- Email: [email protected]
Review of the Revised 2014 American Academy of Child and Adolescent Psychiatry Code of Ethics
TRANSLATIONS Review of the Revised 2014 American Academy of Child and Adolescent Psychiatry Code of Ethics Maria E. McGee,
MD, MS, MPH,
Arden D. Dingle,
C
hild and adolescent psychiatrists (CAPs) have vital societal roles as advocates for the optimal development and overall wellness of youth and their families. The profession has distinct ethical, legal, and clinical responsibilities. In 1847, the world’s first national professional medical organization (the American Medical Association) was founded, and the American Medical Association created the world’s first national code of medical ethics. Previously, in 1844, 13 medical administrator superintendents organized the Association of Medical Superintendents of American Institutions for the Insane, which later became the foundation for the creation of the American Psychiatric Association in 1921. In 1973, the American Psychiatric Association produced its first code of ethics, which has been annotated and revised in subsequent years. In 1930, the American Academy of Pediatrics was founded, and in 2007, the American Academy of Pediatrics adopted for the first time a document focusing on its distinct mission, values, and professionalism. In 1953, practitioners with a primary interest in children’s mental health founded the American Academy of Child (and Adolescent) Psychiatry, which later developed a code of ethics in 1980.1 All these codes of ethics are relevant to CAPs because they function within a general medical ethics framework. Child and adolescent psychiatry necessitates its own ethical guidelines to address the interactions with a vulnerable population characterized by youth who for the most part are minors who have mental health, developmental, cognitive, and substance use needs.2,3 At different stages in a CAP’s particular career path, one is confronted with ethical dilemmas. For example, a trainee’s learning experience and a senior investigator’s research agenda might conflict with a patient’s best interests. This article provides an overview and rationale of the recent revisions to the American Academy of Child and Adolescent Psychiatry (AACAP) Code of Ethics4; highlights how societal changes have influenced the revisions; and includes an illustrative vignette. Children and adolescents are an inherently vulnerable population, and some are more vulnerable than others. Youth are vulnerable by virtue of age; degree of cognitive, social, emotional, and/or physical immaturities; dependence on others for sustenance and protection; legal and societal status; restricted decision-making capacities to determine medical or psychiatric care or participation in medical or psychiatric research; and individual, group, and systemic advocacy needs. Especially vulnerable youth are affected not only by mental health concerns but also by psychosocial adversity, including exposure to trauma, abuse, neglect, homelessness, poverty, involvement in child JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 55 NUMBER 4 APRIL 2016
MD,
Gail A. Edelsohn,
MD, MSPH
welfare and/or the juvenile justice system, gang affiliation, family instability, adolescent pregnancy, or limited education. Youths’ developmental trajectory and overall wellness depend on their resiliency and vulnerabilities. In most societies, youths’ parents or legal guardians are generally accepted as the best representatives to ascertain their interests. A crucial component of ethical challenges in a CAP’s daily practice is the need to consider the perspectives and wishes of the youth and those of the parents/legal guardians.
REVISION RATIONALE The initial version of the AACAP Code of Ethics was adopted in 1980 to provide relevant professional ethical guidelines specific to CAPs’ practices. The AACAP Executive Council twice amended the Code (in 2009 and 2014) based on the AACAP Ethics Committee’s recommendations. The Code reflects the profession’s values and responsibilities in approaching ethical dilemmas that arise while training and practicing in the field. It has evolved to reflect the new challenges produced by changes in psychiatry and society. It is a consensus document providing the foundation for CAPs to build on to manage their administrative, scholarship, and clinical efforts appropriately. The AACAP Ethics Committee reviewed and revised each version of the Code based on consideration of ethical issues relevant to youth and their families that occur within contemporary society and influence practice. While updating the current Code, the societal developments considered included advancements in genetics, neuroimaging, surgery, psychopharmacology, psychotherapy, telepsychiatry, electronic medical records, medical information dissemination, information technology, the media’s presence and role in medicine and the overall culture, and state laws’ variations influencing practice and research. The Committee also examined different documents with guidelines and recommendations for ethical parameters in medical practice (e.g., the updated Declaration of Helsinki, the Mental Health Parity and Addiction Equality Act, and the Patient Protection and Affordable Care Act). The Code’s foundation remains unchanged, standing on 10 core principles, which are grounded in traditional biomedical ethics (Table 1). Recent revisions have focused primarily on incorporating evolving perspectives on youths’ rights and their ability to participate in care; patient assent and consent related to research and other scholarship activities; and language to encompass ongoing advances in science, medical practice, and technology.
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TABLE 1
Summary of the 10 Core Principles of the American Academy of Child and Adolescent Psychiatry Code of Ethics4
Principle
Focus
I: Developmental perspective
This principle is unique to the Code and reviews CAPs’ obligation to understand the developmental context of youth when providing clinical care, conducting research or other scholarly activities, or making consultation recommendations. II: Promoting the welfare of children and This principle reviews CAPs’ obligation to promote the optimal well-being, functioning, and adolescents (beneficence) development of youth, as individuals and as a group. This commitment needs to be prioritized over familial and societal pressures. III: Minimizing harmful effects This principle reviews the Hippocratic maxim, “do no harm.” CAPs need to strive to avoid any and (nonmaleficence) all actions that might be detrimental to the optimal development and wellness of youth and minimize the harmful impact of behaviors of others on youth at the individual, family, local community, and societal levels. IV: Assent and consent (autonomy) This principle reviews the importance of patients and parents/legal guardians making their own informed, un-coerced decisions in their psychiatric care or research participation. Youth and their parents/legal guardians should be involved in the decision-making process. Youth have a right to assent or dissent to treatment to the extent of their capacities to understand options and act rationally, and their parents/legal guardians have a right to consent by proxy or deny treatment except in emergencies. V: Confidentiality (autonomy/fidelity) This principle reviews the right to have the information of patients and parents/legal guardians kept private and confidential. CAPs need to inform youths and their parents/legal guardians about confidentiality, any associated limits to confidentiality, and any possible disclosures of information, preferably in advance. VI: Third-party influence (fidelity) This principle reviews the issues related to the influences of outside entities. CAPs need to prioritize the welfare of the patient above competing interests, constantly self-monitor to preserve the interests of youth, and not allow improper influence on professional judgment by competing interests. VII: Scholarly and research activities This principle reviews the value of scholarship activities but emphasizes the importance of minimizing risks to youth. The scientific advancement of the field is essential; however, CAPs’ first priority is to protect youth from risks. VIII: Advocacy and equity (justice) This principle reviews the importance of competent mental health care being available to all children, adolescents, and their families. CAPs need to support efforts to improve access to care at all societal levels and attempt to minimize youth exposure to injustice. IX: Professional rewards This principle reviews possible issues related to the tangible and intangible reinforcements of a CAP’s practice. CAPs need to be aware of the possible impact of rewards on their judgments and actions. X: Legal considerations This principle reviews the importance of understanding the local, state, and federal laws that affect a CAP’s practice, especially those regulations covering unique issues. However, legal standards do not replace ethical ones. Note: CAPs ¼ child and adolescent psychiatrists.
THE CODE’S REWORDINGS The Code’s rewordings are reflections of to whom the Code applies, the distinction between standards and guidelines, and the evolving nature of contemporary communication technology. The Code’s prior versions identified it as a guide for AACAP members alone. The current Code expands its applicability to AACAP members and all practicing CAPs within the United States, regardless of AACAP membership. Because AACAP is recognized as the leading US medical association dedicated to treating and improving the mental health and wellness of youth and their families, it is a logical extension to reframe the Code’s application to the broader group of all US practicing CAPs. All US practicing CAPs and AACAP members are on an honor system to abide by the Code.
The Code’s prior versions described its principles as “standards” and “not legally binding.” The US National Library of Medicine defines standards as “authoritative statements setting forth levels of performance . [articulating] minimal, acceptable or excellent levels of performance . [and] guidelines [as] statements of principles . [assisting] professionals in ensuring quality in . clinical practice, biomedical research, and health services.”5 The current Code describes its principles as “guidelines” instead of “standards” that assist CAPs in ethical analysis and decision making and cannot be adopted, altered, or rejected based on situational needs. Evolving contemporary communication technologies are changing how individuals relate to one another. In addition to face-to-face communication, CAPs need to consider the use of technologically mediated forms of communication JOURNAL
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(e.g., telephone, email, text messaging, instant messaging, Internet, social networking Web sites, photo- and videosharing sites, and other forms of personal and professional online publishing and discourse) in patients’ lives and their influence on practice. The current Code expands the discussion of issues related to technologically mediated forms of communication through general concepts rather than through excessive specificity, which might quickly cause it to become an obsolete document.
THE CODE’S CONTENT ADDITIONS To capture the practice for CAPs in various roles and settings, the revised Code included content additions. The Code’s content additions are reflections of the importance of obtaining collateral information in practice, scholarly activities, and legal considerations. Psychiatric diagnostic, therapeutic, and prognostic assessments of youth rely on obtaining collateral information from patients’ parents/legal guardians and sources outside patients’ families. This process might compromise patients’ and/or their families’ confidentiality, because delicate or potentially damaging information might be disclosed. Confidentiality promotes trust and is an essential aspect of medical practice. CAPs must attain and maintain the trust of their patients and their patients’ parents/legal guardians to obtain comprehensive histories and implement effective treatment plans. The Code’s prior versions addressed the confidentiality solely of patients. The current Code addresses the necessity to protect the confidentiality of patients and their parents/legal guardians and consider the need to obtain collateral information from outside patients’ families. The Code’s prior versions labeled Principle VII as pertaining solely to “research activities.” The current Code expands Principle VII as pertaining to “scholarly and research activities” to capture the diversity of professional activities. Scholarly activities include research activities; textbooks, book chapters, review articles, and case reports; curriculum development; case-based teaching exercises; clinical quality-improvement projects; patient education material development; and presentations at local, regional, national, and international conferences. These activities are for the field’s betterment and must be held to the same ethical standards as clinical and administrative activities to protect patients and their families. The discussion about legal considerations also is broadened. It emphasizes CAPs’ need to be aware of legal concerns, which might arise in the context of face-to-face patient care or during indirect communications with and about patients and others. It also recognizes that the interface between psychiatry and law necessitates defining the nature and purpose of forensic evaluations and confidentiality limits at the onset of each evaluation. The current Code addresses forensic psychiatric practice, whereas prior versions did not.
PUTTING THE CODE INTO PRACTICE: A CASE ILLUSTRATION Vignette A 14-year-old girl has been in psychotherapy with medications for pervasive anxiety for several years (Dingle AD, JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 55 NUMBER 4 APRIL 2016
DeJong SM, Madaan V, Asherman A; AACAP Ethics Committee. Teaching ethics: a vignette based curriculum. Unpublished manuscript). An extremely conflicted family environment complicates her course. Her mother is the primary parent and caregiver. Recently, the girl has begun to insist that she does not need treatment and does not want to see a CAP. Her mother struggles to get her to the office for sessions every week. The girl’s symptoms have abated and her functioning has slowly improved during the course of treatment despite the ongoing major family and environmental stressors. At this point, she can be described as a generally functional but difficult, unhappy adolescent. Changing therapists has been discussed, but the girl insists that she does not need to see anyone. She also has been resistant to considering different approaches in therapy. In addition to weekly individual psychotherapy and medication management sessions, the CAP spends considerable time consulting with the school and providing parent guidance to the girl’s mother. Her father is willing to come in occasionally. He is ambivalent about his daughter being in treatment. Her mother thinks the girl should stay in therapy.
Discussion The question is, should the girl be allowed to stop treatment? Like most clinical situations, several ethical principles are relevant. Although all principles should be considered, most practitioners emphasize one construct over another depending on their assessment of the child or adolescent, the involved adults, and the CAP’s perspectives on various ethical principles. How one would proceed in this case would depend on how one believes the relevant ethical principles should be prioritized to optimize the girl’s functioning. Valid arguments can be made to support decisions to continue or to pause and interrupt treatment depending on which ethical and clinical factors are viewed as paramount. If acting in the child’s best interests or doing no harm are the principles considered the most important, then insisting that the girl continue treatment would be reasonable. However, developmental concerns and autonomy would support a decision to allow the patient to make the decision and stop therapy.
Principle I (Developmental Perspective) Principle I should always be considered. Principle I states, “the CAP should be aware of, and strive to optimize, the emotional, cognitive, social, and physiological development of all children and adolescents” (p. 3).4 In this case, the adolescent patient can analyze some situations, make some decisions, and function somewhat independently and selfsufficiently. Many adolescents of this age can make decisions as well as adults. Some adolescents cannot truly appreciate the long-term or wider implications of their decisions and fail to consider the possible ultimate consequences of their choices. In this situation, the optimal development trajectory for this girl would be for her to be gratified and productive in all aspects of her functioning now and in the future. Whether treatment should be continued depends on how the CAP conceptualizes her psychiatric and
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psychological issues and whether the CAP judges that ongoing therapy would help the patient become more functional and whether no treatment would significantly worsen her condition and psychological status. Developmentally, the patient should be allowed to make age-appropriate decisions. She might be accurate that discontinuing treatment is in her best interest. However, because she is on medication, a possible compromise might be to decrease the frequency and intensity of treatment, thus respecting the patient’s desires, recognizing the mother’s wishes, and providing some monitoring of the patient’s functioning.
Principle II (Promoting the Welfare of Children and Adolescents [Beneficence]) and Principle III (Minimizing Harmful Effects [Nonmaleficence]) Principles II and III are always factors in clinical situations. Principle II states the CAPs’ “primary concerns are the welfare, functioning, and optimal development of children” (p. 4).4 Principle III states, “The CAP should seek to avoid all actions that may have a detrimental effect on the optimum development of the child or adolescent” (p. 5).4 Determining what is in the girl’s best interests and what is “no harm” depends on who is defining these terms and what is being prioritized. A central question is how much emphasis should be placed on current problems or distress versus longer-term potential. Making these types of decisions often involves attempting to make reasonable predictions about the outcomes of various options. Being forced to participate in a treatment she does not want could worsen the girl’s distress. The risk of contributing to the patient’s current distress might be outweighed by the potential benefits of treatment. The CAP could view the girl’s resentment of treatment as a minor, insignificant source of distress that is outweighed by continuing treatment efforts. One alternative would be to continue treatment with short-term goals, giving the patient the opportunity to demonstrate to the adults that she does not need therapy.
Principle IV (Assent and Consent [Autonomy]) A primary ethical issue in this case relates to patient autonomy. Principle IV states that “Children and adolescents . should play a role in determining the services they receive and their participation in treatments to the extent of their capacities to understand options and act rationally” (pp. 6–7).4 The girl’s mother has given consent, but the patient has not given assent, despite multiple opportunities to do so. How the CAP views assent is a key factor. Although the girl has not verbally agreed to treatment, she comes into the office and stays during the session, which could be construed as some level of agreement. Another consideration is the CAP’s opinion about how the patient’s autonomy, best interests, and optimal development should be balanced. If the CAP considers that interruption of treatment might have a significant negative impact, then the CAP might consider best interests and optimal development to be more important than patient autonomy. Caretaking adults tend to view patient autonomy as subservient to best
interests and optimal development, particularly when decisions have the potential to have a significantly negative impact on the youth’s developmental trajectory. Parents are often in the role of making their children do things that they do not want to do. The CAP must not take on the role of a parent; to do so complicates the therapeutic relationship with patient and parents. Compromising autonomy might be the optimal way to proceed; children and adolescents frequently are required to do things that they do not agree with. The CAP should be clear about the possible options and what his/her professional opinion is about each while providing support to the mother and girl so that they can make the best possible decisions. An important aspect of autonomy is one’s ability to evaluate one’s situation and status and to use this information to make informed choices about what course of action is most appropriate. The mother’s obligation is to optimize the girl’s development and functioning even if that means disagreeing with the girl. The girl’s task is to take responsibility for her behavior and show the involved adults that she can function and achieve without being in treatment if she does not want treatment to continue.
CONCLUSION The Code is the guide for CAPs in the United States for considering and negotiating ethical issues related to social, medical, legal, and other professional relationships. It covers ethical principles, practice, and real-life challenges in the care of youth and their families. It should be interpreted within current societal contexts with case-by-case application using a developmental framework, practical wisdom, discretion, and judgment. The Code ought not to be mechanically applied or construed as absolute. Different principles might provide conflicting guidance. A principle might take precedence in some circumstances but not in others. A case might expose a principle’s inadequacies. Sometimes an ethical action might be creating a principle modification or exception. Thus, the Code’s revision is intended to maintain it as a current and germane set of guidelines for CAPs to analyze and manage ethical issues they confront when working with youth and their families in various arenas. & Accepted January 28, 2016. Dr. McGee is with the American Academy of Child and Adolescent Psychiatry (AACAP) Ethics Committee, the Division of Child and Adolescent Psychiatry at the University of Nebraska Medical Center, Omaha, and the Creighton Psychiatry Residency Training Program, Omaha. Dr. Dingle is with the AACAP Ethics Committee, the University of Texas Rio Grande Valley, and Emory University, Atlanta (Professor Emeritus). Dr. Edelsohn is with the AACAP Ethics Committee and Community Care Behavioral Health Organization, Exton, PA. Disclosure: Drs. McGee, Dingle, and Edelsohn report no biomedical financial interests or potential conflicts of interest. Correspondence to Maria E. McGee, MD, MS, MPH, University of Nebraska Medical Center, 985575 Nebraska Medical Center, Omaha, NE 681985575; e-mail: [email protected] 0890-8567/$36.00/ª2016 American Academy of Child and Adolescent Psychiatry http://dx.doi.org/10.1016/j.jaac.2015.12.017
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REFERENCES 1. Sondheimer AN, Dingle AD. Ethical issues in child and adolescent psychiatry. In: Sadock J, Sadock VA, Ruiz P, eds. Kaplan and Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Philadelphia: Lippincott Williams and Wilkins; 2009:3840. 2. Sondheimer A. Ethics and risk management in administrative child and adolescent psychiatry. Child Adolesc Psychiatr Clin N Am. 2010;19:115-129. 3. Sondheimer AN, Klykylo WM; Ethics Committee, American Academy of Child and Adolescent Psychiatry; Ethics Committee, American Psychiatric Association. The Ethics Committees of the American Academy of Child and Adolescent Psychiatry and the American Psychiatric Association:
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history, process, education, and advocacy. Child Adolesc Psychiatr Clin N Am. 2008;17:225-236, xi-xii. 4. American Academy of Child and Adolescent Psychiatry. Code of ethics. http:// www.aacap.org/App_Themes/AACAP/docs/about_us/transparency_ portal/Code_Of_Ethics_2014.pdf. Accessed December 23, 2015. 5. Collection Development Manual of the National Library of Medicine. 9th ed4th ed. Bethesda, MD: National Library of Medicine, National Institutes of Health, US Department of Health and Human Services, 2004. http://www.nlm.nih.gov/tsd/acquisitions/cdm/formats46.html. Accessed December 23, 2015.
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MD, MS, MPH,
Arden D. Dingle,
C
hild and adolescent psychiatrists (CAPs) have vital societal roles as advocates for the optimal development and overall wellness of youth and their families. The profession has distinct ethical, legal, and clinical responsibilities. In 1847, the world’s first national professional medical organization (the American Medical Association) was founded, and the American Medical Association created the world’s first national code of medical ethics. Previously, in 1844, 13 medical administrator superintendents organized the Association of Medical Superintendents of American Institutions for the Insane, which later became the foundation for the creation of the American Psychiatric Association in 1921. In 1973, the American Psychiatric Association produced its first code of ethics, which has been annotated and revised in subsequent years. In 1930, the American Academy of Pediatrics was founded, and in 2007, the American Academy of Pediatrics adopted for the first time a document focusing on its distinct mission, values, and professionalism. In 1953, practitioners with a primary interest in children’s mental health founded the American Academy of Child (and Adolescent) Psychiatry, which later developed a code of ethics in 1980.1 All these codes of ethics are relevant to CAPs because they function within a general medical ethics framework. Child and adolescent psychiatry necessitates its own ethical guidelines to address the interactions with a vulnerable population characterized by youth who for the most part are minors who have mental health, developmental, cognitive, and substance use needs.2,3 At different stages in a CAP’s particular career path, one is confronted with ethical dilemmas. For example, a trainee’s learning experience and a senior investigator’s research agenda might conflict with a patient’s best interests. This article provides an overview and rationale of the recent revisions to the American Academy of Child and Adolescent Psychiatry (AACAP) Code of Ethics4; highlights how societal changes have influenced the revisions; and includes an illustrative vignette. Children and adolescents are an inherently vulnerable population, and some are more vulnerable than others. Youth are vulnerable by virtue of age; degree of cognitive, social, emotional, and/or physical immaturities; dependence on others for sustenance and protection; legal and societal status; restricted decision-making capacities to determine medical or psychiatric care or participation in medical or psychiatric research; and individual, group, and systemic advocacy needs. Especially vulnerable youth are affected not only by mental health concerns but also by psychosocial adversity, including exposure to trauma, abuse, neglect, homelessness, poverty, involvement in child JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 55 NUMBER 4 APRIL 2016
MD,
Gail A. Edelsohn,
MD, MSPH
welfare and/or the juvenile justice system, gang affiliation, family instability, adolescent pregnancy, or limited education. Youths’ developmental trajectory and overall wellness depend on their resiliency and vulnerabilities. In most societies, youths’ parents or legal guardians are generally accepted as the best representatives to ascertain their interests. A crucial component of ethical challenges in a CAP’s daily practice is the need to consider the perspectives and wishes of the youth and those of the parents/legal guardians.
REVISION RATIONALE The initial version of the AACAP Code of Ethics was adopted in 1980 to provide relevant professional ethical guidelines specific to CAPs’ practices. The AACAP Executive Council twice amended the Code (in 2009 and 2014) based on the AACAP Ethics Committee’s recommendations. The Code reflects the profession’s values and responsibilities in approaching ethical dilemmas that arise while training and practicing in the field. It has evolved to reflect the new challenges produced by changes in psychiatry and society. It is a consensus document providing the foundation for CAPs to build on to manage their administrative, scholarship, and clinical efforts appropriately. The AACAP Ethics Committee reviewed and revised each version of the Code based on consideration of ethical issues relevant to youth and their families that occur within contemporary society and influence practice. While updating the current Code, the societal developments considered included advancements in genetics, neuroimaging, surgery, psychopharmacology, psychotherapy, telepsychiatry, electronic medical records, medical information dissemination, information technology, the media’s presence and role in medicine and the overall culture, and state laws’ variations influencing practice and research. The Committee also examined different documents with guidelines and recommendations for ethical parameters in medical practice (e.g., the updated Declaration of Helsinki, the Mental Health Parity and Addiction Equality Act, and the Patient Protection and Affordable Care Act). The Code’s foundation remains unchanged, standing on 10 core principles, which are grounded in traditional biomedical ethics (Table 1). Recent revisions have focused primarily on incorporating evolving perspectives on youths’ rights and their ability to participate in care; patient assent and consent related to research and other scholarship activities; and language to encompass ongoing advances in science, medical practice, and technology.
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TABLE 1
Summary of the 10 Core Principles of the American Academy of Child and Adolescent Psychiatry Code of Ethics4
Principle
Focus
I: Developmental perspective
This principle is unique to the Code and reviews CAPs’ obligation to understand the developmental context of youth when providing clinical care, conducting research or other scholarly activities, or making consultation recommendations. II: Promoting the welfare of children and This principle reviews CAPs’ obligation to promote the optimal well-being, functioning, and adolescents (beneficence) development of youth, as individuals and as a group. This commitment needs to be prioritized over familial and societal pressures. III: Minimizing harmful effects This principle reviews the Hippocratic maxim, “do no harm.” CAPs need to strive to avoid any and (nonmaleficence) all actions that might be detrimental to the optimal development and wellness of youth and minimize the harmful impact of behaviors of others on youth at the individual, family, local community, and societal levels. IV: Assent and consent (autonomy) This principle reviews the importance of patients and parents/legal guardians making their own informed, un-coerced decisions in their psychiatric care or research participation. Youth and their parents/legal guardians should be involved in the decision-making process. Youth have a right to assent or dissent to treatment to the extent of their capacities to understand options and act rationally, and their parents/legal guardians have a right to consent by proxy or deny treatment except in emergencies. V: Confidentiality (autonomy/fidelity) This principle reviews the right to have the information of patients and parents/legal guardians kept private and confidential. CAPs need to inform youths and their parents/legal guardians about confidentiality, any associated limits to confidentiality, and any possible disclosures of information, preferably in advance. VI: Third-party influence (fidelity) This principle reviews the issues related to the influences of outside entities. CAPs need to prioritize the welfare of the patient above competing interests, constantly self-monitor to preserve the interests of youth, and not allow improper influence on professional judgment by competing interests. VII: Scholarly and research activities This principle reviews the value of scholarship activities but emphasizes the importance of minimizing risks to youth. The scientific advancement of the field is essential; however, CAPs’ first priority is to protect youth from risks. VIII: Advocacy and equity (justice) This principle reviews the importance of competent mental health care being available to all children, adolescents, and their families. CAPs need to support efforts to improve access to care at all societal levels and attempt to minimize youth exposure to injustice. IX: Professional rewards This principle reviews possible issues related to the tangible and intangible reinforcements of a CAP’s practice. CAPs need to be aware of the possible impact of rewards on their judgments and actions. X: Legal considerations This principle reviews the importance of understanding the local, state, and federal laws that affect a CAP’s practice, especially those regulations covering unique issues. However, legal standards do not replace ethical ones. Note: CAPs ¼ child and adolescent psychiatrists.
THE CODE’S REWORDINGS The Code’s rewordings are reflections of to whom the Code applies, the distinction between standards and guidelines, and the evolving nature of contemporary communication technology. The Code’s prior versions identified it as a guide for AACAP members alone. The current Code expands its applicability to AACAP members and all practicing CAPs within the United States, regardless of AACAP membership. Because AACAP is recognized as the leading US medical association dedicated to treating and improving the mental health and wellness of youth and their families, it is a logical extension to reframe the Code’s application to the broader group of all US practicing CAPs. All US practicing CAPs and AACAP members are on an honor system to abide by the Code.
The Code’s prior versions described its principles as “standards” and “not legally binding.” The US National Library of Medicine defines standards as “authoritative statements setting forth levels of performance . [articulating] minimal, acceptable or excellent levels of performance . [and] guidelines [as] statements of principles . [assisting] professionals in ensuring quality in . clinical practice, biomedical research, and health services.”5 The current Code describes its principles as “guidelines” instead of “standards” that assist CAPs in ethical analysis and decision making and cannot be adopted, altered, or rejected based on situational needs. Evolving contemporary communication technologies are changing how individuals relate to one another. In addition to face-to-face communication, CAPs need to consider the use of technologically mediated forms of communication JOURNAL
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AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 55 NUMBER 4 APRIL 2016
TRANSLATIONS
(e.g., telephone, email, text messaging, instant messaging, Internet, social networking Web sites, photo- and videosharing sites, and other forms of personal and professional online publishing and discourse) in patients’ lives and their influence on practice. The current Code expands the discussion of issues related to technologically mediated forms of communication through general concepts rather than through excessive specificity, which might quickly cause it to become an obsolete document.
THE CODE’S CONTENT ADDITIONS To capture the practice for CAPs in various roles and settings, the revised Code included content additions. The Code’s content additions are reflections of the importance of obtaining collateral information in practice, scholarly activities, and legal considerations. Psychiatric diagnostic, therapeutic, and prognostic assessments of youth rely on obtaining collateral information from patients’ parents/legal guardians and sources outside patients’ families. This process might compromise patients’ and/or their families’ confidentiality, because delicate or potentially damaging information might be disclosed. Confidentiality promotes trust and is an essential aspect of medical practice. CAPs must attain and maintain the trust of their patients and their patients’ parents/legal guardians to obtain comprehensive histories and implement effective treatment plans. The Code’s prior versions addressed the confidentiality solely of patients. The current Code addresses the necessity to protect the confidentiality of patients and their parents/legal guardians and consider the need to obtain collateral information from outside patients’ families. The Code’s prior versions labeled Principle VII as pertaining solely to “research activities.” The current Code expands Principle VII as pertaining to “scholarly and research activities” to capture the diversity of professional activities. Scholarly activities include research activities; textbooks, book chapters, review articles, and case reports; curriculum development; case-based teaching exercises; clinical quality-improvement projects; patient education material development; and presentations at local, regional, national, and international conferences. These activities are for the field’s betterment and must be held to the same ethical standards as clinical and administrative activities to protect patients and their families. The discussion about legal considerations also is broadened. It emphasizes CAPs’ need to be aware of legal concerns, which might arise in the context of face-to-face patient care or during indirect communications with and about patients and others. It also recognizes that the interface between psychiatry and law necessitates defining the nature and purpose of forensic evaluations and confidentiality limits at the onset of each evaluation. The current Code addresses forensic psychiatric practice, whereas prior versions did not.
PUTTING THE CODE INTO PRACTICE: A CASE ILLUSTRATION Vignette A 14-year-old girl has been in psychotherapy with medications for pervasive anxiety for several years (Dingle AD, JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 55 NUMBER 4 APRIL 2016
DeJong SM, Madaan V, Asherman A; AACAP Ethics Committee. Teaching ethics: a vignette based curriculum. Unpublished manuscript). An extremely conflicted family environment complicates her course. Her mother is the primary parent and caregiver. Recently, the girl has begun to insist that she does not need treatment and does not want to see a CAP. Her mother struggles to get her to the office for sessions every week. The girl’s symptoms have abated and her functioning has slowly improved during the course of treatment despite the ongoing major family and environmental stressors. At this point, she can be described as a generally functional but difficult, unhappy adolescent. Changing therapists has been discussed, but the girl insists that she does not need to see anyone. She also has been resistant to considering different approaches in therapy. In addition to weekly individual psychotherapy and medication management sessions, the CAP spends considerable time consulting with the school and providing parent guidance to the girl’s mother. Her father is willing to come in occasionally. He is ambivalent about his daughter being in treatment. Her mother thinks the girl should stay in therapy.
Discussion The question is, should the girl be allowed to stop treatment? Like most clinical situations, several ethical principles are relevant. Although all principles should be considered, most practitioners emphasize one construct over another depending on their assessment of the child or adolescent, the involved adults, and the CAP’s perspectives on various ethical principles. How one would proceed in this case would depend on how one believes the relevant ethical principles should be prioritized to optimize the girl’s functioning. Valid arguments can be made to support decisions to continue or to pause and interrupt treatment depending on which ethical and clinical factors are viewed as paramount. If acting in the child’s best interests or doing no harm are the principles considered the most important, then insisting that the girl continue treatment would be reasonable. However, developmental concerns and autonomy would support a decision to allow the patient to make the decision and stop therapy.
Principle I (Developmental Perspective) Principle I should always be considered. Principle I states, “the CAP should be aware of, and strive to optimize, the emotional, cognitive, social, and physiological development of all children and adolescents” (p. 3).4 In this case, the adolescent patient can analyze some situations, make some decisions, and function somewhat independently and selfsufficiently. Many adolescents of this age can make decisions as well as adults. Some adolescents cannot truly appreciate the long-term or wider implications of their decisions and fail to consider the possible ultimate consequences of their choices. In this situation, the optimal development trajectory for this girl would be for her to be gratified and productive in all aspects of her functioning now and in the future. Whether treatment should be continued depends on how the CAP conceptualizes her psychiatric and
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psychological issues and whether the CAP judges that ongoing therapy would help the patient become more functional and whether no treatment would significantly worsen her condition and psychological status. Developmentally, the patient should be allowed to make age-appropriate decisions. She might be accurate that discontinuing treatment is in her best interest. However, because she is on medication, a possible compromise might be to decrease the frequency and intensity of treatment, thus respecting the patient’s desires, recognizing the mother’s wishes, and providing some monitoring of the patient’s functioning.
Principle II (Promoting the Welfare of Children and Adolescents [Beneficence]) and Principle III (Minimizing Harmful Effects [Nonmaleficence]) Principles II and III are always factors in clinical situations. Principle II states the CAPs’ “primary concerns are the welfare, functioning, and optimal development of children” (p. 4).4 Principle III states, “The CAP should seek to avoid all actions that may have a detrimental effect on the optimum development of the child or adolescent” (p. 5).4 Determining what is in the girl’s best interests and what is “no harm” depends on who is defining these terms and what is being prioritized. A central question is how much emphasis should be placed on current problems or distress versus longer-term potential. Making these types of decisions often involves attempting to make reasonable predictions about the outcomes of various options. Being forced to participate in a treatment she does not want could worsen the girl’s distress. The risk of contributing to the patient’s current distress might be outweighed by the potential benefits of treatment. The CAP could view the girl’s resentment of treatment as a minor, insignificant source of distress that is outweighed by continuing treatment efforts. One alternative would be to continue treatment with short-term goals, giving the patient the opportunity to demonstrate to the adults that she does not need therapy.
Principle IV (Assent and Consent [Autonomy]) A primary ethical issue in this case relates to patient autonomy. Principle IV states that “Children and adolescents . should play a role in determining the services they receive and their participation in treatments to the extent of their capacities to understand options and act rationally” (pp. 6–7).4 The girl’s mother has given consent, but the patient has not given assent, despite multiple opportunities to do so. How the CAP views assent is a key factor. Although the girl has not verbally agreed to treatment, she comes into the office and stays during the session, which could be construed as some level of agreement. Another consideration is the CAP’s opinion about how the patient’s autonomy, best interests, and optimal development should be balanced. If the CAP considers that interruption of treatment might have a significant negative impact, then the CAP might consider best interests and optimal development to be more important than patient autonomy. Caretaking adults tend to view patient autonomy as subservient to best
interests and optimal development, particularly when decisions have the potential to have a significantly negative impact on the youth’s developmental trajectory. Parents are often in the role of making their children do things that they do not want to do. The CAP must not take on the role of a parent; to do so complicates the therapeutic relationship with patient and parents. Compromising autonomy might be the optimal way to proceed; children and adolescents frequently are required to do things that they do not agree with. The CAP should be clear about the possible options and what his/her professional opinion is about each while providing support to the mother and girl so that they can make the best possible decisions. An important aspect of autonomy is one’s ability to evaluate one’s situation and status and to use this information to make informed choices about what course of action is most appropriate. The mother’s obligation is to optimize the girl’s development and functioning even if that means disagreeing with the girl. The girl’s task is to take responsibility for her behavior and show the involved adults that she can function and achieve without being in treatment if she does not want treatment to continue.
CONCLUSION The Code is the guide for CAPs in the United States for considering and negotiating ethical issues related to social, medical, legal, and other professional relationships. It covers ethical principles, practice, and real-life challenges in the care of youth and their families. It should be interpreted within current societal contexts with case-by-case application using a developmental framework, practical wisdom, discretion, and judgment. The Code ought not to be mechanically applied or construed as absolute. Different principles might provide conflicting guidance. A principle might take precedence in some circumstances but not in others. A case might expose a principle’s inadequacies. Sometimes an ethical action might be creating a principle modification or exception. Thus, the Code’s revision is intended to maintain it as a current and germane set of guidelines for CAPs to analyze and manage ethical issues they confront when working with youth and their families in various arenas. & Accepted January 28, 2016. Dr. McGee is with the American Academy of Child and Adolescent Psychiatry (AACAP) Ethics Committee, the Division of Child and Adolescent Psychiatry at the University of Nebraska Medical Center, Omaha, and the Creighton Psychiatry Residency Training Program, Omaha. Dr. Dingle is with the AACAP Ethics Committee, the University of Texas Rio Grande Valley, and Emory University, Atlanta (Professor Emeritus). Dr. Edelsohn is with the AACAP Ethics Committee and Community Care Behavioral Health Organization, Exton, PA. Disclosure: Drs. McGee, Dingle, and Edelsohn report no biomedical financial interests or potential conflicts of interest. Correspondence to Maria E. McGee, MD, MS, MPH, University of Nebraska Medical Center, 985575 Nebraska Medical Center, Omaha, NE 681985575; e-mail: [email protected] 0890-8567/$36.00/ª2016 American Academy of Child and Adolescent Psychiatry http://dx.doi.org/10.1016/j.jaac.2015.12.017
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REFERENCES 1. Sondheimer AN, Dingle AD. Ethical issues in child and adolescent psychiatry. In: Sadock J, Sadock VA, Ruiz P, eds. Kaplan and Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Philadelphia: Lippincott Williams and Wilkins; 2009:3840. 2. Sondheimer A. Ethics and risk management in administrative child and adolescent psychiatry. Child Adolesc Psychiatr Clin N Am. 2010;19:115-129. 3. Sondheimer AN, Klykylo WM; Ethics Committee, American Academy of Child and Adolescent Psychiatry; Ethics Committee, American Psychiatric Association. The Ethics Committees of the American Academy of Child and Adolescent Psychiatry and the American Psychiatric Association:
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history, process, education, and advocacy. Child Adolesc Psychiatr Clin N Am. 2008;17:225-236, xi-xii. 4. American Academy of Child and Adolescent Psychiatry. Code of ethics. http:// www.aacap.org/App_Themes/AACAP/docs/about_us/transparency_ portal/Code_Of_Ethics_2014.pdf. Accessed December 23, 2015. 5. Collection Development Manual of the National Library of Medicine. 9th ed4th ed. Bethesda, MD: National Library of Medicine, National Institutes of Health, US Department of Health and Human Services, 2004. http://www.nlm.nih.gov/tsd/acquisitions/cdm/formats46.html. Accessed December 23, 2015.
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