Psychiatry - October 2008 - (Page 43)

[ethics in psychiatry] most appropriate, thus increasing transparency. For example, when patients have paranoid delusions, psychiatrists may use the content and intensity of their delusions as one criterion for deciding whether to hospitalize them involuntarily. These delusions may suggest, for instance, that these patients pose an undue risk to others. Here, psychiatrists can share with these patients that continuing to have such paranoid delusions may be a factor they consider when deciding whether to hospitalize them involuntarily or continue to keep them hospitalized. The effect of treatment transparency may be paradoxical. On the one hand, the patients, knowing the criteria for hospitalization, might then choose to not disclose their delusions. On the other hand, sharing information with patients may increase patient trust in their psychiatrists so that the patients become more willing to disclose their delusions. Sharing information with patients may also increase patient insight as with current cognitive behavioral approaches.2–5 Psychiatrists who choose to share information with patients should also no doubt tell their patients that by continuing to openly report their delusions with their psychiatrists, the patients will benefit over the long run, even if it means they have to go to or remain in the hospital for the short run. As a specific example, psychiatrists can point out that they are better able to individualize the treatment of their patients6 if they are fully aware of their patients’ delusions, and this also can help reduce the chances of patients inadvertently harming someone else. All else aside, however, sharing information with patients may be ethically “indicated” simply on the basis of respecting patient autonomy. A similar value conflict may exist when patients are suicidal. Psychiatrists will hospitalize suicidal patients involuntarily because they are a danger to themselves. When dealing with suicidal patients, however, psychiatrists may want to consider maintaining or increasing treatment transparency by informing these patients about the criteria and underlying rationales they use for continuing to hospitalize them. Psychiatrists may tell suicidal patients that they will keep them in the hospital longer, for instance, if they continue to have thoughts of paradoxically beneficial effect by increasing patient trust over the long run. One patient to whom I gave this information later told me that before I gave him full information on why he was being hospitalized and the criteria for remaining hospitalized he was planning on contesting his involuntary hospitalization in court. Hearing full disclosure from me, however, gave him what he called “unprecedented trust” in me. As a result, he said he decided not to contest his hospitalization and to “stay on” in the hospital until the psychiatrists thought that it was The effect of treatment transparency may be paradoxical. On the one hand, the patients, knowing the criteria for hospitalization, might then choose to not disclose their delusions [or suicidal thoughts]. On the other hand, sharing information with patients may increase patient trust in their psychiatrists so that the patients become more willing to disclose their delusions. suicide or have specific plans for suicide in mind. The conflict is that this information may cause patients great harm because the patients may not share suicidal thoughts in the hope of gaining an earlier release, and as a result they may take their life. Psychiatrists, accordingly, should inform suicidal patients of this risk and also of other risks they may create for themselves over the long run if they keep suicidal thoughts to themselves. Chief among these is the likely effect the early discharge will have on their families. If a suicidal patient leaves the hospital prematurely, their families may be very afraid that these patients will kill themselves at any time, regardless of how these families present themselves and regardless of how they appear. Here again, this approach with its greater transparency may have a sufficiently safe for him to be discharged. As also suggested in this example, sharing this information with patients may additionally give them beneficial insight.7–11 Again, however, whether the patient benefits in this way or in other ways or not at all, it may be that psychiatrists should share this information with their patients simply on the basis of respecting patient autonomy. There are stronger arguments in other contexts for not disclosing more information. One example of this is a patient who, after an accident, suffers acute traumatic quadriplegia. The patient’s brain damage may make it necessary for him to be on a respirator immediately, but over time his capacity to breathe on his own may improve so that he eventually can be weaned off the respirator. The [OCTOBER] Psychiatry 2008 43

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Psychiatry - October 2008 Editor’s Message Editorial Advisory Board Contents Psych Rx Treatment of Migraine and the Role of Psychiatric Medications Play Therapy: A Case-based Example of a Nondirective Approach Delirium and Antipsychotics: A Systematic Review of Epidemiologyand Somatic Treatment Options Severely Mood-disordered Youth Respond Less Well to Treatment in a Community Clinic than Youth with Bipolar Disorder Beyond Informed Consent: The Ethics of Informing, Anticipating, and Warning Asthma: Wheezing, Woes, and Worries Classified Advertising Journal Watch Information for Authors

Psychiatry - October 2008

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