# 02 - 36.2 Ethics in Psychiatry

# 36.2 Ethics in Psychiatry

36.2 Ethics in Psychiatry
Ethical guidelines and a knowledge of ethical principles help psychiatrists avoid ethical
conflicts (which can be defined as tension between what one wants to do and what is
ethically right to do) and think through ethical dilemmas (conflicts between ethical
perspectives or values).
Ethics deal with the relations between people in different groups and often entail
balancing rights. Professional ethics refer to the appropriate way to act when in a
professional role. Professional ethics derive from a combination of morality, social
norms, and the parameters of the relationship people have agreed to have.
PROFESSIONAL CODES
Most professional organizations and many business groups have codes of ethics that
reflect a consensus about the general standards of appropriate professional conduct. The
American Medical Association’s (AMA’s) Principles of Medical Ethics and the American
Psychiatric Association’s (APA’s) Principles of Medical Ethics with Annotations Especially
Applicable to Psychiatry articulate ideal standards of practice and professional virtues of
practitioners. These codes include exhortations to use skillful and scientific techniques;
to self-regulate misconduct within the profession; and to respect the rights and needs of
patients, families, colleagues, and society.
BASIC ETHICAL PRINCIPLES
Four ethical principles that psychiatrists ought to weigh in their work are respect for
autonomy, beneficence, nonmaleficence, and justice. At times, they are in conflict, and
decisions must be made concerning how to balance them.
Respect for Autonomy
Autonomy requires that a person act intentionally after being given sufficient
information and time to understand the benefits, risks, and costs of all reasonable
options. It may mean honoring an individual’s right not to hear every detail and even
choosing someone else (e.g., family or doctor) to decide the best course of treatment.
Psychiatrists need to provide patients with a rational understanding of their disorder
and options for treatment. Patients need conceptual understanding; the psychiatrist
should not simply state isolated facts. Patients also need time to think and to talk with
friends and family about their decision. Finally, if a patient is not in a state of mind to
make decisions for himself or herself, the psychiatrist should consider mechanisms for
alternative decision making, such as guardianship, conservators, and health care proxy.
A young adult experienced a schizophrenic episode in which his religious fervor
turned into psychotic delusions. After being involuntarily hospitalized because he

became suicidal, he insistently refused medication, claiming that his physicians were
trying to poison him. His psychiatrist decided to respect his refusal of medication as
long as his suicidal tendencies could be controlled. As his mental suffering became
more intense, in 1 week the patient changed his mind about medication and agreed to
try it. The therapeutic relationship with his psychiatrist deepened, and the patient left
the hospital willing to continue with both antipsychotic medication and
psychotherapy. Although not all cases work out so well, this one illustrates the
benefits of negotiation about treatment even when hospitalization is involuntary.
Beneficence
The requirement for psychiatrists to act with beneficence derives from their fiduciary
relationship with patients and the profession’s belief that they also have an obligation
to society. As a result of the role obligation of trust, psychiatrists must heed their
patients’ interests, even to the neglect of their own.
The expression of the principle is paternalism, the use of the psychiatrist’s judgment
about the best course of action for the patient or research subject. Weak paternalism is
acting beneficently when the patient’s impaired faculties prevent an autonomous choice.
Strong paternalism is acting beneficently despite the patient’s intact autonomy.
Guidelines have been proposed for permitting beneficence to overrule patient
autonomy; when the patient faces substantial harm or risk of harm, the paternalistic act
is chosen that ensures the optimal combination of maximal harm reduction, low added
risk, and minimal necessary infringement on patient autonomy.
Nonmaleficence
To adhere to the principle of nonmaleficence (primum non nocere or first, do no harm),
psychiatrists must be careful in their decisions and actions and must ensure that they
have had adequate training for what they do. They also need to be open to seeking
second opinions and consultations. They need to avoid creating risks for patients by an
action or inaction.
Justice
The concept of justice concerns the issues of reward and punishment and the equitable
distribution of social benefits. Relevant issues include whether resources should be
distributed equally to those in greatest need, whether they should go to where they can
have the greatest impact on the well-being of each individual served, or to where they
will ultimately have the greatest impact on society.
SPECIFIC ISSUES
From a practical point of view, several specific issues most frequently involve
psychiatrists. These include (1) sexual boundary violations, (2) nonsexual boundary

violations, (3) violations of confidentiality, (4) mistreatment of the patient
(incompetence, double agentry), and (5) illegal activities (insurance, billing, insider
stock trading).
Sexual Boundary Violations
For a psychiatrist to engage a patient in a sexual relationship is clearly unethical.
Furthermore, legal sanctions against such behavior make the ethical question moot.
Various criminal law statutes have been used against psychiatrists who violate this
ethical principle. Rape charges may be, and have been, brought against such
psychiatrists; sexual assault and battery charges also have been used to convict
psychiatrists.
In addition, patients who have been victimized sexually by psychiatrists and other
physicians have won damages in malpractice suits. Insurance carriers for the APA and
the AMA no longer insure against patient–therapist sexual relations, and the carriers
exclude liability for any such sexual activity.
The issue of whether sexual relations between an ex-patient and a therapist violate an
ethical principle, however, remains controversial. Proponents of the view “Once a
patient, always a patient” insist that any involvement with an ex-patient—even one
that leads to marriage—should be prohibited. They maintain that a transferential
reaction that always exists between the patient and the therapist prevents a rational
decision about their emotional or sexual union. Others insist that, if a transferential
reaction still exists, the therapy is incomplete and that as autonomous human beings, expatients should not be subjected to paternalistic moralizing by physicians. Accordingly,
they believe that no sanctions should prohibit emotional or sexual involvements by expatients and their psychiatrists. Some psychiatrists maintain that a reasonable time
should elapse before such a liaison. The length of the “reasonable” period remains
controversial: Some have suggested 2 years. Other psychiatrists maintain that any
period of prohibited involvement with an ex-patient is an unnecessary restriction. The
Principles, however, states: “Sexual activity with a current or former patient is unethical.”
Although not spelled out in The Principles, sexual activity with a patient’s family
member is also unethical. This is most important when the psychiatrist is treating a child
or adolescent. Most training programs in child and adolescent psychiatry emphasize that
the parents are patients too and that the ethical and legal proscriptions apply to parents
(or parent surrogates) as well as to the child. Nevertheless, some psychiatrists
misunderstand this concept. Sexual activity between a doctor and a patient’s family
member is also unethical.
An egregious example of a sexual boundary violation was reported in the Medical
Board of California Action Report (July 2006) of a psychiatrist who had a 7-year affair
with a patient who had schizophrenia. The doctor not only had sex with the patient but
also had her procure prostitutes with whom he and the patient had group sex. He paid
for their services by providing them with prescriptions for controlled substances and
went so far as to bill Medi-Cal for these encounters as group therapy. The physician’s

license was revoked, and he was also criminally convicted of fraud.
Nonsexual Boundary Violations
The relationship between a doctor and a patient for the purposes of providing and
obtaining treatment is what is usually called the doctor–patient relationship. That
relationship has both boundaries around it and boundaries within it. Either person may
cross the boundary.
Not all boundary crossings are boundary violations. For example, a patient may say
to a doctor at the end of an hour, “I have left my money at home, and I need a dollar to
get my car out of the garage. Will you lend me a dollar until next time?” The patient has
invited the doctor to cross the doctor–patient boundary and set up a lender–borrower
relationship as well. Depending on the doctor’s theoretical orientation, the clinical
situation with the patient, and other factors, the doctor may elect to cross the boundary.
Whether the boundary crossing is also a boundary violation is debatable. A boundary
violation is a boundary crossing that is exploitative. It gratifies the doctor’s needs at the
expense of the patient. The doctor is responsible for preserving the boundary and for
ensuring that boundary crossings are held to a minimum and that exploitation does not
occur.
A resident in psychiatry was admonished by her psychotherapy supervisor to never,
under any circumstances, accept a gift from a patient. In the course of treating a
young girl with schizophrenia, she was offered a Christmas gift (a cotton scarf), which
she refused to accept, explaining as gently as possible that it was not permitted by the
“rules of the hospital.” The next day the patient attempted suicide. She experienced
the resident’s refusal to accept the gift as a profound rejection (to which patients with
schizophrenia are exquisitely sensitive), which she could not tolerate. The case
illustrates the need to understand the dynamics of gift giving and the transferential
meaning to the patients of rejecting (or accepting) the gift.
The story (possibly apocryphal) is told of how Freud, who was an inveterate cigar
smoker, was offered a box of difficult-to-find Havana cigars by a patient during the
course of his analysis. Freud accepted the cigars and then proceeded to ask his patient
to explore his motivations in offering the gift. Freud’s reasons for accepting the cigars
are more obvious than the patient’s unconscious motivation for giving them, about
which no information is available.
Harm to the patient is not a component of a boundary violation. For example, using
information supplied by the patient (e.g., a stock tip) is an unethical boundary
violation, although no obvious harm may come to the patient. For purposes of
discussion, nonsexual boundary violations may be grouped into several arbitrary
(overlapping and not mutually exclusive) categories.

Business.
 Almost any business relationship with a former patient is problematic,
and almost any business relationship with a current patient is unethical. Naturally, the
circumstance and location may play a significant role in this admonition. In a rural area
or a small community, a doctor might be treating the only pharmacist (or plumber or
couch upholsterer) in town; then when doing business with the pharmacist–patient, the
doctor tries to keep boundaries in check. Ethical psychiatrists try to avoid doing business
with a patient or a patient’s family member or asking a patient to hire one of their
family members. Ethical psychiatrists avoid investing in a patient’s business ad
collaborating with a patient in a business deal.
Ideological Issues.
 Ideological issues can cloud judgment and may lead to ethical
lapses. Any clinical decision should be based on what is best for the patient; the
psychiatrist’s ideology should play as little a part as possible in such a decision. A
psychiatrist who is consulted by a patient with an illness should tell the patient what
forms of treatment are available to treat the illness and allow the patient to decide on a
course of treatment. Naturally, psychiatrists should recommend the treatment that they
feel is in the best interest of the patient, but ultimately, the patient should be free to
choose.
Social.
 The particular locale and circumstances must be considered in any discussion
of the behavior of an ethical psychiatrist in social situations. The overarching principle
is that the boundaries of the psychiatrist–patient relationship should be respected.
Furthermore, if options exist, they should be exercised in favor of the patient. Problems
often arise in treatment situations when friendships develop between the psychiatrist
and the patient. Objectivity is compromised, therapeutic neutrality is impaired, and
factors outside the consciousness of either party may play a destructive role. Such
friendship should be avoided during treatment. Similarly, psychiatrists should not treat
their social friends for the same set of reasons. Obviously, in an emergency, a person
does what a person must.
Financial.
 For psychiatrists who practice in the private sector, dealing with the
patient about money is a part of treatment. Issues surrounding setting the fee, collecting
the fee, and other financial matters are grist for the mill. Even so, ethical concerns must
be observed. The Principles advises the doctor on such matters as charging for missed
appointments and other contractual problems. Ethics complaints against doctors are
frequently precipitated by financial issues; thus, the doctor must recognize the power
that these issues have in the therapeutic relationship. Because the psychotherapeutic
relationship is so much like a social relationship—the office looks like a living room; the
doctor wears regular clothes; some patients might, without recognizing it, assume that a
friendship exists that forgives payment of a fee. When the bill is presented, feelings,
even though they are unconscious, are ruffled. The idea that psychiatric services are
dispensed in a contractual context cannot be sufficiently emphasized. Early in their
careers, psychiatrists are often reluctant to discuss fees openly out of a sense of

embarrassment over discussing money or a sense of protecting the patient.
How an ethical psychiatrist handles the situation when a patient temporarily or
permanently runs out of money is important. Many options are available—some more
problematic than others. The psychiatrist can certainly lower the fee, but caution is
needed because a fee lowered to the point where the treatment is not somehow being
compensated may evoke countertransference resentment. The number of patients being
seen at a reduced fee is a similar consideration. Running up a bill can also be a
problem. Is there an expectation of eventually being paid? Is the hypertrophic bill a
sham? The frequency of sessions may have to be altered. Any psychiatrist who sees
private patients will definitely face these problems.
Confidentiality
Confidentiality refers to the therapist’s responsibility not to release information learned
in the course of treatment to third parties. Privilege refers to the patient’s right to
prevent disclosure of information from treatment in judicial hearings. Psychiatrists must
maintain confidentiality because it is an essential ingredient of psychiatric care; it is a
prerequisite for patients to be willing to speak freely to therapists. Violating
confidentiality by gossiping embarrasses people and violates nonmaleficence. Violation
of confidentiality also breaks the promise that a psychiatrist has explicitly or implicitly
made to keep material confidential.
Confidentiality must also give way to the responsibility to protect others when a
patient makes a credible threat to harm someone. The situation becomes complicated
when the risk is not to a particular individual, such as when a doctor is impaired or
someone’s mental state adversely affects his or her performance of a dangerous job,
such as police work, firefighting, or use of dangerous machinery. Erosion has also arisen
from the demands of an insurance company for detailed information. Patients must be
told that information may be released to insurance companies, but they do not need to
be warned that information concerning abuse of a child or threat to themselves or others
needs to be reported.
Various settings exist in which patient data can be used to some degree. The general
rule for doing so is to disclose only that information that is truly necessary. In teaching,
research, and supervision, patients’ names or information that might allow others to
identify them should not be unnecessarily released. In ward rounds and case
conferences, in which patient material is presented, attendees should be reminded that
what they hear should not be repeated.
Confidentiality endures after death, with the ethical obligation to withhold
information unless the next of kin provides consent. A subpoena is not automatic license
to release the entire record. A psychiatrist can petition the judge for an in-camera
(private) review to define what precise information must be disclosed.
Ethics in Managed Care
Psychiatrists have certain responsibilities toward patients treated in managed care

settings, including the responsibilities to disclose all treatment options, exercise appeal
rights, continue emergency treatment, and cooperate reasonably with utilization
reviewers.
Responsibility to Disclose.
 Psychiatrists have a continuing responsibility to the
patient to obtain informed consent for treatments or procedures. All treatment options
should be fully disclosed, even those not covered under the terms of a managed care
plan. Most states have enacted legislation making gag rules illegal that limit
information about treatment provided to patients under managed care.
Responsibility to Appeal.
 The AMA Council on Ethical and Judicial Affairs states
that physicians have an ethical obligation to advocate for any care that they believe will
materially benefit their patients, regardless of any allocation guidelines or gatekeeper
directives.
Responsibility to Treat.
 Physicians are liable for failure to treat their patients
within the defined standard of care. The treating physician has sole responsibility to
determine what is medically necessary. Psychiatrists must be careful not to discharge
suicidal or violent patients prematurely merely because continued coverage of benefits
is not approved by a managed care company.
Responsibility to Cooperate with Utilization Review.
 The psychiatrist
should cooperate with utilization reviewers’ requests for information on proper
authorization from the patient. When benefits are denied, it is important to understand
and follow grievance procedures carefully; return telephone calls from review agencies;
and provide documented, solid justification for continued treatment.
With the advent of managed care and the need to send periodic progress reports and
documentation of signs and symptoms to third-party reviewers to pay for treatment,
some psychiatrists may diminish or exaggerate symptomatology. The following case
report and discussion illustrates the ethical difficulties psychiatrists face in dealing with
managed care.
Mrs. P admitted herself to the hospital because she was afraid she might kill herself.
She was experiencing a major depressive episode, but she improved markedly during
the first weeks on Dr. A’s ward. Although Dr. A believed that Mrs. P was no longer
suicidal, he thought she would benefit greatly from continued hospitalization. Because
he knew that Mrs. P could not afford to pay for hospitalization and that the insurance
company would pay only if the patient was suicidally depressed, he decided not to
document Mrs. P’s improvement. He noted in the chart that “the patient continues to
have a risk of suicide.”
Does Dr. A engage in a form of deception? Yes, he intentionally misleads by what
he writes and what he omits writing in the chart. Although what he writes is true in

some literal sense, his statement is misleading in the context of treatment. Mrs. P is
not suicidally depressed in the way that she was.
What Dr. A omits from the chart is also deceptive. Whether a particular omission is
deceptive depends, in part, on the roles and expectations of the people involved. Not
telling a colleague that one dislikes his tie is not a deception. It is simply tact unless
the role or relationship involves the expectation that one offers a candid opinion. Dr.
A’s case is different. His professional role is to document the patient’s course and the
expectation is that he will note any significant improvement. Thus, his failure to
document Mrs. P’s progress accurately is a kind of deception.
The second and more difficult question is whether deception is justified in this
instance. The answer to that question depends on the reasons for the deception, the
reasons against it, and the alternatives available. The reasons for this deception are
obvious. Dr. A’s aim and primary obligation is to help the patient. He believes that
Mrs. P would benefit greatly from continued hospitalization that she cannot afford.
He may also believe that it is unfair for the insurance company to refuse to pay for
inpatient treatment of nonsuicidal depression and that his deception rectifies that
unfair practice.
Important reasons also exist against this deception. The first concerns honesty and
social trust. It is a good thing if people can rely on what others say and write. Without
some honesty and trust, many social exchanges and practices would be impossible.
Deception, even for beneficent purposes, has real potential to damage social trust. A
risk exists that deception may damage people’s trust in the profession of psychiatry
and even patients’ trust in their psychiatrists. Damage to trust may, in turn,
compromise treatment.
The second reason concerns future medical treatment. If Mrs. P seeks medical
treatment in the future, the physicians who attend her will read the misleading notes.
If they believe that the notes are an accurate account of the previous treatment, they
may suggest an inappropriate treatment for the present problem. Even if they have
doubts about the accuracy of the notes in her chart, they are deprived of an accurate
history and report. In either case, the prior deception can hinder treatment.
The third reason concerns obligations and coverage policies. Dr. A seems to ignore
the obligation that he has to the population that is covered by the insurance policy.
He shifts a burden onto this population by forcing the insurance company to pay for
treatment that it did not agree to cover. Perhaps the insurance company should pay
for inpatient treatment in cases such as Mrs. P’s; perhaps its policies are unreasonable
and unfair. However, Dr. A’s deception does not challenge the insurance company
and pressure it to change its policy, nor does his deception encourage patients and
their families to contest the company’s policies. The use of deception simply
circumvents, in an ad hoc way, a policy that should be challenged and discussed.
Dr. A also seems to ignore his obligation to future patients. By introducing an
inaccuracy into the chart, he compromises the value of medical records research. His
deception works, in a small way, to deprive future patients of the benefit of research
that relies on medical records.

Whether the deception is justified depends on both the weight of the reasons for and
against the deception and the available alternatives. One alternative is to tailor the
chart. Another alternative is to describe Mrs. P’s response accurately and to discharge
her to outpatient care. However, a third alternative exists. Dr. A can accurately
document the patient’s course and can recommend continued hospitalization. He can
petition the insurance company for coverage. If the insurance company decides not to
approve further inpatient care for the patient, Dr. A can appeal that decision. This
alternative is more time consuming, and nothing guarantees that it will succeed, but it
avoids all the problems associated with the use of deception.
Impaired Physicians
A physician may become impaired as the result of psychiatric or medical disorders or the
use of mind-altering and habit-forming substances (e.g., alcohol and drugs). Many
organic illnesses can interfere with the cognitive and motor skills required to provide
competent medical care. Although the legal responsibility to report an impaired
physician varies, depending on the state, the ethical responsibility remains universal. An
incapacitated physician should be reported to an appropriate authority, and the
reporting physician is required to follow specific hospital, state, and legal procedures. A
physician who treats an impaired physician should not be required to monitor the
impaired physician’s progress or fitness to return to work. This monitoring should be
performed by an independent physician or group of physicians who have no conflicts of
interest.
The Office of Professional Medical Conduct (OPMC) in New York State regulates the
practice of medicine by investigating illegal or unethical practice by physicians and
other health professionals, such as physician assistants. Similar regulatory agencies exist
in other states. Professional misconduct in New York State is defined as one of the
following:
1. Practicing fraudulently and with gross negligence or incompetence
2. Practicing while the ability to practice is impaired
3. Being habitually drunk or being dependent on, or a habitual user of, narcotics or a
habitual user of other drugs having similar effects
4. Immoral conduct in the practice of the profession
5. Permitting, aiding, or abetting an unlicensed person to perform activities requiring a
license
6. Refusing a client or patient service because of creed, color, or national origin
7. Practicing beyond the scope of practice permitted by law
8. Being convicted of a crime or being the subject of disciplinary action in another
jurisdiction
Professional misconduct complaints derive mainly from the public in addition to

insurance companies, law enforcement agencies, and doctors, among others.
New York State has established a program called Committee for Physician Health (CPH) in which impaired physicians
receive appropriate treatment for their condition without losing their medical license as long as they comply with a
treatment program. For example, a physician addicted to opioids or alcohol might be hospitalized to safely withdraw from
the drugs and then move to a sober house for further rehabilitation that would involve intensive individual and group
psychotherapy, mandatory supervised drug testing and careful oversight by CPH. The physician must be compliant for 5
years during which time he or she may gradually return to practice under supervision. The program has rehabilitated
many physicians successfully.
Physicians in Training
It is unethical to delegate authority for patient care to anyone who is not appropriately
qualified and experienced, such as a medical student or a resident, without adequate
supervision from an attending physician. Residents are physicians in training and, as
such, must provide a good deal of patient care. Within a healthy, ethical teaching
environment, residents and medical students may be involved with, and responsible for,
the day-to-day care of many ill patients, but they are supervised, supported, and
directed by highly trained and experienced physicians. Patients have the right to know
the level of training of their care providers and should be informed about the resident’s
or medical student’s level of training. Residents and medical students should know and
acknowledge their limitations and should ask for supervision from experienced
colleagues as necessary.
Physician Charter of Professionalism
In 2001, a movement to clarify the concept of “professionalism” was begun by the
American Board of Internal Medicine. A set of principles called the Physician Charter of
Professionalism was developed, which describes what it means for physicians to perform
at their highest and most ethical level. Table 36.2-1 lists the principles and commitments
of professional behaviors in the Physician Charter of Professionalism to which all
physicians (including psychiatrists) are expected to adhere.
Table 36.2-1
Physician Charter of Professionalism

A summary of ethical issues discussed in this section is presented in a question-andanswer format in Table 36.2-2.
Table 36.2-2
Ethical Questions and Answers

Military Psychiatry
Psychiatrists in the military face unique ethical problems because confidentiality does
not exist under the military code of conduct.
A 19-year-old white single man, new to military service, presented with a history of
periodic episodes of anxiety when taking showers in groups with other men. He
identified himself as gay and recognized that his anxiety was related to his fear of

acting out his sexual impulses, thus risking court martial and dishonorable discharge,
if he is ever discovered. The psychiatrist was faced with a dilemma: whether to report
the soldier to his commanding officer (as he was obliged to do under the military
code) or to protect the soldier from acting on his impulses that would place him in
danger (in keeping with the medical ethic to do no harm). After discussing various
options, he and the patient agreed on the latter option. A diagnosis of anxiety
disorder was made, which allowed the patient to receive an honorable discharge on
medical grounds based on a recognized psychiatric disorder. No record of his
homosexual orientation was made.
Health Insurance Portability and Accountability Act
The Health Insurance Portability and Accountability Act (HIPAA) was passed in 1996 to
address the medical delivery system’s mounting complexity and its rising dependence on
electronic communication. The act orders that the federal Department of Health and
Human Services (HHS) develop rules protecting the transmission and confidentiality of
patient information, and all units under HIPAA must comply with such rules.
The Privacy Rule, administered by the Office of Civil Rights (OCR) at HHS, protects
the confidentiality of patient information (Table 36.2-3).
Table 36.2-3
Patients’ Rights under the Privacy Rule

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