By Mark Komrad, MD
[Fall 2007; Vol. 34, No. 1; Pg 3, 10]
A
Note From the Editor: This
is the first in a series of columns on Medical Ethics, with particular focus on
Psychiatry. Dr. Komrad is the Chairman of the Clinical Ethics Committee
and Consultation Service for the Sheppard Pratt Health Systems. This role
and his service on the MPS Peer Review Committee have given him considerable
experience consulting on a wide range of ethical dilemmas from both inpatient
and outpatient psychiatry. He has conducted numerous educational seminars
and workshops throughout the area for mental health professionals on topics in
medical ethics. As Dr. Komrad noted in a previous article in The
Maryland Psychiatrist,
social workers and psychologists are required to obtain 3 hours of continuing
educational credits in ethics to
renew their licenses every 2 years. He proposed that physicians,
psychiatrists in particular, should be held to the same requirement.
Awaiting that day when such a requirement is implemented, Dr. Komrad has agreed
to edit “Practicing Ethically”, an educational column for MPS members on
topics in this field. The following
article is provided by Dr. Komrad. Future
articles will focus on the knowledge base and techniques of ethical
decision-making mentioned at the end of his article. Authors are encouraged to
submit articles to Dr. Komrad.
It
is our hope that this column will stimulate readers to submit their own ideas
without concerns about always conforming to APA or MPS policies on ethics.
In fact, these policies deserve ongoing critiques.
With this in mind, it should be understood that the articles in this
column reflect the opinions of their authors, and not those of the MPS, APA or
the editorial board of the Maryland Psychiatrist.
Why
Ethics for Psychiatrists?
Uncertainty
in treatment situations about what is "right” in a moral sense, as
opposed to a scientific sense, is a particular conundrum for psychiatrists, I
believe, more than for other medical specialists. There are two main
reasons for this. The first is the relative isolation in which much of
psychiatry is practiced, especially after residency ends. This is
particularly true in outpatient settings (where the majority of us practice),
but even in hospitals, we often spend a large amount of time sitting alone with
individuals. Moreover, the atmosphere of confidentiality which we
necessarily generate to do our work, penetrates the patients, who are drawn into
the circle of privacy, even secrecy, engendered by this somewhat
"hermetically sealed" and typically unsupervised dyad. Though
this isolation permits us the kind of creativity we can express when we
"dance as if no one is watching," it also deprives us of the compass
that comes from the far more collaborative settings of other specialists who
work with colleagues, nurses, and other personnel in an atmosphere of more
intensive mutual feedback.
The
second reason why ethical clarity is particularly challenging for psychiatrists
is the remarkably wide variance in clinical technique, acceptable in treating
mental health problems. Our field has always been characterized by a large
number of therapies with which to engage patients. Compare, for example,
the range of approaches to treating a person who is depressed or anxious, with
the breadth of approaches to treating someone with an enlarged prostate, or
inguinal hernia. Psychiatry, almost by definition, deals directly and
specifically with what it means to be an individual. Therefore, the
well-known medical dictum of "individualizing treatment" has an
especially strong ring for us. This is one of the reasons why so many
diverse therapy approaches have evolved over the last century. However,
such a quest for individualization is an open invitation to slipping
further and further "off the reservation" of common practice, in the
name of a particular patient's individual needs. Some pundits have
remarked that there are as many different treatment techniques as there are
patients. There can be a strong sense that the touchstone for judging the
"rightness" of a particular treatment is nothing less than really
knowing this particular
patient. How do you know your patient? You treat your patient.
That means that no one can know better than you what is "right" in
working with this patient, because nobody knows your patient like you do.
So, you can end up justifying the rightness of your treatment by simply
asserting--"you had to
be there to understand
why I did this." In other words, the only way for someone to evaluate what
you are doing, is to BE you.
The
good news is that we don't have to go it alone, based on training, hunch, and
clinical intuition. Medical Ethics is now a well-developed field of serious
thought. It is characterized by an extensive literature, an agreed upon
vocabulary, specific
philosophical concepts (some of which are quite old, in our venerable profession
of Medicine), scholarly institutes in academic centers and curricula for medical
students and residents. There are
processes for formulating and resolving ethical dilemmas and for articulating
systematic arguments to support ethically-appropriate courses of action.
Future columns will address this knowledge base and these techniques.
But
first, what exactly do we mean when we say that a clinical course of action is
“ethical” or “unethical?” How
can you even be aware that you are in a situation that calls for asking that
question. For answers—stay tuned
to this column in the next issue of TMP.
Mark
Komrad M.D.
www.komrad.yourmd.com