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Psychiatry and Bioethics
Psychiatry and Bioethics An Exploration ofthe Relationship MAURICE D. STEINBERG, M.D.
Psychiatrists have been extensively involved in ethics in the general hospital over the past two decades and have functioned in that area in a variety of roles. The basis for psychiatry s strong interest in bioethics can be understood as related to three factors: familiarity with many ofthe clinical problems that lead to bioethics consultation. the frequent importance ofpsychiatric aspects of ethics. and the observation that psychiatrists already possess many of the clinical skills necessary for doing ethics work. The particular value of training psychiatrists to serve as ethics consultants. in addition to the importance of their continuing role on hospital ethics committees. is discussed. (Psychosomatics 1997; 38:313-320)
T
en years ago, after the first decade of experience with bioethics in the general hospital, psychiatrists began to explore their proper role in ethics. ' -5 Some authors strongly emphasized the importance of the clinical perspective psychiatry could bring to the teaching of ethics and the need for psychiatrists to be actively involved in ethics education. 2.) At that time, before ethics committees or bioethics consultants had become widely present in most hospitals, opinion was divided as to whether psychiatrists should function as ethics consultants. Some authors argued that psychiatrists were often "expected to perform the role of clinical ethicist" and that consultation-liaison (C-L) psychiatrists were especially well positioned to do SO.4 Others cautioned that psychiatrists had no special expertise in moral theory to justify serving as ethicists, although it might be appropriate for C-L psychiatrists to assist patients, families, or physicians in the process of decision making. 5 Over the last decade, CoL psychiatrists have accumulated considerable additional experience functioning in a variety of roles in bioethics in the general hospital. Many have VOLUME 38. NUMBER 4. lULY - AUGUST 1997
served as members of bioethics committees or as chairpersons of such committees. Often psychiatrists have acted as consultants to bioethics committees on specific cases or issues. A number of psychiatrists have sought additional training in ethics, ranging from intensive weeklong courses to doctoral level work, and have functioned as bioethics consultants. Psychiatric achievements in ethics include the founding of a major ethics journal (the Journal of Clinical Ethics), a preeminent ethics institute (The Hastings Center), and the presidency of an important association ofbioethic consultants (The Society of Bioethics Consultants) (personal communication, S. Youngner). Clearly, many psychiatrists have found bioethics work to be very rewarding and have fulfilled a number of important roles in the field. But while bioethics work has had obvious Received August 14. 1996; accepted November 21. 1996. From the Division of Consultation-Liaison Psychiatry. Long Island Jewish Medical Center. 270-05 76th Avenue. Suite C-46. New Hyde Park. New York 11040. Address reprint requests to Dr. Steinberg. Copyright © 1997 Academy of Psychosomatic Medicine.
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appeal to psychiatrists, the basis for this affinity has been largely unexplored. 6 The purpose of this paper is to address some of the factors that account for psychiatry's extensive involvement in ethics. Examination of these influences will underscore the importance of the contribution psychiatrists make to ethics. While strongly supporting the role of psychiatrists on ethics committees, attention will be drawn to the value of psychiatrists serving more extensively as trained ethics consultants. This latter role seems to be a natural consequence of the nature of the relationship between psychiatric work and ethics consultation in the general hospital. The strong interest of psychiatrists in ethics work, and the particular importance of their involvement in it, derives from the folIowing factors: I) psychiatrists have historicalIy, and currently, been extensively involved in the clinical problems that constitute most ethics consultations; 2) the special nature of psychiatric aspects of bioethics problems; and 3) many of the necessary skills of the bioethicist are similar to those of the C-L psychiatrist who has been specifically trained in these areas. These observations will now be elaborated. 1) Psychiatrists have historically, and currently, been extensively involved in the clinical problems that constitute most ethics consultations. Although the scope of bioethics in medicine has expanded greatly. most cases referred to ethics consultants or committees involve conflicts over treatment and are related to the original mandate for ethics in the general hospital. "to protect and foster shared decisionmaking in the clinical setting:,7 Most commonly, ethics consultation currently involves problems of informed consent related to treatment decisions. The subject of informed consent, according to Beauchamp and Childress. has "probably received more attention than any other issue in biomedical ethics.,,8 The major reason for such interest in informed consent is because it has as its primary function "protecting and enabling individual autonomous choices" by patients, a cornerstone of bioethics, and the gold standard for medical 314
decisionmaking. 8 The majority of ethics consultations involving treatment issues specifically entail decisions about medical treatment at the end of life and especialIy choices to limit care. Several studies have documented that most of the cases seen by their ethics consultation services entailed conflict over limiting treatment. 9 . IO One active bioethics committee in a tertiary care academic center has found that 90% of the ethics consultations it does each month involve end-of-Iife decisions (personal communication, S. Fleishman), The major focus by ethicists on ensuring the adequacy and autonomy of patient decisionmaking has helped develop the prerequisite features of informed consent-that the patient is competent to make a voluntary decision, based upon sufficient information provided in a clear manner. While some see a key role today for ethics in medicine, as the "guardian of informed consent," problems involving informed consent have been a major focus of C-L psychiatry since its inception. In fact, addressing problems arising from patient decisions about treatment has been one of the central roles of the C-L psychiatrist, especialIy when these decisions have led to conflict among patients' families, physicians, or other caretakers. Sider has described a tendency by ethics consultants to see informed consent as a very rational, linear process involving autonomous parties engaged in logical discourse about treatment decisions. 2 A related view of informed consent, known as the event model, in which obtaining consent is seen as a series of stepwise decisions made at specific times, is prevalent among physicians and patients. II Both of these views fail to recognize, however, that informed consent depends strongly on certain interpersonal and intrapsychic conditions for it to occur, such as mutual trust, empathic and compassionate attitudes and behavior, and the capacity for clear communication. The emotionalIy charged experiences of illness and hospitalization can easily interfere with these necessary conditions. As a result, problems surrounding informed medical decisionmaking are common in the general hospital, often leading PSYCHOSOMATICS
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to psychiatric consultation. Most commonly, these problems have presented as patients' refusal of invasive diagnostic procedures, active treatments such as surgery, or life-sustaining interventions such as mechanical ventilation. In addition, conflicts over treatment that lead to psychiatric consultation have involved demands to sign out "against medical advice," problems of compliance, or denial of illness. In recent years, psychiatric consultations for problems arising from patient choices regarding treatment have most commonly involved end-of-life treatment decisions. Psychiatrists have been extensively involved in issues surrounding "do not resuscitate" orders,I2-17 withdrawal of medical treatment,18-22 the provision of medicalIy futile treatment,23.24 and physician-assisted suicide and euthanasia. 25 -32 The primary responsibilities of the psychiatrist in conflicts over medical treatment have been to evaluate the patient's capacity for medical decisionmaking and to correct diminished capacity by treating any reversible mental disorder responsible for it. Psychiatric intervention for patients refusing treatment often leads to a resolution of the treatment refusal, whether the patient was competent or incompetent. 33 In the past, the refusal of treatment was often seen as a psychiatric problem and was addressed in terms of its psychiatric, legal, and administrative aspects. With the recognition of the importance of ethical issues in patient decisionmaking, conflict over treatment choices may now be viewed primarily as an ethical problem, with consultation sought first from an ethicist rather than from a psychiatrist.34 However, generally, clinical responsibility for competence evaluation has remained a medical responsibility and administratively, usualIy, still a psychiatrist's responsibility. But now psychiatric competency evaluations in bioethic cases are often carefulIy scrutinized by clinicians, bioethicists, lawyers, and patient advocates, whose views of competence do not entirely coincide with those of psychiatrists. The former will generally readily accept major psychopathology, such as a VOLUME 38 • NUMBER 4. JULY - AUGUST 1997
dementia, major depression, or psychosis, as a legitimate basis for a lack of capacity; however, they frequently question the relevance of less severe Axis I disorders, Axis II personality disorder influences, or psychodynamic issues, to such decisions, because of a concern about psychiatrists' "pathologizing" patients' decisionmaking. Psychiatrists clearly have a broader perspective on factors influencing autonomous decision making in patients than most other professionals involved in specific cases. The psychiatric view incorporates the wide range of conscious and unconscious emotional and psychosocial factors, known by psychiatrists to affect the treatment decisions of patients, families, or physicians, especialIy at the end of life. Increasingly, psychiatrists believe that alI end-of-life treatment decisions, especialIy, have emotional components to them and that particularly when the patient seeks to hasten death, these factors need to be carefulIy understood. 35 Besides their role in evaluating competency in conflicts over treatment, C-L psychiatrists have been frequently involved in assessing other problems with informed consent as welI, particularly in difficulties arising from inadequate communication among patient, family, and physician. Physicians' difficulties in truth telling or disclosure of diagnosis, such as cancer, in particular, have been the subject of considerable attention from psychiatrists. 36 In the U.S., although physician attitudes have generally changed toward more open discussion of 7 the diagnosis in recent years/ conflicts in this area still occur, leading to psychiatric consultation. In a similar manner, although concerns about liability and an increased awareness of ethical obligation to the patient have led to greater openness by physicians about treatments, problems in disclosure of risks and benefits of treatment still arise. The vital importance of timely and clear communication between physician and the patient or family about treatment options has been especially evident in end-of-life decisions. 38 But the difficulty in altering physician behavior to produce earlier and more open discussion about treatments at the end of life has been clearly demonstrated. 39 C-L 315
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psychiatrists are often involved in consultations arising from such difficulties and have begun to address the problems underlying them. 38 Some have shown that physicians' readiness to discuss end-of-life issues is related to their comfort with their own mortality.40 Facilitating communication between physicians and patients or families has long been a major activity for C-L psychiatrists in their liaison role in the general hospital and in their teaching of clinical interview skills to house staff and physicians. 4 \ 2) The psychiatric aspects of bioethics problems have a special nature. The extensive involvement of psychiatrists in bioethics. and the particular value in their serving as bioethics consultants. is strongly related to the role of emotional and psychiatric factors in ethics problems. Although the psychiatric aspects of ethics cases vary in their importance from patient to patient. their role is often substantial and sometimes critical. The latter applies to those apparent ethical conflicts for which consultation has been sought. which are actually due to underlying emotional factors. In such cases. viewing the difficulty as an ethical dilemma. "masks" or disguises the "true" emotional nature of the problem. 34 Recognition of the emotional or psychiatric factors in such patients is essential to the correct understanding and resolution of the seeming ethical conflict. This scenario is especially common in problems arising around end-of-life treatment decisions because of the particular importance of emotional factors in such decisionmaking. 35 Examples of such problems include patients whose wish to forego treatment or hasten death is primarily due to excessive fears of dependency or helplessness. guilt over burdening their family. or anxiety over the process of dying itself. A focus on the patients' right to refuse treatment or the acceptance of the patients' choice at face value can obscure the key emotional determinants of the patients' decision. In other clinical problems presenting for ethics consultation. psychiatric issues may be one important aspect of the case. along with ethical. legal. religious. and other issues. 316
Lederberg has described the "confluence" of psychiatric. ethical. and legal issues in oncology patients and the importance of recognizing the contribution of each factor to the presenting clinical problem. 42 Psychiatric issues commonly acting as contributing factors to ethical difficulties are the personality style. psychodynamic issues. or psychopathology of the patient; family dysfunction; interpersonal conflict between patient. family. and physician; or the countertransference reactions of physicians to patients or families. Where psychiatric issues such as these contribute to the ethical problem and go unrecognized. resolution of the difficulty is often incomplete or hard to achieve. Strain has emphasized that the crucial issue in understanding ethical problems is the importance of distinguishing between latent versus manifest feelings in patients. He argues that this distinction is the "crux of many. if not most. of the ethical problems presenting to the consulting psychiatrist. ,,43 Although psychiatrists involved in ethics cases are especially likely to emphasize the role of emotional factors in such cases. ethicists vary considerably in the importance they attach to the emotional aspects of ethical problems. Some ethicists view emotional issues as one of the "contextual" features of ethics cases. along with the legal. social. economic. religious. insti44 tutional. and financial factors. More commonly. while ethicists accept the importance of legal. cultural. religious. and other factors in ethics problems. they are mistrustful or ambivalent about the role of psychiatric issues and may disregard them. As previously indicated. they regard the psychiatric perspective as likely to "medicalize" or "pathologize" issues they believe are most likely to be resolved through a focus on universally derived moral principles. Where such attitudes prevail. psychiatric consultation is rarely sought. except in the presence of overt. major psychopathology. The lack of attention to emotional factors is especially problematic in end-of-life treatment conflicts. where an understanding of issues such as the normal psychology of terminal illness is especially important to resolve ethical problems. A PSYCHOSOMATICS
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variety of difficulties surrounding terminal care result from this inattention and from too exclusive a focus on the ethical aspects of end-of-Iife treatment decisions. Hospital requirements that patients give written permission for "do not resuscitate" orders, for example, while legally and ethically appropriate, make patients feel they are signing their own death warrants. Understanding the role of "executioner's guilt," that some families feel in signing papers to forego treatment for relatives, or making such decisions, can be critically important in facilitating surrogate decisionmaking. Although withdrawing medical treatment is seen as morally identical to withholding it by ethicists, in reality withdrawing medical treatment feels very different to many physicians. The public's relatively low level of support for advance directives reflects the fears many people have of confronting death, which "trump" exercises in patient autonomy for many. Clearly addressing feelings and emotional states surrounding end-of-life treatment choices can enhance ethically informed policies and decisionmaking. The psychiatrist, as ethics consultant, is especially likely to be able to do so.
3) Many of the necessary skills of the bioethicist are similar to those of the CaL psychiatrist who has been specifically trained in these areas. Ethicists distinguish the content of ethics consultation, the facts of the case, from the process of consultation work, which is the means by which the consultant applies his knowledge to resolve the presenting problem. 4s Eliciting the content of the ethics consultation entails identifying and analyzing the ethical (and other) questions and issues pertinent to the case. As with psychiatric consultation, however, recognizing the nature of the clinical problem is generally considerably less difficult than resolving the issues, which requires a wide range of clinical skills and abilities by the consultant. The ethicist's effectiveness as a consultant and value as a clinical colleague depends to a large extent on the mastering of these abilities. Many of these skills are similar to those of the C-L psychiatrist and are essential aspects of doing VOLUME 38. NUMBER 4. JULY - AUGUST 1997
C-L psychiatry in the general hospital. Ethical problems arise classically from conflict between competing ethical principles. Practically speaking, such ethical problems often involve conflict in values, attitudes, or behavior between patients, families, physicians, and institutions, as when the staff or hospital attorney disagree with patients' or families' decisions about treatment. Like the C-L psychiatrist, the first responsibility of the ethics consultant is to the patient, and, like the C-L psychiatrist, the ethics consultant must often represent the patient's needs to the other parties involved in the patient's care. The ethicist must be able to clarify the issues of the case, set priorities in approaching them, and bridge the gap between those with differing positions. 46 Clarification of problems requires especially the ability to listen empathically and nonjudgmentally, so as to elicit the facts of the case, while weighing multiple, complex, and often competing issues and concerns. The ethicist must have strong communication skills to interpret or explain the conflicting moral values of the patient, family, physician, or institution to each other. These different positions held by various parties to the conflictual situation need to be resolved through the ethicist's use of skills in conflict resolution, mediation, and negotiation. 47 These include finding acceptable compromises emphasizing common interests instead of opposing positions, while being aware of the needs and interpersonal sensitivities of the various participants. 46 Clearly, many of the skills required by the ethics consultant to resolve ethical problems are identical to those used by the C-L psychiatrist in consultative and liaison work. Many C-L consultations in the general hospital are for emotional problems that either result from or produce conflict between the patient and staff. The C-L psychiatrist identifies the nature and cause of such difficulties, relying extensively on interviewing skills to gather data in the often emotionally charged clinical situation. As Lipowski has written, the C-L psychiatrist "mediates conflicts between patients and staff ... interpreting attitudes and behavior of patients 317
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and staff in an attempt to maintain communication and cooperation to allay conflicts between them.,,48 Success in doing so depends on the psychiatrist's ability to establish a trusting, working alliance with all parties, as is the case for a good outcome in ethics consultation as well. The C-L psychiatrist's liaison skills in establishing himself or herself as a welcome ongoing presence on the ward, are identical to those required by an ethics consultant wishing to be seen as a helpful member of the clinical team, with appropriate credibility. Working with family members, and the understanding of family dynamics, is important to both ethics and psychiatric consultation. Both consultation roles also require an extensive knowledge of hospital administrative and power structure and the ability to work with the wide range of personnel involved in patient care. Both ethics and C-L psychiatric consultation are often very labor intensive and require considerable patience and deliberation in resolving issues. The C-L psychiatrist, however, receives extensive training and experience in most of the above techniques during residency, or fellowship, whereas the bioethics consultant often receives little if any specific training in these skills. No formal or standardized requirements in fact exist currently regarding the training of ethics consultants. As a result, ethics consultants' ability to resolve interpersonal conflict, communicate effectively, or demonstrate the other skills necessary for their clinical work in the general hospital may vary widely. CONCLUSION Psychiatrists are likely to continue to be drawn to ethics work for various reasons, including especially the factors described above. At this point, the majority of psychiatrists involved in ethics function as members or chairs ofethics committees. The particular value of the psychiatrist's presence on ethics committees has been well described by others6 and follows from the observations described above. It is currently also the subject of ongoing empirical study by the Academy of Psychosomatic Medi318
cine's Task Force on The Role of the Psychiatrist on Hospital Ethics Committees. Psychiatrists are likely to continue to be widely sought after for involvement on ethics committees, especially if legally sanctioned physician-assisted suicide becomes an issue for ethics committees to deal with. However, psychiatrists are particularly well suited to function in the distinct role of ethics consultant as well, because of the close relationship between some aspects of C-L psychiatry and ethics work. Although some have called for ethics consultants to be taught psychiatric skills so they can intervene effectively,34 ethicists construe the relevance of psychiatric issues and skills somewhat narrowly.45.46 The possibility that psychiatric skills can be taught to ethics consultants who view their relevance to ethics in a very limited way seems questionable. It seems more practical and effective for psychiatrists to assume a greater role as ethics consultants, with additional training in moral theory and the clinical bioethics curriculum. In this way, the relevance of psychiatric issues and skills to ethics work can be integrated more readily into clinical bioethics practice, and the care of patients with ethical problems can be significantly enhanced.
References
I. Stone A: Law, Psychiatry and Morality. Washington, DC, American Psychiatric Press, 1984 2. Sider RC, Clements C: Psychiatry's contribution to medical ethics education. Am J Psychiatry 1982: 139:498-501 3. McCartney JR: Consultation-liaison psychiatry and the teaching of ethics. Gen Hosp Psychiatry 1986: 8:411414 4. Hayes JR: Consultation-liaison psychiatry and clinical ethics: a model for consultation and teaching. Gen Hosp Psychiatry 1986: 8:415-418 5. Perl MB: Response to the articles "Consultation-Liaison Psychiatry and the Teaching of Ethics" by JR McCartney and "Consultation-Liaison Psychiatry and Clinical Ethics" by JR Hayes. Gen Hosp Psychiatry 1986: 8:419-421 6. Engel CC: Psychiatrists and the hospital ethics committee. Gen Hosp Psychiatry 1992: 14:29-35 7. President's Commission for the Study of Ethical Prob-
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lems in Medicine and Biomedical and Behavioral Research, Making Health Care Decisions: The Ethical and Legal Implication of Informed Consent in the Patient-Practitioner Relationship. Washington, DC, U.S. Government Printing Office. 1982 8. Beauchamp TL, Childress JF (eds): Principles of Biomedical Ethics. Third Edition. New York, Oxford, 1989 9. Perkins HS. Soothoff BI: Impact of medical ethics consultations on physicians: an exploratory study. Am J Med 1988; 85:761-765 10. LaPuma J, Stocking CB, Silverstein MD. et al: An ethics consultation service in a teaching hospital: utilization and evaluation. JAMA 1988; 260:808-811 II. Applebaum PS, Lidy CW. Maisel A: Informed Consent: Legal Theory and Clinical Practice. New York, Oxford University Press. 1987 12. Owen C. Tennant C, Levi J, et al: Resuscitation: patient and staff attitudes in the context of cancer. Gen Hosp Psychiatry 1992; 14:327-333 13. Muslin H. Schade S: On the do not resuscitate policy. Perspect Bioi Med 1988; 31:285-290 14. Karlinsky H, Taerk G. Schwanz K, et al: Suicide attempts and resuscitation di lemmas. Gen Hosp Psychiatry 1988; 10:423-427 15. Sullivan MD, Ward NG, Laxton A: The woman who wanted electroconvulsive therapy and do not resuscitate status. Gen Hosp Psychiatry 1992; 14:204-209 16. Ganzini L. Lee MA, Heintz RT, et al: Do not resuscitate orders for depressed psychiatric inpatients. Hosp Community Psychiatry 1992; 43:915-919 17. Swanz CM, Stewart C: Melancholia and orders to restrict resuscitation. Hosp Community Psychiatry 1991; 42:189-191 18. Sullivan MD. Youngner SJ: Depression. competence and the right to refuse lifesaving medical treatment. Am J Psychiatry 1994; 151:971-978 19. Cassem NH (ed): The dying patient, in The Massachusetts General Hospital Handbook of General Hospital Psychiatry. Third Edition. St. Louis. Mosby Year Book, 1991, pp. 343-371 20. Rodin GM, Chara J, Ennis J, et al: Stopping life sustaining treatment: psychiatric considerations in the termination of renal dialysis. Can J Psychiatry 1981; 26:540-544 21. Cohen L, Germain M. Woods A, et al: Patient attitudes and psychological considerations in dialysis discontinuation. Psychosomatics 1993; 34:399-401 22. Gonda T, Ruark J: Dying dignified. The Health Professionals Guide to Care. California, Addison-Wesley, 1984 23. Youngner SJ: Who defines futility? JAMA 1988; 260:2094-2095 24. Youngner SJ: Futility in context. JAMA 1990; 264: 1295-1296 25. Conwell T. Caine ED: Rational suicide and the right to die-reality and myth. N Engl J Med 1991; 325:1100-1102 26. Block SO. Billings JA: Patient requests for euthanasia and assisted suicide for terminal illness: the role of the
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psychiatrist. Psychosomatics 1995; 36:445-457 27. Block SO. Billings JA: Patient requests to hasten death: evaluation and management in terminal care. Arch Intern Med 1994; 154:2039-2047 28. Hendin H, Klerman G: Physician assisted suicide: the dangers of legalization. Am J Psychiatry 1993; 150: 143-145 29. Hendin H: Selling death and dignity. Hastings Center Repon 1995; 25:19-27 30. Huyse FJ, van Tilburg W: Euthanasia policy in the Netherlands: the role of consultation-liaison psychiatrists. Hosp Community Psychiatry 1993; 44:733-738 31. Huyse FJ. van Tilburg W. Klijn L, et al: Consultationliaison psychiatrists and euthanasia in the Netherlands. Psychiatr Bull 1994; 18:495-500 32. Baile WF. DiMaggio JR, Schapiradv. et al: The request for assistance in dying: the need for psychiatric consultation. Cancer 1993; 72:2786-2791 33. Katz M, Abbey S. Rydall A. et al: Psychiatric consultation for competency to refuse medical treatment: a retrospective study of patient characteristics and outcome. Psychosomatics 1995; 36:33-41 34. Leeman C: Ethics consultation masking psychiatric issues in medicine. ArchInternMed 1995; 155:1715-1717 35. Steinberg M, Youngner 5 (eds): Psychiatry and End-ofLife Decisions. Washington, DC, American Psychiatric Press (in press) 36. Oken 0: What to tell cancer patients: a study of medical attitudes. JAMA 1961; 1120-1128 37. Novack DH, Plumer R. Smith RL, et al: Changes in physician attitudes toward telling the cancer patient. JAMA 1979; 241:897-900 38. Morrison M: Obstacles to patient-physician communication, in Psychiatry and End-of-Life Decisions. Washington. DC, American Psychiatric Press. in press 39. The SUPPORT Principal Investigators: A controlled trial to improve care for seriously ill hospitalized patients. JAMA 1995; 274: 1591-1598 40. Steinberg MD. Gitman P, Hotchkiss E. et al: Physician attitudes towards advance directives. Paper presented at the American Psychiatric Association Annual Meeting,1994 41. Cole S: The Medical Interview: The Three Function Approach. St. Louis, MO. Mosby. 1991 42. Lederberg M: The confluence of psychiatry. the law. and ethics. Handbook of Psychooncology: Psychological care of the patient with cancer, edited by Holland JC, Rowland JH. New York, Oxford University Press, 1989. pp.694-702 43. Strain JJ. Rhodes R, Moros DA. et al: Ethics in medicalpsychiatric practice. in Medical-Psychiatric Practice. edited by Stoudemire A. Fogel BS. Washington. DC, American Psychiatric Press, 1993. Vol 2. pp. 585-{j()7 44. Jonsen AR, Siegler M, Winslade W: Clinical Ethics, Third Edition. New York, McGraw Hill, 1992 45. Thornton BC, Callahan 0, Nelson JL: Bioethics education: expanding the circle of participants. Hastings Cent Rep 1993; 23:25-29
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46. LaPuma J. Schiedennayer DL: Ethics consultation: skills. roles and training. Ann Intern Med 1991; 114: 155-160 47. Dubler NN. Marcus U: Mediating bioethical disputes.
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New York. United Hospital Fund, 1994 48. Lipowski ZJ: Consultation-liaison psychiatry: an overview. Am J Psychiatry 1974; 131 :623-630
PSYCHOSOMATICS
Psychiatrists have been extensively involved in ethics in the general hospital over the past two decades and have functioned in that area in a variety of roles. The basis for psychiatry s strong interest in bioethics can be understood as related to three factors: familiarity with many ofthe clinical problems that lead to bioethics consultation. the frequent importance ofpsychiatric aspects of ethics. and the observation that psychiatrists already possess many of the clinical skills necessary for doing ethics work. The particular value of training psychiatrists to serve as ethics consultants. in addition to the importance of their continuing role on hospital ethics committees. is discussed. (Psychosomatics 1997; 38:313-320)
T
en years ago, after the first decade of experience with bioethics in the general hospital, psychiatrists began to explore their proper role in ethics. ' -5 Some authors strongly emphasized the importance of the clinical perspective psychiatry could bring to the teaching of ethics and the need for psychiatrists to be actively involved in ethics education. 2.) At that time, before ethics committees or bioethics consultants had become widely present in most hospitals, opinion was divided as to whether psychiatrists should function as ethics consultants. Some authors argued that psychiatrists were often "expected to perform the role of clinical ethicist" and that consultation-liaison (C-L) psychiatrists were especially well positioned to do SO.4 Others cautioned that psychiatrists had no special expertise in moral theory to justify serving as ethicists, although it might be appropriate for C-L psychiatrists to assist patients, families, or physicians in the process of decision making. 5 Over the last decade, CoL psychiatrists have accumulated considerable additional experience functioning in a variety of roles in bioethics in the general hospital. Many have VOLUME 38. NUMBER 4. lULY - AUGUST 1997
served as members of bioethics committees or as chairpersons of such committees. Often psychiatrists have acted as consultants to bioethics committees on specific cases or issues. A number of psychiatrists have sought additional training in ethics, ranging from intensive weeklong courses to doctoral level work, and have functioned as bioethics consultants. Psychiatric achievements in ethics include the founding of a major ethics journal (the Journal of Clinical Ethics), a preeminent ethics institute (The Hastings Center), and the presidency of an important association ofbioethic consultants (The Society of Bioethics Consultants) (personal communication, S. Youngner). Clearly, many psychiatrists have found bioethics work to be very rewarding and have fulfilled a number of important roles in the field. But while bioethics work has had obvious Received August 14. 1996; accepted November 21. 1996. From the Division of Consultation-Liaison Psychiatry. Long Island Jewish Medical Center. 270-05 76th Avenue. Suite C-46. New Hyde Park. New York 11040. Address reprint requests to Dr. Steinberg. Copyright © 1997 Academy of Psychosomatic Medicine.
313
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appeal to psychiatrists, the basis for this affinity has been largely unexplored. 6 The purpose of this paper is to address some of the factors that account for psychiatry's extensive involvement in ethics. Examination of these influences will underscore the importance of the contribution psychiatrists make to ethics. While strongly supporting the role of psychiatrists on ethics committees, attention will be drawn to the value of psychiatrists serving more extensively as trained ethics consultants. This latter role seems to be a natural consequence of the nature of the relationship between psychiatric work and ethics consultation in the general hospital. The strong interest of psychiatrists in ethics work, and the particular importance of their involvement in it, derives from the folIowing factors: I) psychiatrists have historicalIy, and currently, been extensively involved in the clinical problems that constitute most ethics consultations; 2) the special nature of psychiatric aspects of bioethics problems; and 3) many of the necessary skills of the bioethicist are similar to those of the C-L psychiatrist who has been specifically trained in these areas. These observations will now be elaborated. 1) Psychiatrists have historically, and currently, been extensively involved in the clinical problems that constitute most ethics consultations. Although the scope of bioethics in medicine has expanded greatly. most cases referred to ethics consultants or committees involve conflicts over treatment and are related to the original mandate for ethics in the general hospital. "to protect and foster shared decisionmaking in the clinical setting:,7 Most commonly, ethics consultation currently involves problems of informed consent related to treatment decisions. The subject of informed consent, according to Beauchamp and Childress. has "probably received more attention than any other issue in biomedical ethics.,,8 The major reason for such interest in informed consent is because it has as its primary function "protecting and enabling individual autonomous choices" by patients, a cornerstone of bioethics, and the gold standard for medical 314
decisionmaking. 8 The majority of ethics consultations involving treatment issues specifically entail decisions about medical treatment at the end of life and especialIy choices to limit care. Several studies have documented that most of the cases seen by their ethics consultation services entailed conflict over limiting treatment. 9 . IO One active bioethics committee in a tertiary care academic center has found that 90% of the ethics consultations it does each month involve end-of-Iife decisions (personal communication, S. Fleishman), The major focus by ethicists on ensuring the adequacy and autonomy of patient decisionmaking has helped develop the prerequisite features of informed consent-that the patient is competent to make a voluntary decision, based upon sufficient information provided in a clear manner. While some see a key role today for ethics in medicine, as the "guardian of informed consent," problems involving informed consent have been a major focus of C-L psychiatry since its inception. In fact, addressing problems arising from patient decisions about treatment has been one of the central roles of the C-L psychiatrist, especialIy when these decisions have led to conflict among patients' families, physicians, or other caretakers. Sider has described a tendency by ethics consultants to see informed consent as a very rational, linear process involving autonomous parties engaged in logical discourse about treatment decisions. 2 A related view of informed consent, known as the event model, in which obtaining consent is seen as a series of stepwise decisions made at specific times, is prevalent among physicians and patients. II Both of these views fail to recognize, however, that informed consent depends strongly on certain interpersonal and intrapsychic conditions for it to occur, such as mutual trust, empathic and compassionate attitudes and behavior, and the capacity for clear communication. The emotionalIy charged experiences of illness and hospitalization can easily interfere with these necessary conditions. As a result, problems surrounding informed medical decisionmaking are common in the general hospital, often leading PSYCHOSOMATICS
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to psychiatric consultation. Most commonly, these problems have presented as patients' refusal of invasive diagnostic procedures, active treatments such as surgery, or life-sustaining interventions such as mechanical ventilation. In addition, conflicts over treatment that lead to psychiatric consultation have involved demands to sign out "against medical advice," problems of compliance, or denial of illness. In recent years, psychiatric consultations for problems arising from patient choices regarding treatment have most commonly involved end-of-life treatment decisions. Psychiatrists have been extensively involved in issues surrounding "do not resuscitate" orders,I2-17 withdrawal of medical treatment,18-22 the provision of medicalIy futile treatment,23.24 and physician-assisted suicide and euthanasia. 25 -32 The primary responsibilities of the psychiatrist in conflicts over medical treatment have been to evaluate the patient's capacity for medical decisionmaking and to correct diminished capacity by treating any reversible mental disorder responsible for it. Psychiatric intervention for patients refusing treatment often leads to a resolution of the treatment refusal, whether the patient was competent or incompetent. 33 In the past, the refusal of treatment was often seen as a psychiatric problem and was addressed in terms of its psychiatric, legal, and administrative aspects. With the recognition of the importance of ethical issues in patient decisionmaking, conflict over treatment choices may now be viewed primarily as an ethical problem, with consultation sought first from an ethicist rather than from a psychiatrist.34 However, generally, clinical responsibility for competence evaluation has remained a medical responsibility and administratively, usualIy, still a psychiatrist's responsibility. But now psychiatric competency evaluations in bioethic cases are often carefulIy scrutinized by clinicians, bioethicists, lawyers, and patient advocates, whose views of competence do not entirely coincide with those of psychiatrists. The former will generally readily accept major psychopathology, such as a VOLUME 38 • NUMBER 4. JULY - AUGUST 1997
dementia, major depression, or psychosis, as a legitimate basis for a lack of capacity; however, they frequently question the relevance of less severe Axis I disorders, Axis II personality disorder influences, or psychodynamic issues, to such decisions, because of a concern about psychiatrists' "pathologizing" patients' decisionmaking. Psychiatrists clearly have a broader perspective on factors influencing autonomous decision making in patients than most other professionals involved in specific cases. The psychiatric view incorporates the wide range of conscious and unconscious emotional and psychosocial factors, known by psychiatrists to affect the treatment decisions of patients, families, or physicians, especialIy at the end of life. Increasingly, psychiatrists believe that alI end-of-life treatment decisions, especialIy, have emotional components to them and that particularly when the patient seeks to hasten death, these factors need to be carefulIy understood. 35 Besides their role in evaluating competency in conflicts over treatment, C-L psychiatrists have been frequently involved in assessing other problems with informed consent as welI, particularly in difficulties arising from inadequate communication among patient, family, and physician. Physicians' difficulties in truth telling or disclosure of diagnosis, such as cancer, in particular, have been the subject of considerable attention from psychiatrists. 36 In the U.S., although physician attitudes have generally changed toward more open discussion of 7 the diagnosis in recent years/ conflicts in this area still occur, leading to psychiatric consultation. In a similar manner, although concerns about liability and an increased awareness of ethical obligation to the patient have led to greater openness by physicians about treatments, problems in disclosure of risks and benefits of treatment still arise. The vital importance of timely and clear communication between physician and the patient or family about treatment options has been especially evident in end-of-life decisions. 38 But the difficulty in altering physician behavior to produce earlier and more open discussion about treatments at the end of life has been clearly demonstrated. 39 C-L 315
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psychiatrists are often involved in consultations arising from such difficulties and have begun to address the problems underlying them. 38 Some have shown that physicians' readiness to discuss end-of-life issues is related to their comfort with their own mortality.40 Facilitating communication between physicians and patients or families has long been a major activity for C-L psychiatrists in their liaison role in the general hospital and in their teaching of clinical interview skills to house staff and physicians. 4 \ 2) The psychiatric aspects of bioethics problems have a special nature. The extensive involvement of psychiatrists in bioethics. and the particular value in their serving as bioethics consultants. is strongly related to the role of emotional and psychiatric factors in ethics problems. Although the psychiatric aspects of ethics cases vary in their importance from patient to patient. their role is often substantial and sometimes critical. The latter applies to those apparent ethical conflicts for which consultation has been sought. which are actually due to underlying emotional factors. In such cases. viewing the difficulty as an ethical dilemma. "masks" or disguises the "true" emotional nature of the problem. 34 Recognition of the emotional or psychiatric factors in such patients is essential to the correct understanding and resolution of the seeming ethical conflict. This scenario is especially common in problems arising around end-of-life treatment decisions because of the particular importance of emotional factors in such decisionmaking. 35 Examples of such problems include patients whose wish to forego treatment or hasten death is primarily due to excessive fears of dependency or helplessness. guilt over burdening their family. or anxiety over the process of dying itself. A focus on the patients' right to refuse treatment or the acceptance of the patients' choice at face value can obscure the key emotional determinants of the patients' decision. In other clinical problems presenting for ethics consultation. psychiatric issues may be one important aspect of the case. along with ethical. legal. religious. and other issues. 316
Lederberg has described the "confluence" of psychiatric. ethical. and legal issues in oncology patients and the importance of recognizing the contribution of each factor to the presenting clinical problem. 42 Psychiatric issues commonly acting as contributing factors to ethical difficulties are the personality style. psychodynamic issues. or psychopathology of the patient; family dysfunction; interpersonal conflict between patient. family. and physician; or the countertransference reactions of physicians to patients or families. Where psychiatric issues such as these contribute to the ethical problem and go unrecognized. resolution of the difficulty is often incomplete or hard to achieve. Strain has emphasized that the crucial issue in understanding ethical problems is the importance of distinguishing between latent versus manifest feelings in patients. He argues that this distinction is the "crux of many. if not most. of the ethical problems presenting to the consulting psychiatrist. ,,43 Although psychiatrists involved in ethics cases are especially likely to emphasize the role of emotional factors in such cases. ethicists vary considerably in the importance they attach to the emotional aspects of ethical problems. Some ethicists view emotional issues as one of the "contextual" features of ethics cases. along with the legal. social. economic. religious. insti44 tutional. and financial factors. More commonly. while ethicists accept the importance of legal. cultural. religious. and other factors in ethics problems. they are mistrustful or ambivalent about the role of psychiatric issues and may disregard them. As previously indicated. they regard the psychiatric perspective as likely to "medicalize" or "pathologize" issues they believe are most likely to be resolved through a focus on universally derived moral principles. Where such attitudes prevail. psychiatric consultation is rarely sought. except in the presence of overt. major psychopathology. The lack of attention to emotional factors is especially problematic in end-of-life treatment conflicts. where an understanding of issues such as the normal psychology of terminal illness is especially important to resolve ethical problems. A PSYCHOSOMATICS
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variety of difficulties surrounding terminal care result from this inattention and from too exclusive a focus on the ethical aspects of end-of-Iife treatment decisions. Hospital requirements that patients give written permission for "do not resuscitate" orders, for example, while legally and ethically appropriate, make patients feel they are signing their own death warrants. Understanding the role of "executioner's guilt," that some families feel in signing papers to forego treatment for relatives, or making such decisions, can be critically important in facilitating surrogate decisionmaking. Although withdrawing medical treatment is seen as morally identical to withholding it by ethicists, in reality withdrawing medical treatment feels very different to many physicians. The public's relatively low level of support for advance directives reflects the fears many people have of confronting death, which "trump" exercises in patient autonomy for many. Clearly addressing feelings and emotional states surrounding end-of-life treatment choices can enhance ethically informed policies and decisionmaking. The psychiatrist, as ethics consultant, is especially likely to be able to do so.
3) Many of the necessary skills of the bioethicist are similar to those of the CaL psychiatrist who has been specifically trained in these areas. Ethicists distinguish the content of ethics consultation, the facts of the case, from the process of consultation work, which is the means by which the consultant applies his knowledge to resolve the presenting problem. 4s Eliciting the content of the ethics consultation entails identifying and analyzing the ethical (and other) questions and issues pertinent to the case. As with psychiatric consultation, however, recognizing the nature of the clinical problem is generally considerably less difficult than resolving the issues, which requires a wide range of clinical skills and abilities by the consultant. The ethicist's effectiveness as a consultant and value as a clinical colleague depends to a large extent on the mastering of these abilities. Many of these skills are similar to those of the C-L psychiatrist and are essential aspects of doing VOLUME 38. NUMBER 4. JULY - AUGUST 1997
C-L psychiatry in the general hospital. Ethical problems arise classically from conflict between competing ethical principles. Practically speaking, such ethical problems often involve conflict in values, attitudes, or behavior between patients, families, physicians, and institutions, as when the staff or hospital attorney disagree with patients' or families' decisions about treatment. Like the C-L psychiatrist, the first responsibility of the ethics consultant is to the patient, and, like the C-L psychiatrist, the ethics consultant must often represent the patient's needs to the other parties involved in the patient's care. The ethicist must be able to clarify the issues of the case, set priorities in approaching them, and bridge the gap between those with differing positions. 46 Clarification of problems requires especially the ability to listen empathically and nonjudgmentally, so as to elicit the facts of the case, while weighing multiple, complex, and often competing issues and concerns. The ethicist must have strong communication skills to interpret or explain the conflicting moral values of the patient, family, physician, or institution to each other. These different positions held by various parties to the conflictual situation need to be resolved through the ethicist's use of skills in conflict resolution, mediation, and negotiation. 47 These include finding acceptable compromises emphasizing common interests instead of opposing positions, while being aware of the needs and interpersonal sensitivities of the various participants. 46 Clearly, many of the skills required by the ethics consultant to resolve ethical problems are identical to those used by the C-L psychiatrist in consultative and liaison work. Many C-L consultations in the general hospital are for emotional problems that either result from or produce conflict between the patient and staff. The C-L psychiatrist identifies the nature and cause of such difficulties, relying extensively on interviewing skills to gather data in the often emotionally charged clinical situation. As Lipowski has written, the C-L psychiatrist "mediates conflicts between patients and staff ... interpreting attitudes and behavior of patients 317
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and staff in an attempt to maintain communication and cooperation to allay conflicts between them.,,48 Success in doing so depends on the psychiatrist's ability to establish a trusting, working alliance with all parties, as is the case for a good outcome in ethics consultation as well. The C-L psychiatrist's liaison skills in establishing himself or herself as a welcome ongoing presence on the ward, are identical to those required by an ethics consultant wishing to be seen as a helpful member of the clinical team, with appropriate credibility. Working with family members, and the understanding of family dynamics, is important to both ethics and psychiatric consultation. Both consultation roles also require an extensive knowledge of hospital administrative and power structure and the ability to work with the wide range of personnel involved in patient care. Both ethics and C-L psychiatric consultation are often very labor intensive and require considerable patience and deliberation in resolving issues. The C-L psychiatrist, however, receives extensive training and experience in most of the above techniques during residency, or fellowship, whereas the bioethics consultant often receives little if any specific training in these skills. No formal or standardized requirements in fact exist currently regarding the training of ethics consultants. As a result, ethics consultants' ability to resolve interpersonal conflict, communicate effectively, or demonstrate the other skills necessary for their clinical work in the general hospital may vary widely. CONCLUSION Psychiatrists are likely to continue to be drawn to ethics work for various reasons, including especially the factors described above. At this point, the majority of psychiatrists involved in ethics function as members or chairs ofethics committees. The particular value of the psychiatrist's presence on ethics committees has been well described by others6 and follows from the observations described above. It is currently also the subject of ongoing empirical study by the Academy of Psychosomatic Medi318
cine's Task Force on The Role of the Psychiatrist on Hospital Ethics Committees. Psychiatrists are likely to continue to be widely sought after for involvement on ethics committees, especially if legally sanctioned physician-assisted suicide becomes an issue for ethics committees to deal with. However, psychiatrists are particularly well suited to function in the distinct role of ethics consultant as well, because of the close relationship between some aspects of C-L psychiatry and ethics work. Although some have called for ethics consultants to be taught psychiatric skills so they can intervene effectively,34 ethicists construe the relevance of psychiatric issues and skills somewhat narrowly.45.46 The possibility that psychiatric skills can be taught to ethics consultants who view their relevance to ethics in a very limited way seems questionable. It seems more practical and effective for psychiatrists to assume a greater role as ethics consultants, with additional training in moral theory and the clinical bioethics curriculum. In this way, the relevance of psychiatric issues and skills to ethics work can be integrated more readily into clinical bioethics practice, and the care of patients with ethical problems can be significantly enhanced.
References
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