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Psychiatrists who toil in the public sector may be frustrated by a code of professional ethics that provides limited guidance for dealing with the unique quandaries they commonly encounter. During a symposium at APA’s Institute on Psychiatric Services in October, public-sector psychiatrists from diverse settings described some of the troubling ethical questions they regularly confront.
The strict code of ethics psychiatrists must follow was developed largely for those working in "dyadic relationships with competent patients," suggested symposium chair Julia Eilenberg, M.D. The public mental health arena, however, requires psychiatrists and program administrators to wrestle with ethical issues involving rationing of care, paternalism versus autonomy, and maintaining confidentiality in situations where ethics codes provide insufficient guidance for professionals who operate outside of traditional office and hospital settings.
Fulfilling the mandate to deliver certain services to mentally ill individuals, and to do so in the face of shrinking resources, means these ethical dilemmas must often be resolved in situations where a quick but complex decision has to be made "in the heat of the moment."
Confidentiality must sometimes be breached, for example, when negotiating an apartment lease with a landlord on behalf of a chronically mentally ill client, pointed out Ronald Diamond, M.D., a professor of psychiatry at the University of Wisconsin who works extensively with public mental health programs. There are so few landlords willing to consider renting to mentally ill people that if one asks for some information about how a patient’s illness or behavior symptoms might affect how he or she treats the owner’s property, the public agency would do the patient a disservice to issue a blanket refusal to reveal relevant information, he said. Similar issues arise when a case manager is discussing a job placement with a prospective employer or helping a mentally ill person cope with a shopping trip.
Questions of confidentiality in community mental health settings "do not come in neat packages with clear releases of information," Diamond emphasized, "but out of the informal complexity of interacting with people in the community." Ethical dilemmas arise for the public-sector psychiatrist in situations such as these when "the good that accrues so clearly outweighs the possible harm from breaching confidentiality and patient autonomy."
He offered the following guidelines he hoped would help psychiatrists and mental health professionals negotiate the ethical maze that characterizes confidentiality protection in public mental health care:
Clinicians and administrators who work in the public sector are also unable to avoid ethical dilemmas arising from having to allocate scarce funds among a population with enormous needs.
While psychiatrists know the efficacy of biopsychosocial treatment approaches, and in an ideal world would employ such a model, in public mental health they frequently face the unpleasant task of prioritizing patients’ needs and selecting treatment modalities for which funds are readily available, said Eilenberg. She is the medical director of the Ulster County Mental Health Department in upstate New York.
The need to ration care when politicians and taxpayers determine your treatment budget regularly confounds traditional medical ethics, she said.
Among examples of the bewildering ethical problems rationing has forced her to confront in her rural community mental health center is one caused by an influx of dually diagnosed, mentally retarded persons referred to her center after the closing of state residential facilities. These patients need intensive services, but to treat them in the face of a staff shortage and little time to plan for their needs, some other treatment services must be curtailed or less ill patients not treated.
How does a psychiatrist or administrator decide who doesn’t receive needed care, she wondered, and how do you square such a decision with ethics standards? "Should efforts be made to treat any and all in distress, albeit superficially, or should resources be directed to those most ill and/or dangerous?"
She also asked the audience to think about the difficulties of deciding just who should bear responsibility for making such complex choices when governing bodies, clinical administrators, professional staff, and consumers all have a stake in how a public agency operates.
Answers to these thorny questions will not be forthcoming any time soon, she predicted, particularly since "officially" few will admit that rationing is occurring. "Unofficially," however, Eilenberg acknowledged that it happens all the time.
To highlight a different ethical concern, Eilenberg described a disagreement between a young psychiatrist new to the CMHC and a social worker colleague over the social worker’s routine practice of hugging or patting patients on the back at the end of therapy sessions. The social worker contended that such actions do not violate her ethics code and had never been misunderstood. The psychiatrist, however, refused to continue being a cotherapist with her because he perceived this as violating ethical boundaries. Whose ethics code does the administrator of a public mental health clinic follow?
These unique issues have been ignored in discussions by medical ethicists, she said, and are missing from the research literature.
Yet another area where psychiatry’s ethics code does not offer sufficient guidance is spotlighted in the rapidly expanding handover of Medicaid services to the for-profit managed care industry, said Arthur Meyerson, M.D., a professor of psychiatry at the University of Medicine and Dentistry of New Jersey.
Psychiatrists who lead public health efforts often find their knowledge about a Medicaid patient’s treatment needs in conflict with managed care practices that, for example, minimize the need for intensive outpatient care and select participating providers based on cost, not efficacy. The best mental health commissioners try to write requests for proposals that limit managed care profits in Medicaid contracts and build in outcome measures, he said.
Among the advice he gave to public health officials venturing into Medicaid managed care was, when writing contracts, "bargain like hell"; if you don’t think you can do the work well, don’t sign the contract; never sign contracts that contain gag clauses; know up front the limits of your professional staff’s productivity; and model your treatment plans on nationally accepted guidelines and make sure HMO officials supply you with theirs.
Even following these steps, trying to balance cost concerns, political pressures, and quality of care issues is like walking an ethical "tightrope," Meyerson warned.