Psychiatrists must identify ethical conflicts that arise among their practice, personal beliefs, and the needs and beliefs of the patient.
Ethics is an endeavor. It refers to ways of understanding what is good and right in human experience. It is about discernment, knowledge and self-reflection, and it is sustained through seeking, clarifying and translating. It is the concrete expression of moral ideals in everyday life. Ethics is about meaning, and it is about action.
In psychiatry, ethics is about the use of specialized expertise to prevent and alleviate the suffering of mentally ill individuals. Ethics in this context is unusually complex. This is partly due to the specific form of suffering that defines mental illness: the distortion of cognition, feeling, perception and behaviors and the erosion of relationships, societal role and sense of self. Mental illness affects these most basic of human qualities and, accordingly, psychiatrists enter their patients' lives in ways that are distinctly personal and distinctly powerful. The goal of treatment in this context is to relieve suffering through the transformation of the thoughts, experiences, behaviors and relationships of ill individuals. Psychiatrists' therapeutic repertoire thus encompasses skills that range from attentive listening to compassionate, insistent intervention. For these reasons, the care of people with mental illness raises extraordinarily difficult ethical questions about our understanding of personhood and about the principled use of power in clinical care.
Ethical practice in psychiatry is informed by philosophical bioethics concepts, by sound ethical skills and, increasingly, by evidence (Figure) (Appelbaum and Grisso, 1995; Grisso and Appelbaum, 1995; Grisso et al., 1995). There are several bioethics concepts that are central to psychiatry. Respect for persons is the full regard for an ill individual's values, life experience, autonomy and dignity. Fidelity is the commitment of the clinician to serve faithfully the well-being and best interests of the patient without divided loyalties. Beneficence is the duty to do good by alleviating suffering and by working to enhance the life of the ill person, whereas non-maleficence is the duty to avoid and minimize harm. Clinical competence is closely linked to these principles, in that a professional should apply specialized expertise in the care of the patient, without stepping outside of one's scope of knowledge and skill. Confidentiality relates to the obligation to protect information disclosed by patients or observed in caring for patients without their explicit permission or a legal imperative to disclose it. Veracity is the duty to tell the truth and to assure accurate understanding. Justice is the equitable distribution of resources and burdens in the context of health care and research. Finally, respect for the law is the responsibility of the psychiatrist to live according to the shared rules governing society and, when necessary, to seek changes in the law. These ideals translate into safeguards such as therapeutic boundary-keeping; informed consent; confidentiality protections; clinical peer review and monitoring; access to emergency care; and the duty to report, duty to warn and duty to protect.
Beyond this conceptual basis, there are several essential ethics skills in psychiatric practice (Table). The first of these is the ability to identify ethical features and conflicting values present in a patient's care. Balancing the wishes of concerned parents against the confidentiality needs of their adolescent child or thinking through the need for medication for an agitated, distressed, decisionally compromised patient who is experiencing significant psychotic symptoms requires sensitivity to a number of underlying, conflicting ethical pressures.
The second skill relates to the clinician's capacity for self-observation in seeking to help and minimize harm to mentally ill patients. This proficiency is certainly essential in preventing boundary transgressions and violations in treatment, but it is also important in avoiding diagnostic errors of overemphasis or underemphasis. This second skill is also important for clinicians in recognizing when they are in situations that are uncomfortable and may signal latent ethical problems in the care of a patient.
The third skill is the ability to discern one's areas of clinical expertise and to work within one's appropriate scope of practice, except in unusual circumstances (e.g., in emergencies or in rural communities). A corollary to this skill is the commitment to ongoing education to assure that one can provide appropriate care to one's patients in relation to community and national standards.
The fourth skill is the ability to apply a formal ethical decision-making model in response to an ethically complex patient-care situation. Different models have been proposed and possess various strengths. Jonsen and colleagues (1998) suggested a clinical ethics decision-making strategy that places primacy on beneficence and involves four major components in order of importance: 1) clinical indications; 2) preferences of patients; 3) quality of life; and 4) contextual features. Beauchamp and Childress (2001) proposed an analysis approach that examines the roles of the four main ethics principles of beneficence, autonomy, non-maleficence and justice. Hundert (1987) proposed a strategy in which conflicting values are made explicit and are resolved through prioritization and clarification.
Fifth is the ability to anticipate and work responsibly through high-risk ethical situations, such as reporting suspected abuse, hospitalizing patients against their preferences or caring for an especially difficult patient. In such situations where the clinician must intentionally use power in a manner that encroaches upon usual rights of individuals in order to assure safety, every effort must be made to do so respectfully and in a manner that minimizes the invasiveness and burden of the intervention.
The sixth skill is appropriate use of consultants (e.g., clinical or ethical specialists) and information resources (e.g., clinical data, codes of ethics, legal guidelines) to clarify ethical choices.
Finally, ethical psychiatric practitioners will have the skill of building in additional protections (e.g., advance directives, alternative decision-makers, confidentiality safeguards) for individuals who are especially vulnerable due to illness or circumstance.
In recent years, there is an increasing emphasis on empirical evidence in shaping ethical practices in psychiatry. Examples include the positive role of education in protecting confidentiality in small communities, strategies for enhancing informed consent processes, the creation of empirically derived and validated tools for assessing the clinical decision-making capacity of mentally ill people, the influence of pharmaceutical marketing in clinicians' choices, and the effectiveness of training interventions in enhancing clinicians' ethical problem-solving skills. With the intensified focus on measurable skills in diverse competence domains, including ethics and professionalism, data-driven, performance-based testing in psychiatry residencies and specialty certification exams is also growing.
It is clear that ethical ideals, skills and evidence-based approaches map nearly exactly upon excellent clinical care practices for mentally ill patients. This is the essence of the field of clinical ethics, which is the application of insights from the multidisciplinary field of bioethics to address morally important aspects of everyday care for individual patients. The ethical dimensions of patient care are inseparable from other aspects of clinical excellence, in meaning and in action. In this approach, ethics is not extrinsic or supplemental: it is an endeavor fundamental to the care of the mentally ill and to the work of the psychiatrist.
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