Ethics and Psychiatry

Ethics and Psychiatry Richard L. Elliott, MD, PhD Professor of Psychiatry and Medicine Director. Medical Ethics Adjunct Professor Mercer University School of Law

A 65-year-old woman is brought to the ER around 10 PM in January by Macon Police after being found walking the streets in her nightie singing hymns. Records indicate she has insulin dependent diabetes mellitus. Physical examination was difficult to perform because she is refusing all medical care, but she appears very thin and her right foot is dark in color. • She insists on leaving so that she can bring the “word of the Lord” to the people. • What do you do?

Offer her food and a warm (not too hot) beverage • Negotiate for overnight stay • Offer clothing • Try to find out where she lives, any contacts • Get permission to call • 1013

Criteria for 1013 • a mentally ill person requiring involuntary treatment

BY AUTHORITY OF SECTIONS 37-3-41 AND 37-3-42, OFFICIAL CODE OF GEORGIA ANNOTATED. STATE OF GEORGIA, COUNTY OF _________________________________, GEORGIA. To Emergency Receiving Facility known as _______________________________________ and to the Peace Officer: This is to certify that I have personally examined ___________________________________________________ ___________________20___ at _________m, which has within the preceeding 48 hours of the signing of this certificate. In my opinion this person appears to be a mentally ill person requiring involuntary treatment in that he/she appears to be mentally ill AND: (a) presents a substantial risk of imminent harm to self or others as manifested by recent overt acts or recent expressed threats of violence which present a probability of physical injury to self or to other persons, or (b) appears to be so unable to care for his/her own physical health and safety as to create an imminently life-endangering crisis. At the time of my evaluation, the conditions checked below were present: This individual appears to be mentally ill. My opinion is based on the following observations:_______________________ ________________________________________________________________________________________________ Has committed recent overt acts of violence to others. For example:__________________________________________ ________________________________________________________________________________________________ Has expressed recent threats of violence towards others. For example:________________________________________ _________________________________________________________________________________________________ Has committed recent acts of violence to self. For example:_________________________________________________ ________________________________________________________________________________________________ Has expressed recent threats of violence towards self. For example:__________________________________________ ________________________________________________________________________________________________ Presents an imminently life-endangering crisis to self because he/she is so unable to care for his/her own Health and safety. For example:_______________________________________________________________________ _________________________________________________________________________________________________

What is mental illness? • "Mental illness" means a disorder of thought or mood which significantly impairs judgment, behavior, capacity to recognize reality, or ability to cope with the ordinary demands of life. • "Traumatic brain injury" means a traumatic insult to the brain and its related parts resulting in organic damage thereto which may cause physical, intellectual, emotional, social, or vocational changes in a person. It shall also be recognized that a person having a traumatic brain injury may have organic damage or physical or social disorders, but for the purposes of this chapter, traumatic brain injury shall not be considered mental illness as defined in paragraph (11) of this Code section.

What is a patient? • "Inpatient" means a person who is mentally ill and: (A)(i) Who presents a substantial risk of imminent harm to that person or others, as manifested by either recent overt acts or recent expressed threats of violence which present a probability of physical injury to that person or other persons; or (ii) Who is so unable to care for that person's own physical health and safety as to create an imminently life-endangering crisis; and (B) Who is in need of involuntary inpatient treatment. • 37-3-1. Definitions

Immunity • § 37-3-4. Immunity of physicians, peace officers, or other private or public hospital employees from liability for actions taken in good faith compliance with admission and discharge provisions of chapter Any physician, psychologist, peace officer, attorney, or health official, or any hospital official, agent, or other person employed by a private hospital or at a facility operated by the state, . . ., who acts in good faith in compliance with the admission and discharge provisions of this chapter shall be immune from civil or criminal liability for his actions in connection with the admission of a patient to a facility or the discharge of a patient from a facility.

Questions on involuntary hospitalization? • What ethical and legal concepts form the basis for involuntary treatment? • Beneficence • Parenspatriae • Police powers

What would you do? • In the EC you examine an attractive patient whom you’ve known for some time. You are members of the same church, notice she becomes tearful when you ask how she has been. You empathize, ask what’s troubling her, and she looks down. She says, after a pause, “I’d like to talk, but it would be so much easier over a cup of coffee. This just seems so impersonal in here.”

“Well, if that’s how you feel, I guess there isn’t much I can do for you.” • “Would you like for me to refer you to a psychiatrist?” • “Coffee? There’s no harm in that. How about after I finish here?” • “This does seem a bit impersonal. I am not sure I can do it right now, but how would it be if we scheduled a time in the next day or two to talk in the office.”

What would you do? • A patient of yours is a depressed 29-year-old woman, who is in the middle of a child custody battle. A officer of the court comes to your office with a subpoena demanding you turn over your medical records to the court.

You ask your receptionist to photocopy and turn over the records, noting that the court is responsible for such costs. • You refuse to turn them over, stating that until you have had time to discuss this with your patient the records are confidential (privileged).

What would you do? • A 24-year-old graduate from India is brought to the ER by his roommate, who says he is concerned Mr. Poddar has become obsessed by a female student. Mr. Poddar has begun taping his calls to the young woman, has been walking by her house several times a day, and, today, after he approached her house, she told him to go away. He became very angry, stating that “What she has done is wrong and cannot go unanswered.” Mr. Poddar is very polite, denies wishing to harm anyone, stated he came as a courtesy to his Indian roommate, and asks to leave.

Attempt to get Mr. Poddar’s permission to speak with the young lady • Notify Macon Police you cannot hold him involuntarily and ask them to contact the woman and to warn her • Proceed with involuntary hospitalization

Topics • Boundary violations • Competence and informed consent • Involuntary hospitalization and treatment • Tarasoff and the Duty to Protect • Criminal issues

Boundary Violations • Ethical principles of beneficence, non-maleficence (fiduciary relationship) • Must not misuse relationship with patient • sexual, financial • Dual relationships - who is the “patient?” • clinical vs. court-ordered vs. employer vs. …. • individual vs. family

Informed Consent • Ethical principle of autonomy • Three elements required to give informed consent • Adequate information • Competence • Voluntary

Information for Informed Consent • Information related to decision being assessed • For medical treatment: • Nature of condition, nature of proposed treatment, alternatives, risks, prognosis with and without treatment • potential conflicts of interest

Competence • Competence is ability or capacity • Competence to do what? • Final decision is legal, not medical • Level of competence is continuum • Competence expected is related to risk/benefit

Continuum of Competence • Lowest level - can communicate a decision • Decision based on rational understanding • Decision based on full appreciation

Competence and Risks/Benefits • For decision involving high risk, low or unknown benefit, level of competence should be high • For decision of low risk, high benefit, level of competence may be low

Voluntariness • Freedom from coercion

Exceptions to Informed Consent • Emergency • Advance directive • Surrogate decisionmaker • Therapeutic privilege

Involuntary Treatment • 1013 and 2013 forms for confinement to Emergency Receiving Facility • mentally ill (1013) or substance abusing (2013) • law vague about what is mental illness • Imminent danger to self • Imminent danger to others • Gravely disabled

Involuntary Treatment - II • 1013 or 2013 good for 72 hours • Must be based on personal examination • Not the same as civil commitment • 1013 or 2013 does not provide for involuntary treatment

Tarasoff and the Duty to Protect • 1974 and 1976 • Prosenjit Poddar killed Tatiana Tarasoff • Family sued University of California • Alleged therapist should have warned Tatiana • Tarasoff I “Duty to warn” • Tarasoff II “Duty to protect” • Not recognized in all states

Criminal Issues and Psychiatry • Insanity defense • At time of offense: • mentally ill • AND unable to distinguish right from wrong with respect to act • OR delusional compulsion renders unable to resist • Rare • Most often uncontested • May “serve” longer time than if pled guilty

Ethics and Psychiatry