Commentary on Opinions of APA Ethics Committee VIII

Continued from Commentary on Opinions of APA Ethics Committee VI with more miscellaneous items:

 G.1.b. (1977, 2001? page 31): Execution and assisted suicide
This opinion states, with regard to psychiatrist participation in execution: "... the physician-psychiatrist is a healer, not a killer..." But now at least two states allow "death with dignity" or assisted suicide in which a terminal patient might conceivably ask a psychiatrist to provide a prescription for a lethal dose of drug. Perhaps more likely the psychiatrist's "participation" might consist only of determining whether the terminal patient is competent to decide to end his or her life under such a statute.

When I asked the committee for an opinion the chairman responded thus (personal communication 10.26.2009):
"I read with interest about this relatively new statute (passed in November 2008) on line. As you know, the ethics surrounding a physician providing patient care in any given setting are unique. The physicians who participate in your death with dignity procedures are truly in a position to best comment on the ethics involved, given they have firsthand experience and can best judge the competing interests that weigh into the decision to participate or not for any given case. I would encourage them to write or otherwise communicate about the ethics of this area so we can all learn from their experiences. I have attached the AMA CEJA opinion on this area which you have probably seen, and I know that not all physicians agree with this view, one that has been greatly debated."

"Opinion 2.211 - Physician-Assisted Suicide
Physician-assisted suicide occurs when a physician facilitates a patient’s death by providing the necessary means and/or information to enable the patient to perform the life-ending act (eg, the physician provides sleeping pills and information about the lethal dose, while aware that the patient may commit suicide).

"It is understandable, though tragic, that some patients in extreme duress--such as those suffering from a terminal, painful, debilitating illness--may come to decide that death is preferable to life. However, allowing physicians to participate in assisted suicide would cause more harm than good. Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.

"Instead of participating in assisted suicide, physicians must aggressively respond to the needs of patients at the end of life. Patients should not be abandoned once it is determined that cure is impossible. Multidisciplinary interventions should be sought including specialty consultation, hospice care, pastoral support, family counseling, and other modalities. Patients near the end of life must continue to receive emotional support, comfort care, adequate pain control, respect for patient autonomy, and good communication. (I, IV)

"Report: Issued June 1994 based on the reports "Decisions Near the End of Life," adopted June 1991, and "Physician-Assisted Suicide," adopted December 1993 (JAMA. 1992; 267: 2229-33); Updated June 1996."

I believe this is a cop out. APA should decide now whether to rubber stamp the AMA position and issue an opinion as to whether psychiatrists can ethically participate in competence evaluations for assisted suicide. Member psychiatrists and their patients deserve no less. APA should also address the ethics of participation in such competence evaluations where the psychiatrist might allow personal beliefs to influence the determination.

N.6.b. (1985, page 69): Admission of a patient to the hospital where he or she is employed
The opinion correctly states that no ethical question arises, but fails to point out that the patient's wishes should weigh heavily in the decision.

N.6.c. (1988, page 69): Continuity of care from office to hospital
The psychiatrists at a local mental health center do not have or want privileges at the local hospital. The committee opines that for these psychiatrists to refuse to care for "their" patients at the hospital might constitute abandonment rather than an ethical question. Abandonment is very much an ethical matter, but even in 1988 psychiatrists in many communities restricted their practices to office work, and rightly so. Continuity of care may have advantages for the patient, but there are also many advantages for the patient in accepting care from a different psychiatrist in the hospital, not the least of which is a built in second opinion.

O.2.b. (1978, page 70): Who's in charge here anyway?
The committee answers a question about whether an ethical psychiatrist can list his or her practice in a "professional" directory correctly as yes, but then recommends taking up any question about what might be considered "adverstising" with the "local medical society." Another cop out. The committee should take responsibility for addressing questions like this without deferring to some other unnamed organization. Advertisement show themselves even when you do not want them to. You must know what you are looking for to find a practice in a directory. Directory listing clearly does not constitute advertising.

D.4.f. (1987, page 24): Ethics of "completing forms"
According to this opinion it is not only unethical to decline to complete an insurance form but, at least in the case of a so-called "simplified" insurance claim form (Dose anyone even know what that is?), it is also unethical to charge for the time. This opinion belongs on the scrap heap. Completing a form is really a euphemism for whatever purpose the form serves. Insurance claim forms related to a contract between patient and physician. The physician's only obligation should be to the patient and should be restricted to providing diagnosis and medical care. I would argue that for the physician to take responsibility for obtaining benefits for the patient might be UNethical. The physician should certainly make it known to the patient up front if her policy is to not assist with insurance claims or to charge a fee for completing them. The patient can decide whether to accept the psychiatrist's terms of treatment, so-called "local custom" notwithstanding.