Psychiatrists as Patient Advocates

“What has been will be again, what has been done will be done again; there is nothing new under the sun”

—Ecclesiastes 1:9, New International Version, Bible

Advocating for patients is central to the practice of medicine. I have yet to meet a physician who is not driven by the desire to heal their patients’ suffering or one that purposely sets out to hurt patients. As far back as the 4th century, the Hippocratic Oath declared: “I will prescribe regimens for the good of my patients according to my ability and judgments and never do harm to anyone. ... In every house where I come, I will enter only for the good of my patients, keeping myself far from all intentional ill-doing. …”

It is important for us psychiatrists to always remember that as physicians, we are first and foremost advocates for our patients. We have always been and will always be advocates. Before the advent of new age patient advocates, there were physicians. A list of designated patient advocates in some hospitals includes advocates employed by the hospital, legal advocates, not-for-profit advocacy groups available to patients, patients’ family members and friends, and even fellow patients. Nowhere in these documents will you see the patients’ psychiatrist described as their advocate. In fact, if you observed an interaction between some of these designated advocates and psychiatrists, you would leave with the impression that psychiatrists were professionals whose actions must be carefully monitored and from whom the patients must be protected. The most painful interactions often occur between legal advocates and psychiatrists; attending psychiatrists have sometimes been subjected to vigorous and painful cross-examination by these advocates in front of patients and other treatment team members, as if they were in court.

Legal advocates are obligated to represent the expressed wishes of patients even if these wishes are potentially dangerous to the patient or the public at large. Psychiatrists, in contrast, are obligated to focus on what is in the best interest of patients and the public rather than only on the patients’ expressed wishes, especially if their capacity to arrive at logical decisions is impaired by mental illness. This then sets the stage for a clash between patients and their legal advocate on one side and psychiatrists on the other.

In such situations, psychiatrists should be patients’ real advocate, in my opinion. Statements and actions of the officially designated advocate intended to force psychiatrists to comply with patients’ problematic wishes that are born out of an impaired mental status should be resisted. Of course, psychiatrists should always recognize and respect the decisions of patients who have the capacity to give informed consent, even if their decisions are potentially perilous. This process must not be vitiated. However, the psychiatrist should point out to the designated advocate that he/she is also an advocate for the well-being of the patient and insist that both the psychiatrist and the designated advocate work together for the benefit of the patient.

Advocating for our patients is so important in medicine that four of the nine principles of medical ethics (sections of psychiatric ethics) speak to it. Section III encourages psychiatrists to seek changes in laws that are contrary to the best interest of patients, and Section VII reminds us of our responsibility to participate in activities contributing to the improvement of the community and the betterment of public health. Section VIII focuses on our critical obligation to regard responsibility to patients as paramount, and Section IX urges us to support access to medical care for all. Thus, the calling to serve individuals dealing with the ravages of mental and substance use disorders is intricately linked with advocating for their well-being. It is our fiduciary responsibility that remains relevant today as it was in ancient times.

In summary, the privilege of taking care of patients includes vigorously advocating for what is in their best interest. This special role cannot, must not be abdicated by psychiatrists no matter who else is designated or involved. Psychiatrists and others should pursue areas of collaboration and compromise for the benefit of patients, and for no other motive. Our patients, and indeed society, expect no less from us. ■

Charles C. Dike, M.D., M.P.H., is chair of the APA Ethics Committee and former chair of the Ethics Committee of the American Academy of Psychiatry and the Law. He is also an associate professor of psychiatry; co-director of the Law and Psychiatry Division at the Yale University School of Medicine; and medical director in the Office of the Commissioner, Connecticut Department of Mental Health and Addiction Services.