Special Report: Ethical Decision-Making in Contemporary Psychiatric Practice—An Evolving Challenge

What ethical issues might arise when a psychiatrist includes artificial intelligence decision tools in her clinical practice?

Why, and how, should one intervene when a colleague is potentially impaired?

In what ways can one safeguard the autonomy of a patient who is living with a severe but intermittent disorder affecting mood and cognition? What ethical tensions might one anticipate and prepare for?

Psychiatrists regularly confront both age-old and new questions in their practice, from those that involve the cornerstone values of beneficence and respect to those that involve the cutting edge of technological innovation.

Ethics is a formal branch of philosophy that seeks to more deeply understand the moral aspects of human nature and action. Within the profession of medicine, ethics has evolved into an applied discipline. Medical ethics is rooted in formal research and evidence as it emerges from everyday clinical practice, as well as in historical concepts that have endured and evolved over many centuries, such as autonomy, beneficence, nonmaleficence, and justice. This discipline includes specific clinical skills that are as crucial to being a competent and compassionate physician as taking a careful history, evaluating symptoms, and forming a diagnosis.

Closely allied with ethics is the concept of professionalism. Professionalism is intrinsically grounded in the ideals of a profession (such as truthfulness, respect for dignity of patients, and humility), although how such ideals are expressed at any given moment in history and in different contexts will change. A profession has moral importance because of the trust and privileges conferred on it by society. Being a member of a profession has moral standing because society requires that professionals possess certain qualities and adhere to a set of duties. The good conduct of members of a profession confirms the investment of power that society has placed in them and in their field, fostering a relationship of trust and equipoise.

Psychiatrists face a unique set of ethical challenges and professional obligations related to the specifics of their work. They confront issues of personhood and autonomy, continuously grappling with definitions of health and illness and the very components that make up behavior and identity. Ethical issues of beneficence, nonmaleficence, confidentiality, altruism, justice and nondiscrimination, professionalism, trust, and other seemingly abstract concepts regularly emerge in the daily work of psychiatrists.

The second edition of Professionalism and Ethics, Second Edition: Q & A Self-Study Guide for Mental Health Professionals, newly published by American Psychiatric Association Publishing, seeks to encompass everyday ethical challenges with a focus on clinical skills. These skills, like any other, require practice, as past APA President Paul Appelbaum, M.D., emphasizes in a wise introductory comment to the book.

“Just as good people do not instinctively follow good diagnostic practices without the training required to do so, just as they cannot be expected to have an intuitive sense of interactions among medications without studying pharmacology, so good people are not necessarily able to avoid the pitfalls inherent in the ethical challenges ubiquitous in clinical work,” Appelbaum writes. “Sound ethical practice, like good psychotherapy, requires a judicious mixture of theoretical knowledge, supervised learning, and reflective practice. And like most other aspects of the job of a clinician, learning ethics takes time and intellectual effort.”

New Ethical Challenges in an Evolving Landscape

Each decade brings new, unexpected ethical challenges that evolve over time. Among them:

The Neuroscience Revolution

Over the past few decades, neuroscience has taken up a central role in medicine as the conceptual basis for understanding and treating people with mental illness. The study of the brain’s functioning and the recursive application of advancements in our metacognitive understanding to influence the brain and mind carry ethical questions that are not present elsewhere in the biological sciences. These questions belong to the emerging field of “neuroethics.”

Examples of topics in neuroethics include the following:

• Emerging biomedical and neuroimaging technologies

• Mobile health technology and wearable devices

• Neuromodulation

• Neurotechnology research

• The role of technology in the lives of young people

• Brain death and the definition of death

• Ethical issues in neurodegenerative conditions

• Environmental neuroethics

• Neurobiology of addiction

• Neuroscience and the law

Novel Tools and Treatments

Ethical issues accompany the advent of any new diagnostic and evaluative tools. Advances in genetics, genomics, and other biomarkers (such as neuroimaging) hold the potential to bring the practice of psychiatry into the realm of “precision medicine.” Precision psychiatry will raise issues of autonomy (does the patient fully comprehend and voluntarily agree to the use of the diagnostic tool or method?); beneficence (will such novel diagnostic schema have clear benefits for the patient?); nonmaleficence (are there any foreseeable harms associated with the new methods?); and justice (is access to novel diagnostic or evaluative methods fair and nonexploitative of vulnerable populations?).

Psychiatric researchers are also exploring a range of novel therapeutic approaches to address unmet needs in patients with mental illness. For example, investigations are ongoing into the potential use of psychedelic compounds (such as psilocybin) for treatment-resistant depression. Novel neurosurgical approaches are also being evaluated for their efficacy in treating patients with psychiatric conditions (including substance use disorders, eating disorders, and neurocognitive disorders). These endeavors raise a number of ethical issues including the following:

• Ensuring that patients enrolling in novel therapeutics trials provide informed, authentic consent

• Ensuring that protocols (whether in the research or treatment context) are designed with adequate safeguards for both known potential risks and unforeseen adverse events

• Disseminating accurate, judicious information about the known benefits and risks of these emerging therapies

The Digital Revolution and Use of ‘Big Data’

Emerging methods of prediction in clinical care are bringing a range of new ethical questions to the forefront. The use of machine learning and artificial intelligence to predict illness course or the possibility of specific behaviors (including suicide attempts) may affect the patient-clinician relationship in unexpected ways, for example, by influencing treatment decision-making or the allocation of resources.

Algorithmic bias poses great risk in decision-making involving machine learning algorithms, as it can operationalize biases already at work in human decision-making under the guise of sophistication. Transparency about when algorithms are being used and how such algorithms affect patient confidentiality are extremely important. Ensuring adequate communication with patients about algorithms and obtaining proper informed consent are also crucial. It is unfortunate that many algorithms are developed without adequate transparency to stakeholders. Clinicians should consider how algorithms were trained and whether appropriate safeguards were implemented to protect against bias in the context of training (for example, ecological validity of the training data and choice of learning model). There is very little consensus about how to ethically utilize algorithms in clinical care, including for mental health applications.

Assisted-Suicide and Physician-Assisted Death Laws

In recent years, the topic of physician-assisted dying (also known as medical aid in dying and physician-assisted suicide) and the related (but distinct) practice of euthanasia have become contentiously debated issues in the United States and many other countries. Physician-assisted dying refers to a physician’s providing either the means or information necessary for a patient to end his or her life. Euthanasia refers to the termination of life by a physician or another clinician. From ethical and legal points of view, assisted dying and euthanasia are distinct from withholding or withdrawing care necessary for continued life. Additionally, assisted dying and euthanasia are viewed as different from administering medications to relieve pain or to bring greater comfort, as the primary intention in this case is not to end the patient’s life. In the United States, physician-assisted dying is legal in some states, while euthanasia remains illegal across the country. APA released a statement in 2016 stating that “a psychiatrist should not prescribe or administer any intervention to a non-terminally ill person for the purpose of causing death.”

Concerning data have been reported regarding the use of assisted dying and euthanasia in some European countries for individuals with psychiatric and neurocognitive disorders. Commentators in certain countries have suggested that extending eligibility criteria for euthanasia beyond “reasonably foreseeable natural death” to include psychiatric illnesses could result in ethical conflicts between a patient’s desire to end suffering and limitations in access to specialized psychiatric care, send the implicit message that individuals with chronic or severe psychiatric illnesses do not have lives worth living, erode the ethical principle of nonmaleficence, and contribute to provider moral distress and burnout.

Equitable, Patient-Centered Care

The need to include all voices as full partners in clinical care—including individuals with lived experience of mental illness, individuals who seek mental health care services, and underrepresented populations—represents a crucial ethical challenge for psychiatrists today. However, this challenge is “new” only to the extent that it is, at last, more widely recognized and acknowledged; structural inequities in access to care, the quality of care that patients receive, and inequities in research have plagued medicine and psychiatry for generations. Successfully negotiating this moral territory requires a departure from prior, more hierarchical and paternalistic models of care. Mental health professionals need a new set of skills, including the ability to mediate disputes, negotiate power sharing, manage more complex legal situations, and participate in struggles for social justice and political parity, without which adequate mental health care and its funding cannot be achieved.

Social Media

Online platforms and media bring new opportunities and challenges. All psychiatrists need to make conscientious and informed choices about whether, how, what, and how much to interact and disclose online. Given that the majority of psychiatry trainees, and an increasing number of physicians, have social media accounts, outright avoidance or rejection of social media has become impractical. Moreover, these sites now play integral and positive roles for many physicians as facilitators of social interaction. Furthermore, if psychiatrists act carefully and proactively, they can maintain their standards of ethics and professionalism online and ensure appropriate boundaries. Suggested guidelines center around basic issues of trust, privacy, professional standards of conduct, and awareness of potential implications of all digital content and interactions. Simply put, online expression should be viewed as “the new millennium’s elevator,” where psychiatrists have little control over who hears what they say.

Where the Rubber Meets the Road: Clinical Skills and Ethical Decision-Making

Mental health professionals tend to rely on a set of six core ethics skills. The ability to recognize ethical issues requires some familiarity with key ethics concepts and the interdisciplinary field of bioethics. As a corollary, this ability presupposes the clinician’s capacity to observe and translate complex phenomena into patterns, using the common language of the helping professions (for instance, conflicts among autonomy, beneficence, and justice when a person with mental illness threatens the life of a specific individual and is thus involuntarily held for evaluation).

The first of these core skills is the ability to identify ethical issues as they arise. For some, this is an intuitive insight—that is, an internal sense that something is not right—and for others this is derived more logically.

The second key ethics skill is the ability to understand how one’s personal values, beliefs, and sense of self may affect one’s care of patients. Attentiveness to interpersonal aspects of the clinician-patient relationship is a crucial safeguard for ethical decision-making by professionals to serve the needs and best interests of patients. In recent years, the role of implicit bias has been identified and studied vigorously, demonstrating the influence of attitudes and social stereotypes related to gender, race, cultural background, and other aspects of identity on many aspects of health care. The impact of implicit bias is felt by patients and health professionals and can adversely affect patient care practices, quality, safety outcomes, and health system policies.

The third key ethics skill is an awareness of the limits of one’s own medical knowledge and expertise and the willingness to practice within those limits.

The fourth skill is the ability to recognize high-risk situations in which ethical problems are likely to arise. Such circumstances can occur when a mental health professional must step out of the usual treatment relationship to protect the patient or others from harm or to protect the patient’s or others’ best interests, even when the patient may not agree.

The fifth skill is the willingness to seek information and consultation when faced with an ethically or clinically difficult situation and the ability to make use of the guidance offered by these sources.

The sixth and final essential skill for the mental health professional is the ability to build appropriate ethical safeguards into one’s work.

Many clinicians use an eclectic approach to ethical problem-solving that makes intuitive use of principles, case experiences, lessons learned from colleagues, and a combination of inductive and deductive reasoning. Such an approach typically yields not one “right” answer but, rather, an array of possible and ethically justifiable responses that may be acceptable in the specific set of circumstances.

A more systematic and explicit approach widely used in the clinical setting is the four-topics method described by Albert Jonsen, Ph.D., and colleagues in the influential 2002 text Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. This method entails gathering and evaluating information about (1) clinical indications, (2) patient preferences, (3) patient quality of life, and (4) contextual or external influences on the ethical decision-making process.

Many ethical dilemmas in clinical care involve a conflict between clinical indications and patient preferences. Working through such a dilemma requires exploring fully and thoughtfully the patient’s preferences as well as the clinical indications.

Why does the patient refuse treatment? Does the patient have the capacity to make this decision at this time? Is there a range of options, perhaps some that have not been previously considered, that may offer benefit? How urgent is the clinical situation, and is time available for discussion, collaboration, and perhaps compromise?

If the patient lacks decision-making capacity, the dilemma is at least temporarily resolved by identifying an appropriate alternative decision-maker. If the patient does have the ability to provide informed consent—involving capacity for decision-making and capacity for voluntarism—then, under most foreseeable circumstances, the patient’s preferences must be followed. However, by engaging the patient in a meaningful dialogue in which the mental health professional describes the full range of treatment options and demonstrates sensitivity to the reasons for the patient’s refusal, it may often be possible to discover a solution that the patient can willingly accept and the clinician can justify as medically beneficial.

Informed consent is the process by which individuals make free, knowledgeable decisions about whether to accept a proposed intervention, such as clinical care or research study participation. Informed consent is thus a cornerstone of ethical practice in both treatment and research settings. Although informed consent is a legal requirement in both contexts, its philosophical roots as a medicolegal doctrine are deeply embedded in our societal and cultural respect for individuals and in affirming individuals’ freedom of self-determination. An adequate process of informed consent thus reflects and promotes the ethical principle of autonomy.

A model of shared, deliberate decision-making fits with a larger commitment to patient-centered care. Shared decision-making and patient-centered care are grounded in the principle of respect for persons and demonstrate deep regard for the dignity of individuals who receive clinical care. Actions that promote shared decision-making include ensuring that patients are well informed, encouraging patients to play a direct role by making choices and making clear the values and preferences underneath these choices, and protecting and supporting patients’ interests.

Conclusion

Every era of medicine has ethical challenges—some new, such as we have experienced with the COVID-19 pandemic and effects of recent extreme weather events caused by climate change, and some not as new, such as how to uproot systemic barriers to equity in the workplace and in the provision of care and how to demonstrate respect for patients’ cultural values, self-governance, and privacy.

Psychiatrists and other clinicians caring for people with mental illness and substance use disorders encounter additional and specific ethical concerns, also modern and ancient. The questions and quandaries posed by these ethical issues in everyday clinical practice are thorny, sometimes challenging our own deeply held attitudes and beliefs and engaging the most fundamental aspects of what it means to be a physician.

The answers to these problems are nuanced and dependent on multiple factors and context. For these reasons, psychiatrists, trainees, and practitioners in related health fields must understand the requirements of professionalism and cultivate a strong set of skills for making sound ethical decisions. ■

WHAT WOULD YOU DO?

Case 1: Psychiatrist Asked to Treat an Acquaintance

A 19-year-old has been isolated at home for several weeks after graduating from high school. Her plans for college shifted because of her family’s financial situation and because of an infectious disease pandemic. She made one phone call in an effort to get mental health care, but she could not find sufficient privacy in her home, which is a small apartment. She reached out to a high school friend whose father is a psychiatrist and asked if it would be possible to text the psychiatrist from time to time and to get a prescription for antidepressant medications.

• What ethical issues and conflicts are present in this clinical scenario?

• What contextual factors are influencing the situation and the decision and options available to the psychiatrist?

• What kinds of potential risks exist for this psychiatrist in providing care in this particular situation?

• How might you handle this situation? What are the most important next steps for the psychiatrist?

• What other expertise or resources may be introduced to help or address ethical issues or professionalism challenges in this situation?

Case 2: Psychiatrist Feels Overextended at Work

A 68-year-old psychiatrist is the sole mental health professional in a multispecialty group practice. The group practice has become increasingly busy: The volume of referrals to the psychiatrist has grown dramatically, and the kinds of patient care situations have become much more severe since a local inpatient unit was closed. The psychiatrist is concerned about stress and has noticed that his notes are not as complete and that he awakens at night, worrying over questions he forgot to ask or problems he failed to address in caring for patients the previous day.

• What ethical issues and conflicts are present in this clinical scenario?

• What contextual factors are influencing the situation and the decisions and options available to the psychiatrist?

• What kinds of potential risks exist for patients and for this psychiatrist in this particular situation?

• How might you handle this situation? What are the most important next steps for the psychiatrist?

• What other expertise or resources may be introduced to help or address ethical issues or professionalism challenges in this situation?

Case 3: Psychiatry Resident Wishes to Improve Patient Care

An addiction psychiatry trainee is on a three-month rotation in which she provides care for patients in a general mood disorders clinic. She notices that one of the teaching attending psychiatrists seldom asks about addiction-related issues and never asks about safety in the home when evaluating patients. She wishes to raise her concerns, especially regarding female patients with multiple health issues, but she feels very intimidated by the attending psychiatrist, who always seems stressed, irritable, and quick to offer a harsh or negative comment.

• What ethical issues and conflicts are present in this clinical scenario?

• What kinds of potential risks exist for patients and for the psychiatry trainee in this particular situation?

• How might you handle this situation? What are the most important next steps for the psychiatry trainee?

• What other expertise or resources may be introduced to help or address ethical issues or professionalism challenges in this situation?

Case 4: Psychiatrist ‘Stretches’ to Deal With System Challenges

A psychiatrist accepts a telehealth contract to provide consultations on psychiatric patients who come to emergency rooms in a five-county region. The psychiatrist has a full-time “day job” but felt he could handle the extra work and hoped to be able to pay off his school debt more quickly by accepting the added role. The emergency rooms are located in urban and rural community hospitals, which are typically understaffed, and the number of patient evaluations per contracted shift may range from four to 18. The psychiatrist loves the work and feels he is helping to identify patients who are in the greatest immediate need for psychiatric expertise. He also enjoys working with his emergency medicine colleagues, even in this limited way, but worries that a brief telehealth visit does not really help patients in the long run and is just a “Band-Aid” on an inadequate system.

• What ethical issues are present in this clinical scenario?

• What inherent risks exist in this situation?

• What other expertise or resources may be introduced to help or address ethical issues or professionalism challenges in this situation?

• How are the psychiatrist’s roles as clinician, colleague, and advocate relevant in this scenario?

Case 5: Chief Resident Intervenes to Address Team Member Distress

A medical student rotating through a psychiatry emergency/crisis clinic for a third-year clerkship becomes extremely distraught after seeing a patient (with the attending psychiatrist) who described her experience surviving childhood sexual abuse. Recognizing the student’s distress, the chief resident met with the student. The student described being upset by the patient’s personal story and the attending psychiatrist’s manner, which the student felt was “insensitive” because of the psychiatrist’s efforts to direct the patient to the “here and now.”

• What ethical issues are present in this clinical scenario?

• What inherent risks exist in this situation?

• What other expertise or resources may be introduced to help or address ethical issues or professionalism challenges in this situation?

• How are the student’s, attending psychiatrist’s, and chief resident’s roles and professional duties influencing the ethical dimensions of the situation?

• If you were the chief resident, how might you handle this situation? What are the most important next steps?

Case 6: Psychiatrist Asked to Treat VIP Patient

A psychiatrist receives a VIP referral from a primary care colleague. The VIP patient is a well-known celebrity who is frequently featured in the news and on social media. The patient is experiencing extreme anxiety after a recent event that “went viral” online. The psychiatrist recognizes the patient’s name and is tempted to investigate the patient’s background and circumstances prior to the initial evaluation.

• What ethical issues are present in this clinical scenario?

• What inherent risks exist in this situation?

• What other expertise or resources may be introduced to help or address ethical issues or professionalism challenges in this situation?

• How might you handle this situation? What are the most important next steps?

Case 7: Psychiatrist Wants to Review Patient Records for Possible Research Project

A psychiatrist wishes to conduct a quality assurance project that will involve reviewing the electronic medical records of recent psychiatric inpatients to verify the presence of appropriate documentation of sexual history, suicidality, and substance use. The psychiatrist is hoping that eventually there will be an interesting research project to come out of the quality assurance work.

• What ethical issues are present in this clinical scenario?

• What inherent risks exist in this situation?

• What other expertise or resources may be introduced to help or address ethical issues or professionalism challenges in this situation?

• What issues should the psychiatrist consider in setting up appropriate safeguards for the quality assurance project? And if it becomes a research project? What are the most important next steps?

^{Laura Weiss Roberts, M.D., M.A.}

^{Conflict of Interest Disclosure 2021}

^{Dr. Laura Roberts serves as the Chairman and Katharine Dexter McCormick and Stanley McCormick Memorial Professor in the Department of Psychiatry and Behavioral Sciences at the Stanford University School of Medicine.}

^{Dr. Roberts has received federal funding for competitive, peer-reviewed research grants and competitive, peer-reviewed small business grants and contracts. The key stakeholders, such as Stanford University and the NIH, are fully aware of this arrangement and have given prior approval for this set of professional commitments. In addition, she often serves as a consultant for federally funded scientific projects with collaborators across the United States.}

^{Dr. Roberts is the Editor-in-Chief, Books for the American Psychiatric Association Publishing. Funds associated with these duties are provided to Stanford University.}

^{Dr. Roberts is the Editor-in-Chief of Academic Medicine, a peer-review publication of the Association of American Medical Colleges. She receives a stipend for this professional service to the AAMC.}

^{Dr. Roberts does not receive direct funding from pharmaceutical companies for her work and she is not on any “Speakers’ Bureaus” of any kind. She does give academic and public/community talks for which she receives honoraria.}

^{Dr. Roberts has published books and receives royalties. These royalties represent a very small proportion of Dr. Roberts’ overall income. Dr. Roberts has owned Terra Nova Learning Systems (TNLS), a small company that developed science-based educational products in the past.}

Laura Weiss Roberts, M.D., M.A., is chair of the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine and the Katharine Dexter McCormick and Stanley McCormick Memorial Professor of Psychiatry. She is the co-editor of Professionalism and Ethics, Second Edition: Q & A Self-Study Guide for Mental Health Professionals and editor-in-chief of the books division of APA Publishing.

Gabriel Termuehlen, B.A., is an editor in the Department of Psychiatry and Behavioral Sciences in the Stanford University School of Medicine and the book’s co-editor. APA members may purchase the book at a discount here.