Tuesday, March 16, 2010

Commentary on Opinions of APA Ethics Committee VII

Continued from Commentary on Opinions of APA Ethics Committee VI these next items do not easily fall together in a category:

E.2.d. (2001, page 27): Healing from reporting professional misconduct?
In this case a psychiatrist asks whether it would be ethical to report sexual misconduct of another psychiatrist to the licensing board over the objection of the patient. Not an easy question, the answer may depend on reporting statutes, but I object to the committee's opinion that the treating psychiatrist suggest that the patient report the misconduct "as part of a healing process." As in many of these cases the opinion appears to presume that the current treatment involves psychotherapy, but makes no mention of treatment modality. Even assuming a psychotherapy context it seems presumptuous to suggest that reporting might contribute to healing. Potential also exists for further harm. The opinion make no mention of diagnosis. Should the psychiatrist devote visit time to pushing this presumably separate issue? But what bothers me most is that while the psychiatrist should keep this patient's welfare foremost, reporting seems more likely to satisfy the psychiatris's own needs and possibly protect other patients in the future. I believe simply informing the patient of the option might constitute the most ethical course.

N.4.b. (1988, page 66):
In this case the psychiatrist want to know whether there might be an ethical problem with asking the phone company to intervene with an ex-patient who harasses with abusive calls. I agree with the committee that as a last resort the psychiatrist can ethically enlist the phone company's assistance, but with the proviso that the psychiatrist does not have to tell the phone company that the individual named was a patient. This opinion, however, begs for an update to the day of voice mail and stalking. New technologies may enable the victim of such harassment to block the calls, but the psychiatrist may want to consider other steps to ensure safety.

A.2.b. (1978, page 8): Investment advice from the psychiatrist
This psychiatrist wants to know whether an ethical problem exists with accepting a "finder's fee" after providing investment advice. The opinion correctly identifies an ethical problem with the implied exploitation, but incorrectly attributes this to giving advice, rather than the real exploitation: accepting a fee. The suggestion that this would be a "strange form of psychotherapy," however, is gratuitous. While we might characterize many methods of psychotherapy as strange, first, the question makes no mention of psychotherapy, and second, there is no suggestion that giving investment advice was part of the treatment at all. This question involves dual roles: that of treating physician and that of investment adviser. We can presume the goal of the latter would be to obtain money for the patient (not to mention the fee for the psychiatrist). The opinion here may conflict with other opinions where the committee has endorsed a similar role of obtaining money for the patient by "completing forms" or assisting in a disability or other claim. Of course the psychiatrist should not accept a "finder's fee" in connection with either of these roles, but I would argue that even without such a fee ethical problems exist. One can no more be treater and investment adviser than treater and lover.

N.4.e. (1993, page 67): Do records go to the patient after the psychiatrist dies?
The committee opines in this case that after the death of a psychiatrist executors should refuse to provide treatment records to a patient requesting them. This opinion may conflict with law, including HIPAA, which may require such release unless there is reason to believe the patient or someone else might be endangered as a result. Unfortunately the executors probably cannot make such a determination, and probably should not access the records anyway. To fully comply with the law may require that a professional review the records and the request, and/or attempt to convince the patient to agree to have the records forwarded to a new treating professional who might assist with such a determination.

N.6.a. (1978, page 68): Unethical to refuse Medicaid?
A retiring psychiatrist cannot find new providers to assume the care of patients covered only by Medicaid. The committee states, "Your colleagues might wish to consider their roles as ethical providers in assisting you and your patients in your time of need." This statement seems to imply that refusing to accept a patient covered by Medicaid might be unethical. This conflicts with Section 6 which indicates a physician shall be "free to choose whom to serve." If we took it upon ourselves to serve all those who cannot afford it we physicians would enter that group as well.

I.4.b. (1998, page 41): Insurer audit by "appropriate" clinician
This opinion addresses some of the ethical issues surrounding audit of patient charts by insurers (managed care companies). The opinion omits the fact that clinicians must allow such an audit only if they have contracted with the payer. Agreeing to certain terms of such contracts raises ethical issues as well. The opinion here states that the audit should take place in the psychiatrist's office and implies that the psychiatrist should insure that only "appropriate clinicians" see the records. This of course assumes that the insurer has not demanded that the psychiatrist send them a copy of the records in which case the psychiatrist will not be able to observe who sees the records. But suppose the audit does take place in the office. What constitutes an "appropriate clinician." Review of such records does not constitute clinical activity, and even if it did, how does the committee propose that a psychiatrist verify the credentials of the reviewer. The best way to avoid this predicament is to eschew contracts with insurers, but for those who choose to agree to their terms it is not within the capability of a practicing psychiatrist to verify the credentials of anyone who happens to work for an insurer.

C.6.a. (1990, page 20): How to determine competence of replacements
A psychiatrist leaving a hospital want to know whether it is ethical to turn over patients to a psychiatrist whose "competency" (I think they meant competence.) is unknown to her. I get the feeling another agenda might be hiding here. I suspect the hospital, right or wrong, may want this psychiatrist to leave, and the psychiatrist is trying to make a case against the hospital. The committee's easy answer is to advise the hospital to seek competent replacements. Is that it? And what choice does this psychiatrist have? Wait indefinitely until this competent replacement appears? And how does this psychiatrist determine this individual is competent? That job belongs to the medical staff or the hospital itself, not the departing psychiatrist.

D.2.b. (1993, page 22): Public perception counts.
The question and answer here count less than the justification. The committee invokes the importance of the "public's perception of psychiatry" in supporting the opinion. While this may not seem as relevant to ethics on the surface as, for example, sex with a patient, in my opinion it goes to the heart of professional ethics. For our patients to trust us to provide treatment they must perceive that we behave ethically.

Commentary on Opinions of APA Ethics Committee VIII

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