The goal of the survey was to go beyond ethical lessons, useful as these may be, and to learn how Psychiatric Times’ readers-who are on the front line of psychiatric practice-handle a series of hypothetical ethical scenarios.
An Apology to Our Readers
Not long ago, we posted a survey on our website that included a series of questions about ethical dilemmas mental health professionals face in daily practice. Exactly 1400 of you responded to that survey. . . and more than half of the respondents were psychiatrists. The idea for the survey came from our editorial board member, Cynthia Geppert, MD, PhD, MPH, who subsequently wrote an overview of the survey results. Dr Geppert's commentary, which was based on a summary of the copious data derived from the survey, was published in the May issue of Psychiatric Times, and -- on June 7th-- it was posted to our website.
When that essay was posted, it contained a live link to the original ethics survey. Our intent in including that link was to give interested readers a chance to review the original survey questions and to click on the hundreds of detailed responses to those questions. The day after the essay was posted, it was brought to our attention by a reader that – with enough drilling down – the names and email addresses of some of the respondents could be found. Dr Geppert was not aware of this, nor were we because we worked from the same data summary instead of the live survey. We immediately deleted the link and disabled the survey itself so that it would no longer be accessible to anyone. Still, the survey was live for about 16 hours.
The irony that this breach occurred in the context of one of the largest surveys ever on ethical issues facing psychiatrists – and in the middle of an essay about whether ethical dilemmas have changed in recent years and how prepared we are to manage changing dilemmas –- is not lost on us.
We know full well how much you value your privacy and we sincerely apologize to our survey respondents. We’ve taken steps to ensure that this won’t happen again.
We and Dr Geppert plan another ethics survey next year. We hope you’ll join in.
Please let us hear from you? Slings? Arrows? We’d welcome your thoughts and comments.
Group Editorial Director
The pages of Psychiatric Times and other journals and newspapers both scholarly and popular are replete with stories about the ethical controversies of modern psychiatry and the crises of the profession. The overwhelming response among physicians in general to a recent Medscape ethics survey1 inspired me to work with Psychiatric Times to develop a survey uniquely geared toward psychiatrists and other mental health professionals. The goal of the survey was to go beyond ethical lessons, useful as these may be, and to learn how Psychiatric Times’ readers-who are on the front line of psychiatric practice-handle a series of hypothetical ethical scenarios. The survey ran from January 13 through February 28, 2011. The responses were all anonymous and reported in aggregate.
The thoughtfulness and courage of the psychiatrists who participated was impressive. They volunteered a window into their personal moral struggles regarding a host of sensitive ethical subjects as evident in this prcis. Two questions dealt with emerging end-of-life issues in psychiatry-involvement in physician-assisted suicide and whether patients with mental illness ever reach the state where continued care is futile. Three others focused on the more familiar boundary concerns of personal disclosure and romantic involvement.
Two scenarios described patients with difficult behaviors and asked how the clinician would handle the problems. Respondents were asked how they would deal with the conflict between confidentiality and nonmaleficence when a patient threatens an identified victim and how they handle the increasingly common dilemma of an elderly patient for whom driving preserves independence but threatens the public. There were also questions about the influence of third-party forces such as insurance companies, managed care, regulatory authorities, and the pharmaceutical industry on contemporary practice.
I hope this brief description whets your appetite for future fare. Here I offer a tentative and broad interpretation of what the results tell us about how often psychiatrists grapple with complex ethical issues, whether those dilemmas have changed in recent years, and how prepared psychiatrists feel they are to manage these challenging dilemmas.
The survey asked participants to respond to a range of ethical dilemmas encountered in daily practice. The questions were multiple choice, with space provided for free text comments. The first 3 questions asked for basic demographic information such as age, whether the respondent was a physician, and his or her specialty. An amazing 708 psychiatrists took the time to respond to the survey along with other mental health professionals, including nurses, psychologists, and students, for a grand total of 1400 responses. The survey participants ranged in age from 20 years to 71 and older.
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.”
The respondents singled out the ascendancy of psychopharmacology in an era of limited resources as the postmodern focus of many ethics conflicts between patient autonomy and the physician’s duty to do no harm. “Persons presenting on medication without clear symptom-derived diagnoses. Over prescribing of potentially damaging medication. Persons requesting medication to solve lifestyle and nonpsychiatric issues.” Several practitioners mentioned the role of the pharmaceutical industry and managed care to explain why ethics questions more frequently come up in medication management. “Related to consumer marketing of medications, differences between docs on prescribing patterns-use of controlled substances.”
Ethics out in the open
Psychiatrists are obviously frustrated with many of the countervailing movements in the social, economic, and legal sphere that jeopardize their efforts to provide efficacious and humanistic care for patients who have mental illness. Yet these physicians also speak with a clear and strong voice that the greater attention given to ethics is a salutary advance. “It’s a good thing. Ethical issues used to just get buried in denial, now they are out in the open.” In subsequent columns and podcasts, I plan to explore the wisdom of readers regarding specific survey topics along with the best current legal and ethical thinking regarding the subject. We hope to make the ethics survey an annual event as one small contribution to what the results of our survey show is a growing ethical awareness among psychiatrists, “Ethical dilemmas are becoming more nuanced as different issues are identified and brought to the fore of one’s consciousness.”
1. Kane L. Exclusive Ethics Survey Results: Doctors Struggle With Tougher-Than-Ever Dilemmas. Medscape Medical Ethics. November 11, 2010. http://www.medscape.com/viewarticle/731485. Accessed April 7, 2011.