Psychiatry - October 2008 - (Page 46)

[ethics in psychiatry] my interviewing her could have resulted in her losing the custody of her child. This price would be as dear as any one could imagine. I should have warned and informed her that in my view her being open and honest would be best for both her and her child. It fortunately turned out that her use of herbs was not so improper that the other psychiatrists or I felt we had to report it. She subsequently has done well herself. As another more “generic” example, I was consulted once to see a patient who had told her psychiatrist the date on which she planned to end her life. She would not tell him how or what time she would do it. He could have hospitalized her involuntarily, but he feared that this would only make her worse. She had been hospitalized for suicide attempts many times, and now she said that if he hospitalized her again, she would “definitely” kill herself once released. I told her that I, along with her psychiatrist, would follow her case, but that I could not promise that I would not do all I could to try to hospitalize her if she continued to have this plan. I valued her life, I told her, and I had hope that she would come to value and enjoy her life in a way that she could not envision at this time. “I don’t think I could ever see you in the morning and then say good bye,” I said, “knowing that this is the day on which you said you’d kill yourself. Therefore I cannot tell you what I might do or when.” This, like telling a patient with paranoid delusions or suicidal wishes the criteria I would use to continue to hospitalize them, posed a most serious risk. Instead of continuing to divulge the day on which she planned to end her life, she might have clammed up. She 46 Psychiatry 2008 [ O C T O B E R ] might then have decided to say nothing or lie and then might have carried through her plan as she intended. However, my warning to her hopefully conveyed to her that she was too important, not only to me but perhaps to others, to just let her die. This may have ultimately increased her trust. Ultimately, she did not end her life and has thrived. This example epitomizes again the possibility that even if this patient had not benefited, giving her this warning may still have been ethically right, though the price of this could have been her ending her life. CONCLUSION I have suggested here that psychiatrists should consider respecting patients by informing, anticipating, and warning them, even when this may harm them. In forensic psychiatry, there is a hypothetical image that psychiatrists use when trying to determine whether a person who committed a criminal act had at that time an irresistible impulse. They ask themselves whether this person at this time would have committed this same crime if he or she had had a police officer at his or her elbow.26 Likewise, psychiatrists, when deciding whether or not to be more transparent to their patients, might ask what patients would do if they had the same psychiatric and legal knowledge as their psychiatrists. As any psychiatrist who has treated other psychiatrists or lawyers knows, treating others who have knowledge comparable to his or her own (like other psychiatrists and lawyers) can result in changing his or her practices with these patients. That is, when psychiatric patients have the same knowledge that their psychiatrists have regarding such facts as the criteria the psychiatirsts will use for involuntary commitment or the possiblilty that genetic testing will show nonpaternity, psychiatrists will not be tempted to hope that their patients’ not knowing these facts may contribute to an optimal result. Rather, psychiatrists, in these instances, have no choice but to depend entirely on other factors for achieving an optimal clinical outcome, such as their patients gaining greater insight and/or gaining greater trust in the psychiatrists. This way of practicing may, however, be best for treating all other patients as well. The patient/physician relationship that occurs when a psychiatrist is treating another psychiatrist or lawyer may be for this very reason not only unique but exceptionally gratifying and instructive. I believe this is because there is greater transparency in these patient/psychiatrist relationships, which makes the playing field more equal. This value may be something for which to strive when treating your nonpsychiatrist/nonlawyer patients too. REFERENCES 1. Swenson SJ, Cortese DA. Transparency and the “end result idea.” Chest. 2008;133:233–235. Bucci S, Startup M, Wynn P, et al. Referential delusions of communication and interpretations of gestures. Psychiatry Res. 2008 158:27–34. Haddock G, Tarrier N, Spaulding W, et al. Individual cognitivebehavioral therapy in the treatment of hallucinations and delusions: a review. Clin Psychol Rev. 1998;18:821–838. Ritzler BA. Paranoia—prognosis and treatment: a review. Schizophr Bull. 1981;7:710–728. Versmissen D, Janssen I, Myin- 2. 3. 4. 5. 46

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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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