Minding the Children

December 1, 2002

Mental health care professionals must be aware of the responsibilities and conflicts that present when patients are children and adolescents. Prescribing medications to minors and working with the child's guardian in treatment decisions are discussed.

Clinicians who work with children face particular ethical issues, but they are not exempted from the general ethical considerations that face all mental health clinicians.

Almost always, psychiatric treatment for minors is initiated not by the patient, but through the pressure of others. In most instances, the pressure is from parents, physicians, school personnel and/or legal authorities. Since child psychiatric patients are especially vulnerable to coercion by others, their clinicians must be particularly careful to know their own ethical responsibilities and their patients' rights.

Many practitioners remember the Accreditation Council for Graduate Medical Education residents' required lectures and seminars on ethics as dull, irrelevant or skipped. Learned physicians (Brewin, 1993) have questioned the usefulness of teaching ethics, at least of an "academic" type, rather than the more clinically based type. I agree, but I believe the quite common negative response of residents' exposure to ethics is not due mainly to poor teaching. I believe it is because ethics, once acknowledged, demand complicated, uncomfortable thinking. It is much easier to only think of other peoples' ethics, not our own.

Most ethical issues are complex and subject to multiple interpretations, perspectives and reactions. Seldom are there obvious, easy solutions. Ethical considerations are often a balance between gray concepts. Unethical decisions can occur when one "good" impinges too much on or denies another "good." For example, a young teen-age patient smokes marijuana. You believe she is not using it in a way that puts her in immediate physical danger, but it is against the law. You discuss with the patient the fact that she seems to recklessly put herself in danger of being arrested. She does not change her behavior. Circumstances should dictate whether informing the parents would help or hurt the best interests of the child. The impact of the decision on the patient-doctor relationship may be crucial.

AACAP Code of Ethics

The American Academy of Child and Adolescent Psychiatry (AACAP) published a Code of Ethics with 17 ethical principles in 1980. Highlights are in the Table. A handful of points made in the code and several ethical aspects of research are covered elsewhere in this section.

The clinician's overriding commitment must be to the patient. More often than with adults, fees are not paid by the patient. The primary commitment cannot be to the payer, parents, authorities or oneself. The clinician's task is to not only avoid harming the child, but to also effect the best or ultimate good for the patient, all things considered. No one would disagree with this seemingly simple precept, but the devil then comes in the details. Both "ultimate good" and "all things considered" are cotton candy terms--luscious looking, but mainly air.

As stated in the code's preamble:

The issues of consent, confidentiality, professional responsibility, authority, and behavior must be viewed within the context of development and the overlapping and potentially conflicting rights of the child or adolescent, of the parents, and of society.

While the child's welfare is paramount, this should optimally be assessed in the context of family and community. At the same time, it is our duty to protect the child as much as we can from deleterious actions by family and community. Balancing the above two sentences often demands careful thinking. For example, an adolescent patient may terrorize family members to the point of substantial suffering, but not break a law. A residential school may be indicated in your opinion, but the patient refuses to leave home or stop exerting control over siblings and parents. In addition, you believe the patient's sadistic machinations are psychologically self-destructive as well. The ethical concerns here may be difficult to sort out.

Clinicians must be aware of their own views of child rearing, values and behaviors. It is our task, as long as they do no harm or stunt the child's development, to support the individual qualities of our patients and their parents. Individual value preferences vary greatly, and it is unethical for the therapist to base decisions on what is actually personal bias.

Including the patient as much as possible in therapeutic decisions is much more difficult with children and adolescents than it is for adults. Since the patient is a minor--with few exceptions--the parents have the legal right to approve or disapprove of the clinician's medical recommendations. However, the wise clinician is aware that a treatment's course, except for our youngest patients, is determined mostly by the quality of the clinician-patient relationship. It is the clinician's ethical duty, in providing information to the patient, to judge the amount of information and mode of communication that provides "as thorough an understanding as can usefully be grasped and therapeutically utilized in the care of the child" (AACAP, 1980).

When discussing treatment options, it is important to realize that developmental stage, not age, is the more important variable on which to base children's cognitive abilities. At times, there will be a difference of opinion between parent and patient in regard to the clinician's recommendation. When this happens, the therapist's role is to work toward a decision or compromise that is best for the child. This, of course, may not always be the choice of the child. In these cases, much careful therapeutic work is required to, if possible, help the patient understand that it is because of their best interests that you support the decision. Patients will often be convinced by health reasons for a decision, rather than by what they perceive as parental or societal reasons based on tradition or morality.

Principles X through XIII deal with the complicated issues of confidentiality with minors (AACAP, 1980). The first anecdote touches on this issue. It is very helpful to discuss confidentiality during the first minutes of the first patient meeting. Particularly with adolescents, most clinicians prefer to meet initially with parents or guardians in order to obtain a full history. After the first meeting with the adolescent, meetings with such family members must be done carefully. Typically, the patient is told that confidentiality can be breached in situations when the clinician fears imminent danger to or by the patient, or when the patient gives permission. Younger, and sometimes older, patients give standing permission to provide information to parents. Nonetheless, it is usual to tell patients what you will communicate or, based on developmental considerations, have them present. Most practitioners welcome parental input, but a confidentiality pact must then be made with the parent as to whether or not you will share with the patient their information and its source. Here, too, the ethics must be based primarily on what is in the patient's best interests. There are circumstances, such as court evaluations, when there is no confidentiality, and this reality must be communicated at the onset. Patients cannot be used for teaching purposes without their understanding, permission and parental consent.

The burgeoning of managed care and other reimbursement systems followed a shift in public opinion whereby there was an increased acceptance that patient privacy be reduced in order to reduce medical costs. The AACAP's annotations (1996) reiterated the primacy of the patient's best interests. The clinician must help parents and patients understand the trade-off between divulging information to a payer and obtaining reimbursement. Increasingly, child and adolescent psychiatrists are dropping out of reimbursement plans. Some base this on intolerable invasions of patient privacy by insurers. This ethical stand, however, raises the ethical question of diminishing the already insufficient number of practitioners available to treat mentally ill minors.

The Issue of Prescribing

The recent surge in prescription psychopharmaceuticals for minors is probably the largest area for ethical questions. It is unethical not to use medications when they are the best treatment available, but even the thoroughly documented success of stimulants for the treatment of attentional problems is disputed by some. There has been much published about the ethical questions of direct-to-consumer advertising (Rosenthal et al., 2002); pharmaceutical firms' marketing to patients whose names were made available by pharmacists (Zimmerman and Armstrong, 2002) and their tracking of physicians' prescribing patterns (Kaiser Family Foundation, 2002); and physicians' acceptance of gifts, trips and money from these firms (Wazana, 2000). The ethics of rushing to use new drugs was raised in a survey that found on average 20% of newly approved drugs are either withdrawn or later must carry a "black box" warning of serious side effects (Lasser et al., 2002). A counterbalancing ethic is that when using new drugs, clinicians can be a positive force. Efficacy demonstrated in strict research settings must be demonstrated to be effective in clinical settings, and it then must be disseminated successfully to all clinicians (Hoagwood and Olin, 2002). The AACAP is strenuously recruiting members into child and adolescent psychiatry trial networks to aid the transition of efficacy to effectiveness findings. A case can be made that if one uses medications, it is unethical to refuse to help assess their safety and effectiveness.

Conclusions

The topic of ethics is usually not thought about, because it is difficult. On the other hand, practitioners who do think about ethics are better clinicians. Less important, but worthwhile, is that those who think about ethics are less likely to be called before ethics committees. If one never thinks about ethical issues, one never will see them, until it is too late. A useful and probably necessary step is to consult with trusted colleagues when unsure of your conduct. No one is value-free, and ethics requires value balancing. If you do not wish to discuss a troubling issue with a friendly colleague, it is best to re-think your position. Acknowledging and wrestling with ethical issues can lead to greater clinical wisdom.

References:

References 1.AACAP (1980), Code of Ethics. Washington, D.C.: AACAP.
2.AACAP (1996), Annotations to AACAP ethical code. AACAP News, pp17-20.
3.Brewin TB (1993), How much ethics is needed to make a good doctor? Lancet 341(3):161-163.
4.Hoagwood K, Olin SS (2002), The NIMH blueprint for change report: research priorities in child and adolescent mental health. J Am Acad Child Adolesc Psychiatry 41(7):760-767.
5.Kaiser Family Foundation (2002), National Survey of Physicians Part II: Doctors and Prescription Drugs. Menlo Park, Calif.: The Kaiser Family Foundation.
6.Lasser KE, Allen PD, Woolhandler SJ et al. (2002), Timing of new black box warnings and withdrawals for prescription medications. JAMA 287(17):2215-2220.
7.Rosenthal MB, Berndt ER, Donohue JM et al. (2002), Promotion of prescription drugs to consumers. N Engl J Med 346(7):498-505.
8.Wazana A (2000), Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA 283(3):373-380.
9.Zimmerman A, Armstrong D (2002), Useof pharmacies by drug makers to pushpills raises privacy issues. The Wall Street Journal. May 1, p1.