Should APA Continue Involvement in Ethics Enforcement?

During recent discussions about the APA budget, a proposal to cut financial support for ethics enforcement was raised as one way to lower costs. At first blush this proposal appears reasonable in light of APA's efforts to trim the budget. In times of economic crisis, even sacred cows must justify their existence as organizations strive to remain financially viable. But what would be the effects of such a budget cut? If it resulted in the end of ethics enforcement, would that necessarily be a bad outcome? Would it not be better for the APA Office of Ethics and district branch (DB) ethics committees to abandon enforcement and focus on ethics education instead? Has the idea of eliminating ethics enforcement been considered before?

In brief, the APA ethics process works in the following way. Charges raised by a complainant against an APA member are received at the DB level and investigated and resolved according to APA's “Procedures for the Handling of Complaints of Unethical Conduct.”

Baseless complaints are dismissed early on, less-serious complaints are diverted through the “Educational Option,” and more-serious complaints are processed through the “Enforcement Option.” In the third pathway, if a complaint of unethical conduct against a member is sustained, he or she will typically receive a sanction ranging from reprimand to expulsion. The APA Ethics Committee reviews the work of the DBs to assure that complaints received an investigation that was comprehensive and fair and in accordance with procedures.

The idea of eliminating ethics enforcement is not new. Critics of enforcement have generally cited three reasons why it should be eliminated: (1) it is too expensive, (2) the enforcement process is not evenly applied from one DB to another, and (3) psychiatrists are physicians, not prosecutors.

Jeremy Lazarus, M.D., chaired the Task Force on Ethics Regulations and Ethics Education, which considered the elimination idea (Psychiatric News, July 19, 2002), along with other ideas for ethics reform, several years ago. However, instead of recommending elimination of enforcement, that task force argued for maintaining it on several grounds. The task force noted that without ethics enforcement it would be difficult to drop members who committed serious unethical behavior, deterrence would be weakened, and complainants would hesitate to bring ethics charges forward if there would be no penalties.

The task force recommendations, approved by the Board of Trustees in 2002, also brought to bear a “triage model” for ethics complaints that allowed for the addition of the nonadversarial “Educational Option” to the ethics procedures. This alternative gave DBs more flexibility in handling complaints through a route in which there is no determination as to whether the respondent psychiatrist violated ethics principles.

So what would happen if APA cut funding for ethics enforcement? The outcome would be the demise of ethics enforcement. Why is this the case, given that the lion's share of ethics enforcement costs are volunteer hours donated by Ethics Committee members?

The answer is that there are certain due-process requirements for medical peer review as set forth by Congress in the Health Care Quality Improvement Act of 1986, and without sufficient funds allotted to ensure that APA and its DBs comply with these standards, then enforcement would not be possible given the associated liability.

Also key to consider is that ethics enforcement is important for the stature of APA as a self-regulating organization. By holding our members to the highest standards of conduct, we are communicating our commitment to the safety of our patients and society. If we stop policing ourselves, then another entity will fill the vacuum for us, namely state medical boards. Ethics complaints coming in to APA or DBs could not be ignored, and we would be left with no recourse but to inform complainants that they could seek redress from the state boards of medicine that licensed the members. Psychiatrist members on boards of medicine are unfortunately rare, and the nuances and intricacies of psychiatric practice might not be adequately grasped by the investigating body. Consequently, disciplinary responses would be at increased risk of being overly harsh or, contrarily, underestimated.

While psychiatrists are not prosecutors, and the APA ethics enforcement system is not perfect, our Ethics Committee members are in a far better position to judge their peers fairly than are physicians from other specialties who may have had minimal exposure to psychiatry during their careers.

It is imperative that we continue to value enforcement of our ethics principles and provide the resources to do so. Upholding our moral code adds a special worth and meaning to APA membership. If we give up this endeavor, then other agencies with lesser capabilities will take over for us, and our standing in the public eye will diminish. Policing ourselves is a difficult and unpleasant task, but if we stop doing so, we risk lessening our individual and organizational professionalism.