Dual Roles Not Unethical, but Tread Carefully

Q:I am a psychiatrist providing services for seriously mentally ill indigent individuals. The doctors where I work have been asked to fill out a Social Security Administration form titled “Medical Source Statement of Ability to Do Work-Related Activities (mental).” My concern is that I am placing myself in an unethical situation of dual agency and that completing this form places me in an evaluative as well as a treating role. Could you advise?

A: Psychiatrists commonly find themselves in dual roles. While there is nothing inherently unethical about dual roles, they may lead to outcomes that are not in the patient’s interest. Academic psychiatrists are torn by allegiances to patient and medical school, prison psychiatrists have duties owed to their patients and to the prison system, and so on. In some contexts, the balancing act is easy, and in others it requires considerable thought and reflection. An important question is whether one can adhere to both commitments without undermining the connection to the patient.

When facing such a dilemma, the clinician is advised to think through, and perhaps discuss with a colleague, the pros and cons of conducting the evaluation. In some cases, doing the evaluation may be an act of beneficence. In other cases, it would be of no service to the patient and could injure the patient’s interests. Similarly, not doing the evaluation could reflect the physician’s lack of commitment to the patient, but not doing it could also be a reasoned outcome, as the clinician recognized an inability to do the evaluation objectively. The point is that the decision should be clinically informed and not decided casually. The spirit of the ethics guideline in this context is to protect the patient’s interests (2011). ■