showed that approximately the same number of consultations were received for the capacity to consent to a treatment or procedure, the capacity to refuse a treatment or procedure, the capacity to leave the hospital against medical advice, and the 

The importance of patient self-determination requires that, at the outset, we recognize the legal limits of medical capacity assessments. Only a judge or other officer of the court can make the legal determination of competence. Although our capacity assessments often inform the court’s decision, medical assessments of incapacity are not formal legal adjudications that patients are incompetent with all the attendant limitations on their rights and responsibilities as citizens. Although some experts believe this distinction is purely semantic, the 2 terms functionally refer to quite distinct but related processes.

This is an especially salient distinction when applied to patients with psychiatric disorders who have been involuntarily committed. Many clinicians, including psychiatrists, may confuse and conflate commitment and capacity, not recognizing that many patients who are committed retain the ability to participate in treatment decisions and provide informed consent (

). Conversely, there is an inherent assumption that when a patient refuses a recommended hospitalization, test, or procedure or suggested medical treatment, he or she “must be mentally ill.” Similar to innocence in our system of criminal justice, in Anglo-American bioethics, the patient should be presumed capacitated unless it is clear that the refusal is based on a psychiatric disorder that is interfering directly with the decision-making process. Persons with neuropsychiatric illness have the same rights as all patients and can refuse or consent to medical care.

Determination of decisional capacity: who and how?

While law and policy endow any physician with the requisite training and scope of practice to perform a capacity evaluation, in reality, when non-psychiatric physicians are struggling with the evaluation or are confronted with a particularly complicated patient, they often turn to psychosomatic physicians to conduct the assessment. A 

 that compared the capacity of medical inpatients to make major decisions using the Mini-Mental State Examination (MMSE), clinical impression, and expert evaluation showed that the MMSE and clinical impression were often inaccurate predictors of decision-making.

 However, this does not mean that there is no structured or standardized approach for performing capacity assessments. A widely accepted and utilized method for analysis of decisional capacity is 

Communication and understanding can be conceptualized as the lower order of abilities necessary to make the most basic decisions, such as choosing a surrogate, while rationality and appreciation are higher-order abilities needed for complex decisions, such as selecting surgery, chemotherapy, or radiation for cancer. Using the MacArthur Assessment Tool, 

 found that patients who scored low on the understanding component were not likely to be capacitated. Appreciation was a better test of capacity in psychiatric patients, while reasoning was superior in those with systemic medical disorders. The correlation of brain imaging with specific capacity impairments is in its infancy but is a promising future direction for capacity research.

In assisting patients and clinicians to determine whether a patient has the capacity to make 

, psychosomatic medicine physicians are fortunate to have access to several useful decision aids. The MacArthur Competence Assessment Tools for Clinical Research and Treatment is the most evidence-based tool, and the Aid to Capacity Evaluation (ACE) is among the most clinically useful.

 These instruments can provide results that can also support psychosomatic medicine psychiatrists in the presentation of their findings to other clinicians and family members and document the results of an evaluation in a formal report suitable for submission to social service agencies or courts.

One of the most significant pitfalls to avoid when using any structured instrument is to realize that it cannot supplant-only supplement-the clinical evaluation. Research suggests that medical patients who score on the low end of the range on cognitive instruments are more likely to lack decision-making capacity; similarly, those with near-normal scores are probably able to make decisions. In the middle range, however, there is no exact or predictable correlation.

It is precisely in the most complex of capacity evaluations where relevant clinical context is crucial and where a clinical “gradient” decisional capacity model can be highly beneficial in formulating the evaluation. On this gradient, capacity is conceived as “dimensional,” in that different decisions require different levels of sophistication (

). It is important to recall that many otherwise cognitively impaired patients may at least name a surrogate decision maker.

As such, assessment for the capacity to name a surrogate (can the patient understand the role of a surrogate, when the surrogate would be used, and that the surrogate may not make the decision the patient “would have wanted”) is often a practical matter, even if the patient cannot demonstrate decisional capacity for the medical or surgical intervention at hand. While some have criticized sliding-scale types of models, 

The gradient of capacity should remind the capacity evaluator that even patients who perform poorly on cognitive screens may have intact functional capacity and are able to care for themselves in the community through routine and a network of friends and family; or a patient with progressive cognitive impairment may have “good old-fashioned common sense” and recognize, for example, that he is unsafe at home and agree to assisted living. In these decisions, balancing respect for patient autonomy and the duty to keep the patient safe are the paramount ethical values in conflict.

Evaluators must be cautious to avoid too quickly substituting their preferences as a substituted judgment. Refusal of care, including psychiatric treatment, accentuates this challenge.

In consultations to determine the patient’s future decisional capacity for independent living and self-care (ie, “dispositional capacity”), as opposed to a decision about a specific medical intervention-where the Appelbaum and Grisso framework is most clearly applicable-additional consultation with an occupational therapist for a Kohlman Evaluation of Living Skills and similar in vivo dynamic assessment of self-care skills may greatly add to the psychiatrist’s assessment.

Ethical challenges are intensified in marginalized and underserved populations, such as individuals who are undomiciled or marginally housed, undocumented immigrants, the elderly, and persons with addiction or other psychiatric disorders-all of whom are vulnerable to exploitation and victimization. Ironically, although we recognize the fragile position of the economically disadvantaged and incapacitated, the wealthy can also be vulnerable and victimized. Take, for example, the widely publicized case of Brooke Astor whose son stole and sold artwork and other valuables worth millions from his mother, including works of art that she personally treasured.

Emerging research on the challenges of determining capacity in persons who are undomiciled is illustrative of the difficulties in evaluating decision-making in marginalized groups. When caring for undomiciled individuals, 

 with feelings of anger-directed at “the system” or the undomiciled individual-lack of empathy, disgust, and even futility.

 These emotional responses can impair objective assessment of patient needs, decisional capacity, and reaction to behaviors. There may be an excessive reluctance to discharge undomiciled patients, even with resolution of acute medical needs. Alternatively, there may be a risk of refusing care or of faster than indicated discharge as a consequence of negative countertransference to the undomiciled individual.

Evaluators must be cautious to avoid too quickly substituting their preferences as a substituted judgment. Refusal of care, including psychiatric treatment, accentuates this challenge. Legal precedents have supported the right of homeless psychotic individuals to refuse care. When considering capacity in a homeless individual, the same general standards need to be applied, while keeping in mind some of the potential complicating factors:

• Distrust of medical profession based on prior encounters

• Higher potential for medical consequences of refusing care

• Risk of alienation from future care with forced treatment

There is no one-size-fits-all in decisional capacity. Every assessment is determined on a case-by-case basis. Understanding the myths and facts about decisional capacity allows patients to preserve dignity and autonomy and helps clinicians mediate conflicts, meet the bioethical challenges of determination of decisional capacity, and provide compassionate resolutions for both patients and their caregivers.

The authors acknowledge Christina Wichman, DO, FAPM, and Catherine C. Crone, MD, of the Academy of Psychosomatic Medicine (APM) for helping bring this article to fruition. The APM is the professional home for psychiatrists providing collaborative care bridging physical and mental health. Over 1200 members offer psychiatric treatment in general medical hospitals, primary care, and outpatient medical settings for patients with comorbid medical conditions.

Dr. Geppert is Professor of Psychiatry and Director of Ethics Education, University of New Mexico School of Medicine; and Chief, Consultation Psychiatry and Ethics, New Mexico VA Health Care System, Albuquerque, NM. Dr. Cohen is Clinical Professor of Psychiatry, Icahn School of Medicine at Mount Sinai, New York. Dr. Bourgeois is Clinical Professor and Vice Chair of Clinical Affairs, department of psychiatry, Langley Porter Psychiatric Institute, University of California, San Francisco. Dr. Peterson is Associate Professor in Psychiatry, University of Wisconsin School of Medicine and Public Health and Director of Hospital Psychiatric Services, University Hospital, Madison, WI. The authors report no conflicts of interest concerning the subject matter of this article.

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The authors parse myths and facts about decisional capacity, with the goal of preserving patients' dignity and autonomy and helping you mediate conflicts, meet bioethical challenges, and provide compassionate resolutions.

Author | Cynthia Geppert, MD, MA, MPH, MSBE, DPS, FAPM

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