Resource Document May Provide Guide to Ethical Issues in Everyday Practice

An educational resource on psychiatric ethics is being developed to provide APA members with practical guidance about how to approach ethical dilemmas that arise in everyday practice.

Ellen Dallagher

At a symposium at IPS: The Mental Health Services Conference in New York last month, Rebecca Brendel, M.D., J.D., described the work that an APA Board-appointed ad hoc work group is doing to develop the document, which may be presented to the Board at its meeting next month in Washington, D.C.

She emphasized that the educational document will be based on the existing Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry, last revised and approved by the Board of Trustees in 2013.

“We want to produce a comprehensive document that will provide practical guidance on major topics including tools to manage ethical dilemmas that come up in day-to-day practice,” Brendel said at the meeting. “The document will not be freestanding but will be cross-referenced to the existing APA principles so we can be clear about where the ethical tenets we are applying to any situation are coming from.”

She added, “This document could never tell a psychiatrist exactly what to do in any given situation, but it could help the psychiatrist to think systematically and in a theoretically vigorous way about what values are at stake and why the particular situation poses a dilemma. If we can help our colleagues have the tools, the rationale, and the resources to engage ethical challenges, it could really be a critical resource for the profession.”

Brendel explained that the idea for the resource document was first conceived under past APA President Paul Appelbaum, M.D. An early draft of an ethics resource document was developed by a work group chaired by Laura Roberts, M.D., and Edward Hundert, M.D.; however, that document was never acted on and and hadn’t been updated since 2008.

APA President Renée Binder, M.D., and immediate past President Paul Summergrad, M.D., both wanted to revive the document and update it. Binder made it a priority and appointed the ad hoc work group with Brendel as chair. The other members of the work group are Wade Myers, M.D., of the APA Ethics Committee; Charles Dike, M.D., chair of the Connecticut District Branch Ethics Committee and and consultant to the APA Ethics Committee; Harold Ginzburg, M.D., J.D., of the APA Assembly; and Robert Weinstock, M.D., of the Council on Psychiatry and Law. Phil Candilis, M.D., serves as a corresponding member, while Appelbaum, Roberts, and Ezra Griffith, M.D., who is chair of the Ethics Committee, serve as consultants.

“Our professional ethics are the backbone of psychiatric practice,” Binder told Psychiatric News after the IPS. “This new resource document, developed by a distinguished group of psychiatrists with expertise in ethics, will help our members understand how our Annotations are relevant to the challenges and dilemmas we face in our day-to-day practice.”

At the IPS, Brendel told psychiatrists that the composition of the work group is intended to facilitate input from relevant components of APA and continuity with the earlier draft of the resource document. She noted that while many portions of that 2008 document need to be updated, some portions are still relevant.

She led psychiatrists at the symposium in a conversation about the key concepts underlying the document and some of the specific topics the resource may cover. Core concepts of ethics include “deontology” (or duty to the patient), consequentialism (for instance, the question of whether an ethical professional should work toward the greatest good for the greatest number of people); virtue ethics and professional ethics; and principlism, which is a system of ethics based on the four principles of autonomy, beneficence, nonmaleficence (“do no harm”), and justice.

Each of these core concepts engages specific issues in contemporary psychiatric practice when what constitutes ethical practice may or may not be clear. “For some situations, there is a bright line and clear guidance,” Brendel said. “These tend to be situations in which only one ethical tenet is called into question. They implicate so intrinsically one major principle of psychiatric ethics that there really is never a conflict about what constitutes ethical practice. More nuanced problems and ethical conflicts arise when two or more competing values that we hold to be important come into conflict with one another.”

Some of the specific topics the resource document will cover include confidentiality, informed consent, boundaries, philanthropy (institutional versus patient perspectives), relationships with colleagues, working in organized systems of care, clinical innovation, end-of-life issues, relationships with industry, use of technology in practice, and physician participation in executions or interrogations.

In comments to Psychiatric News, Appelbaum said the resource document is intended to fill a gap that exists with regard to educational materials in psychiatric ethics.

“APA’s Annotations, which are the basis on which the ethics committees of APA and its DBs adjudicate ethics complaints, were never intended to provide a comprehensive overview of ethics in psychiatry, and hence they are of limited value as an instructional tool,” he said. “Until now APA has lacked a document that offers a clear overview of the area. This new resource, which reflects the thinking of an experienced group of psychiatrists and experts in ethics about the state of art of psychiatric ethics, should be an excellent resource in residency training and for continuing education of practicing psychiatrists.” ■