Dr. Hsin is with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California (e-mail: ude.drofnats@ronoh). Dr. Torous is with Brigham and Women’s Hospital and the Department of Psychiatry, Harvard Medical School, Boston.
Copyright © 2016 by the American Psychiatric AssociationSound ethical decision making is essential to astute and compassionate clinical care. Wise practitioners readily identify and reflect on the ethical aspects of their work. They engage, often intuitively and without much fuss, in careful habits—in maintaining therapeutic boundaries, in seeking consultation from experts when caring for patients who are difficult to treat or have especially complex conditions, in safeguarding against danger in high-risk situations, and in endeavoring to understand more about mental illnesses and their expression in the lives of patients of all ages, in all places, and from all walks of life. These habits of thought and behavior are signs of professionalism and help ensure ethical rigor in clinical practice.
Psychiatry is a specialty of medicine that, by its nature, touches on big moral questions. The conditions we treat often threaten the qualities that define human beings as individual, autonomous, responsible, developing, and fulfilled. Furthermore, these conditions often are characterized by great suffering, disability, and stigma, and yet individuals with these conditions demonstrate tremendous adaptation and strength. If all work by physicians is ethically important, then our work is especially so. As a service to Focus readers, this column provides ethics commentary on topics in clinical psychiatry. It also offers clinical ethics questions and expert answers in order to sharpen readers’ decision-making skills and advance astute and compassionate clinical care in the field.
Laura Weiss Roberts, M.D., M.A.
Depression affects nearly 15 million adults in the United States each year. As the second leading cause of disability, depression is an illness that profoundly affects quality of life for individuals and creates significant socioeconomic burdens for society as a whole. Depression is also an important risk factor for suicide, an outcome that claims approximately one life in the country every 13 minutes. The clinical care of depression combines an urgency of crisis with the deeply experienced and pervasive feelings of hopelessness and sadness among patients, raising many ethical issues related to the need for patient safety, the appropriate treatment of disease, and the restoration of individual self-agency.
Against the backdrop of modern health care, where people receiving treatment for depression are predominantly seen in primary care clinics, recent developments in innovative therapeutics and methods of care delivery promise to raise many more ethical questions than answers. Some contexts for ethical tension are inherited, such as the split-care model of pharmacotherapy and psychotherapy in the treatment of depression, whereas others are completely novel, such as mobile health care and integrated care systems in disease management. Elements of therapeutic boundaries and alliance are being challenged in these settings. Last, research in new treatment modalities with distinct repertoires of benefits and potential harms, such as deep brain stimulation, suggests a continued role for ethical discussion in years to come.
In this commentary, we describe several clinical cases illustrating only a handful of these issues. We hope these cases pique our readers’ interest in the application of ethical principles to practice and highlight the importance of ethical decision making in modern clinical care of patients experiencing this disorder.
A 65-year-old male with no prior psychiatric diagnosis is brought by police to the emergency room for suicidal ideation. One hour earlier, the patient had called his wife, stating he was at the train tracks, “ready to say goodbye.” She called 911 immediately out of concern for his safety, and police officers found the patient standing on the local train station platform. During his psychiatric assessment, the patient reveals that he had been feeling depressed and “hopeless” for the past three months, after he was hospitalized for his first heart attack. He lost ten pounds during this period, which he attributes to a loss of appetite. He spends most of his days lying in bed, unmotivated to leave the house. He reports difficulty falling asleep due to anxious and guilty ruminations, as well as poor concentration and low energy. He asks periodically throughout the interview if he can be released from the emergency room. He expresses frustration that the police stopped him from jumping and states that he plans to return to the train tracks tonight to end his life.
He has a history of coronary artery disease, hypertension, and hyperlipidemia, with a 40-pack-year smoking history. He denies any alcohol or illicit substance use. His medications include antihypertensive and antihyperlipidemic agents.
The mental status exam reveals a thin, elderly male, malodorous with poor grooming, who was cooperative in the interview. He shows evidence of psychomotor slowing. Affect is withdrawn, with slowed but spontaneous speech. His thought process is linear and coherent. He denies experiencing hallucinations or delusions of paranoia or grandeur.
The psychiatrist should make which of the following initial clinical decisions in response to the patient’s request for discharge?
The psychiatrist should hospitalize the patient involuntarily and deceive the patient about this decision—a response that reflects tensions between the ethical principles of beneficence and veracity.
The psychiatrist should hospitalize the patient involuntarily and inform him of this decision—a response that reflects tensions between the ethical principles of beneficence and autonomy.
The psychiatrist should explore whether the patient would consider voluntary hospitalization—a response that reflects tensions between the ethical principles of beneficence and autonomy.
The psychiatrist should discharge the patient because emergency resources are limited—a response that reflects tensions between the ethical principles of beneficence and justice.
The psychiatrist orders several lab tests, including a urine toxicology screen; a complete blood count; an electrolytes panel; and liver, thyroid, and renal function tests. These tests reflect the psychiatrist’s adherence to which principle?