by Jonathan Bauman, M.D. LFAPA, Editor
Not that I’m an expert on ethical issues, but like most of us I have faced my share of such issues in my years of practice. They often raise interesting questions and dilemmas that are challenging and thought provoking. While I’ve thought about writing on this topic for some time, I was motivated to move ahead after reading an article on the ethics of palliative care in psychiatry in the New York Times. I will get to that article after I share my thoughts on a few personal experiences, some of which you may have had.
Not long ago I asked Bard (of AI fame) to write an essay on this topic. It came up with an acceptable though typically robotic essay on ethical issues such as confidentiality, conflicts of interest, discrimination, medication over objection, and involuntary hospitalization. These issues seemed fairly mundane and, well, lacked humanity, at least as written. I then narrowed my query down to an essay on the ethics of prescribing medication for performance enhancement. This was an issue I faced many times in treating adolescents and young adult in my practice. How many of you have had a college student request Ritalin or Adderall because they were given a pill by their roommate and it really helped them focus and get their work done?
Bard assured me that this was a complex question with no easy answer. It pointed out that one issue was whether the medication was safe and effective for the desired effect. Another was whether benefits and risks were fully discussed. Well, duh, these are bread-and-butter tasks of our work. Nothing enlightening here. Bard however did get down to a more serious dilemma, i.e., what are the societal implications for promoting an advantage for some lucky individuals but not others. It did not mention the message that you’ve given to the patient by prescribing for performance enhancement, i.e., it’s okay to cheat.
Of course, when faced with evaluation of a patient for ADHD, we would do a thorough bio-psycho-social assessment to determine if, indeed, they have the disorder. The “clearly yes” and “clearly no” conclusions are fairly easy to deal with, whether you are or are not inclined to prescribe for performance enhancement. If you weren’t one who’d prescribe a stimulant for performance enhancement then, obviously, you wouldn’t in the “no”case. But if you were, then you would.
My experience was that in cases where it wasn’t so clear, I had two options, depending on my level of uncertainty, but also on the pressure/ urgency I was getting from the patient and, quite often, family. One option was to recommend psycho-diagnostic testing to help clarify the diagnosis. Because of the expense, those I suspected were looking for a “quick fix” would not usually pursue the matter, or if they did, testing would support my decision either way. Another option, for patients who could clearly not afford psych testing, was to closely follow a trial of medication to assess its effect on specific and global functioning. For those patients who were in it for the performance boost, their use would be situational, sporadic and demonstrably inappropriate.
This dilemma is similar to the issue, faced by other specialists, of prescribing GLP-1 inhibitors for weight loss. Is it truly for obesity, or is it for cosmetic enhancement? Is prescribing for vanity “fair” in terms of social equity, or is it cheating? Should insurance not pay for vanity or do we “jimmy” the system?
Another ethical issue I was faced with, not infrequently, was whether to write a letter for a patient supporting their need for an “emotional support animal”. It may seem simple enough to write a letter in support and win your patient’s gratitude, however I found such requests to be much like cheating. For example, should a patient with a mental health problem be able to reside in an apartment with a dog when others are prohibited from doing so? I had read about situations where people were getting letters to permit them to ride on the bus with turkeys or snakes that gave them “emotional support”. After all, isn’t any pet an emotional support animal? In my practice my policy was that I would not write such a letter because there were ADA guidelines accommodating “service” animals that wouldn’t require a note from me. I did lose a patient or two because of my stance.
Involuntary hospitalization of a suicidal patient is another challenge with lots of gray area between high risk and low risk patients. The ethical dilemma here is between one’s self-interest, i.e. covering ones butt to avoid getting sued, vs. exposing the patient to the negative side-effects of commitment unnecessarily. For patients who I didn’t know, or barely knew, it was easier for me to make a decision. If they were clearly not at imminent risk, then the task was to arrange for adequate follow-up outpatient treatment. If matters weren’t so clear, then they’d be held involuntarily for further evaluation and treatment as an inpatient.
But patients with whom I had an ongoing psychotherapy relationship presented a more difficult dilemma. If my patient was at imminent risk, then they’d usually follow my advice for admission, which would occur voluntarily. If I was uncertain and my patient was strongly against hospitalization (and other risk factors - impulsivity, substance abuse, social isolation - were not in play), then commitment might ease my mind but would likely destroy the therapeutic relationship. In such a case, if I were reasonably confident that the therapeutic attachment and whatever plan we made would sustain them until our next visit, I would not force involuntary hospitalization. These were the situations that would sometimes keep me up at night.
This brings me to the topic of anti-suicide contracts. Frankly, I think a written and signed contract is only done for the therapist’s comfort, under the misbegotten belief that it will stop a patient from killing themself or protect the doctor from litigation. For a patient who is a stranger, a written or verbal contract is worthless. Who or what would hold them to it? For a patient with whom you have an ongoing therapeutic relationship, it is unnecessary because it’s the ongoing work of therapy and the plan you agree upon that is sustaining, not a piece of paper. In fact, written contracts are not recommended and do not eliminate the need for careful evaluation and documentation.
My one experience with physician assisted suicide was interesting and memorable. Full disclosure…I do not oppose physician assisted suicide and, in fact, I think current state laws in the U.S. should extend the “only 6-month before expected death” rule for cases where protracted, progressive, severe disability, such as with Huntington’s Disease or ALS, can go on for years. In my case, a 75 year-old woman was brought to me in a wheel chair by her daughter. She was diagnosed with progressive supra-nuclear palsy and she and her daughter had done their homework about PSP. This woman had already lost use of her legs, but not yet her speech or her cognitive functioning. An avid hiker and reader, she could not countenance life as a vegetable.
The woman and her daughter had already been in contact with a program abroad that provided assisted suicide and had helped a relative die from some other disorder. In her situation she needed a letter from a psychiatrist testifying that she was in her right mind and not suffering from depression or another psychiatric disorder. Her internist had prescribed her an SSRI to help with her distress about her plight. The patient did not endorse any symptoms of depression, did not appear depressed, and did not think the medication was doing anything, as her daughter confirmed. I therefore agreed to write the letter reporting my findings that she was of sound mind and capable of making an informed decision about her care. She and her daughter were grateful for my help, and went on their way. I received no information about the eventual outcome. Admittedly I was a few steps removed from what I presume it was, but I don’t think I would have had any compunctions if I had been closer to the action.
Here’s what seems to me a trickier ethical issue, as outlined in the aforementioned article in the New York Times. About palliative care in psychiatry, it’s entitled, “Should Patients Be Allowed to Die From Anorexia” (NY Times Magazine,1/3/24). The article describes a woman in her 30’s who had undergone numerous courses of treatment — including inpatient (often coercive), outpatient, residential, medication — for AN and recurrent emaciation, with only transient benefit. Like most eating disordered patients, she was legally competent but tenacious in her abhorrence of food and weight gain.
Surely many of you have had adolescent anorexics who, though challenging, have made adequate recovery with standard treatments to live satisfying and productive lives. Not so with this woman, who repeatedly lost jobs and relationships because of her illness. She reminded me of some of the patients I treated at a psychiatric hospital years ago, adolescents and young adults, usually female, who had nasogastric tubes inserted (sometimes by me) for re-feeding.
Long story short, this patient finds treatment with a psychiatrist who accepts the reality that hope has its limits. He agrees to treat this miserable and hopeless woman with palliative care — that is, without coercive treatment for the natural consequences of her starvation, which would eventually lead to death. He would only use coercion if she were actively suicidal. As her psychiatrist he would offer compassion and empathy. In essence, he was giving her permission to die.
I will leave it to you, reader, to peruse the entire NY Times article. But the ethical question to be grappled with is: is an ethical psychiatrist obliged to promote hope, as we medical professional usually reflexively do, or is it ethically permissible to accept the limits of treatment and provide emotional care for patients who choose to risk dying from their illness?
