APA Commentary on Ethics in Practice: An Additional Ethics Resource

The Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry, a resource that provides the basis for determining psychiatric professional ethics, has guided APA members for decades. It is based on the ethics principles adopted by the AMA and was last updated in 2013. In December 2015, the APA Ethics Committee released a 12-page document that provides additional commentary on the content of the Principles. The APA Commentary on Ethics in Practice offers succinct, relevant explanations about contemporary issues in psychiatric practice, including working in multidisciplinary teams, clinically innovative practices, professional use of the Internet and modern technology, and political advocacy. When faced with a professional dilemma, psychiatrists may refer to this resource for guidance. This article will illustrate three examples of using the commentary to assist in decision making.

Many psychiatrists now work in large care systems such as mental health centers, the Veterans Administration, and academic medical centers. A psychiatrist in these settings may at times experience a conflict between their clinical and institutional responsibilities. For example, a psychiatrist in a busy outpatient clinic may be aware that the administrator wants clinicians to see their patients no more than once every three months in order to ensure service to the entire catchment population. The psychiatrist may feel torn when determining the follow-up interval for a relatively unstable patient: an appointment in three months is clinically inappropriate, but three weeks means bumping another patient out of the schedule or overbooking and then seeing everyone on that day’s schedule for less time to fit in the extra patient. The Commentary advises:

“In increasingly complex systems of care, treating psychiatrists will encounter situations in which the primacy of individual patient care competes with other compelling interests and obligations. … Psychiatrists practicing within such systems must be honest about treatment restrictions, … ensure reasonable access to care within the system, and help identify alternatives available outside of the system when the patient’s psychiatric or medical well-being requires it.”

After reading this commentary, the psychiatrist might consider alternatives within the system, such as interim visits with a nonpsychiatric provider or transfer to a more intensive level of treatment, or discuss with the patient a referral to another treatment setting with more resources (if one exists). Despite institutional pressures, the psychiatrist’s first responsibility is always to the patient.

Another contemporary challenge is determining when and how to introduce innovative technologies or treatments into clinical practice. For example, should one order genetic testing to help guide diagnostic or therapeutic decision making? Or recommend ketamine infusions for a patient with treatment-resistant depression? These interventions are prominent in the experimental literature, and patients may ask about them. The Commentary suggests:

“Since innovative practice sometimes leads to important scientific advances, it should not be categorically discouraged; however, because it may prove ineffective or even harmful, psychiatrists should proceed with caution in their use of clinical innovation. When considering use of clinical innovation, psychiatrists should consider first consulting colleagues and exploring other resources to ensure that careful thought has been given to possible alternatives as well as to the safest and most effective use of innovative interventions.”

After reviewing the Commentary, a psychiatrist might pause long enough to obtain consultation or a second opinion rather than rushing forth into innovative and experimental interventions. The Commentary also reminds psychiatrists of the importance of informed consent discussions for all treatment, and especially for treatments outside established practice guidelines.

A third conundrum in contemporary practice is the difference between legal and ethical standards of confidentiality. A psychiatrist who treats a patient who is subsequently prosecuted for a crime may be compelled to testify in court about the patient’s psychiatric diagnosis and treatment. The testimony becomes part of the public record of the trial. From a legal standpoint, that information may no longer be considered private, so a psychiatrist may be asked to repeat the information by the press or other interested party. The Commentary clearly distinguishes between legal and ethical standards of confidentiality:

“Medical confidentiality is the physician’s obligation to his or her patient not to reveal the patient’s personal or health information without that patient’s explicit, informed permission. This obligation is an ethical duty distinct from the legal duty to protect patient privacy. … Disclosures, even with informed consent, should be limited to the requirements of the situation, particularly when legal privacy rules provide a lower standard of protection than ethics require” (page 4).

After reading this, the psychiatrist may feel more confident in asserting an ongoing duty of confidentiality despite information divulged during the legal proceedings.

The Commentary is a welcome addition to APA resources for psychiatric ethics. It joins the Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry and the Opinions of the Ethics Committee (updated in 2016) as valuable tools for practicing psychiatrists striving to recognize and respond to ethical dilemmas. All three documents are available on APA’s website. ■