Psychiatry - October 2008 - (Page 44)

[ethics in psychiatry] patient may remain fully competent at all times, and he may tell the psychiatrist early on in treatment that he does not want to live in this state and would rather die.12,13 Should the psychiatrist inform him that if he decides at an earlier time that the respirator should be stopped, it is more likely that he will die, but if he waits longer before the respirator is stopped, it is more likely he will survive? Should the psychiatrist explain that if the patient survives without the respirator then the only way he will be able to die is to refuse to eat? The process of dying via starvation is very different and of course will take much longer. If the psychiatrist informs the patient that he may be able to die more quickly by having the artificial respiration stopped sooner, this may result in the patient choosing this alternative when, without this infomation, he may not make this choice. If the psychiatrist does not take initiative to give the patient this information, alternatively, the patient may not make this early choice but may stay alive on the respirator longer. The longer the patient stays alive, then the more likely he may find that even in this different state, like the late Christopher Reeve, life can be meaningful and, therefore, he may want to continue to live. In a case such as this, the psychiatrist may enhance the patient’s autonomy in a different way by introducing him to other people who are quadraplegic who have found life to be meaningful. But the psychiatrist must consider that to do this too early in the treatment may pose a greater risk of demoralizing the patient. ANTICIPATING POTENTIALLY ADVERSE OUTCOMES THAT CAN BE AVOIDED Often the only way in which psychiatrists can avoid harming 44 Psychiatry 2008 [ O C T O B E R ] patients is to anticipate how an event can harm patients and then take steps to try to avoid the event before it occurs. A paradigmatic example here is genetic testing. A child and his or her parents undergo genetic screening for medical reasons. This screening results in an incidental finding of nonpaternity. Once these results are obtained, ethically, it may be difficult to determine who should be told.14,15 It is possible that if both parents are told, the psychiatrist can help them successfully respond to this new information, but this may not always be the case. However, if the psychiatrist anticipates the possibility of knowledge of nonpaternity, he or she can inform the parents before the genetic testing occurs that only the genetic findings relevant to the purpose for which they are being tested will be discussed or disclosed. This approach leaves unanswered, however, an even harder question: Should psychiatrists in this situation take initiative to inform the parents prior to the genetic testing that a finding of nonpaternity is possible, even though the psychiatrist will not share this information if this occurred? Or, should the psychiatrist take initiative to state this only if parents ask? Two considerations may most affect this decision: First, if the psychiatrist states that nonpaternity could be discovered only if parents ask, this could, in effect, discriminate between parents who are more knowledgeable or more assertive and those who are less knowledgeable or less assertive. This, ethically, would violate equity. Second, in this particular case, the paramount concern is for the child, who is the most vulnerable. This suggests that psychiatrists perhaps should not take the initiative to inform the parents of the possibility of nonpaternity, because if they do, parents might then want to find this out. A second example here is when a patient who has a fatal illness shows denial. Here, if the psychiatrist simply tells the patient that the illness is fatal, this may make the denial worse. The psychiatrist’s goal, then, is to respond in the ways that will most help the patient emotionally. This may, as a secondary effect, also help the patient overcome the denial. A psychiatrist may help this patient most by exploring his or her preferences before the likely fatality of the illness becomes known. The psychiatrist may ask the patient, for instance, whether or not that patient would want the psychiatrist to tell him or her if the illness was fatal. If the patient is not sure how to answer this, the psychiatrist then could ask the patient whether he or she wants to discuss the pros and cons of having this information. Psychiatrists using this second approach would be applying some of the principles of motivational interviewing. This approach “presupposes” that most patients change only in stages and, in this case, this approach would presuppose that if patients are “in denial,” psychiatrists should respond to the stage they are in by asking if they want to discuss the pros and cons of having versus not having this information. The psychiatrist, accordingly, should not confront or even try to persuade such patients to want to have this information. Rather, they might, ideally, even “side with the patients’ desire to not know so that it becomes the patient who is the one arguing for change.”16 Ngo-Metzger, et al., offers a superb, additional example of how care providers, early on, might best do this. They 44

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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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