Open Space
Consultation-Liaison Psychiatry and Bioethics
The relationship between Philosophy/Ethics and Psychiatry goes as far back as the two disciplines and western culture, since the Greek civilization was the first to attempt to provide a rational answer to the question of good and evil, and the first to advance a medicine based on reason. However, this relationship had quite distinct focuses:
A psychiatry of ethics – “Addiction as an illness” (evil is an error, and whoever chooses it is wrong about its true nature, whether as a result of ignorance or illness).
An ethics of psychiatry: “Illness as an addiction” (all illnesses, at least serious ones, due to the fact they cause pain and suffering, imply a type of mental disturbance that would make human beings incapable of discernment, rationality, and prudence).
The complexity of the relationships and problems involved in the practice of contemporary medicine (Barbosa, 1988, 1997b) often confers consultation-liaison psychiatry the role of a mediator between the perspectives of doctors, nurses, and patients and their families in particular clinical situations.
Consultation-liaison psychiatry is a field of clinical psychiatry that includes all psychiatry/psychology activities in non-psychiatric units at general hospitals. These activities take place at three levels: 1) clinical, including diagnosis, therapy, and prevention; 2) educational, that is, the psychological/psychiatric training of other technicians; 3) research. We have been developing these activities since 1987, the year the Liaison Psychiatry Unit of Santa Maria hospital formally started its activity.
The psychiatric aspects of bioethical problems are very common and go hand in hand with issues of a legal, economic, social, institutional, and religious nature (Lederberg, 1997). Consultation-liaison psychiatrists are traditionally, and on a daily basis, amply involved in clinical problems that often constitute true ethical consultations (Steinberg, 1997), and they are almost always well positioned to do so (Binder, 2002).
The main ethical issues in consultation-liaison psychiatry basically are:
1. Issues regarding the principle of respect for autonomy
Each patient is a competent being with intact human rights. The interruption of his/her human rights (hospitalization or treatment against the patient’s will) can only occur exceptionally and always aimed at the benefit of the patient.
When assessing the capacity of patients, the psychiatrist may also perpetuate past mistakes (considering all patients as being incapable, or certain types of patients, such as psychiatric ones, as incapable, or, quite the opposite, resort to rigorous, adequate and up to date criteria of a functional nature).
2. Issues regarding the principle of beneficence.
One of the most frequent conflicts between beneficence and autonomy is refusal on the patient’s part to start treatment, or his/her express will to cease treatment in progress prescribed by the medical team or doctor. This requires a psychiatric evaluation to determine whether the patient is able to make a decision and is not putting him or herself, or others, at risk as a result of this decision.
3. Issues regarding the principle of non-malificence.
Loss of confidentiality may avoid damage being done to others, but also problems deriving from the right to know, or not, the truth, from negligence, malpractice, and ignorance.
4. Issues regarding the principle of justice
Ethics based on non-discrimination, segregation or marginalization, avoiding hospitalization as “punishment”, as well as the distribution of scarce resources to avoid that the most vulnerable (the weaker, frailer, mental patients) suffer.
5. Issues regarding relational ethics
Interpersonal and inter-team communication difficulties, as well as distorted beliefs on the part of health professionals on what should be part of the realm of the ethical and what should belong to the psychological or psychiatric sphere (Barbosa, 2010).
6. Psychiatric Issues with incidence on ethical problems
Patients’ decision-making capacity may be disturbed by actual fear or resurgence of older fears, or may be caused by a defensive problem of denial (normal or pathological). For instance, when a surgery is refused, the majority of causes are of a psychological nature, such as fear, anxiety, negative previous surgical experiences or that took place at that particular hospital, mistrust of doctors, communication problems (Barbosa, 1989).
Another psychological factor that is often difficult to recognize is depression, because the patient with depression generally provides rational explanations for the choices made (Barbosa, 1984). It is important to evaluate feelings of abandonment, neglect, despair, of a meaningless future, or suicidal ideas. The depression aspects that most undermine patients’ capacity are distorted evaluations of themselves, of the world, and of the future. Sometimes antidepressant treatment may be useful to ascertain if depression is interfering with the patient’s decision-making capacity.
Main psychiatric aspects related to ethical difficulties
- Diagnosable psychopathology in any of those involved in the ethical conflict
- Personality styles and psychodynamic problems
- Family dysfunction
- Interpersonal conflicts between patient, family, and health professionals
- Conflicts or non-cooperation among the health intra-team
- Countertransference reactions on the part of health professionals with regard to patients, family, and other agents
- Disproportionate involvement or rejection on the part of the health team
Three types of situations that often occur in the practice of a consultation-liaison psychiatrist can be identified:
a) Pseudo-psychiatric evaluation when an apparent situation of a psychiatric nature disguises an underlying ethical problem.
Following an impasse in patient care due to a conflict of values (conflict between a patient’s family and the medical team about continuing aggressive and invasive medical interventions on a patient with a serious condition who is totally incapable), a request for psychiatric evaluation may be made. This type of situation deserves ethical consideration more than psychiatric evaluation of the patient’s decision-making capacity.
b) Pseudo-ethical evaluation, when psychiatric problems lie at the basis of an ethical problem.
This type of problem is particularly common in end-of-life treatment decisions, due to the importance of emotional aspects in decision-making processes (Callahan, 1988). An example is when patients wish to stop treatment or speed up death, primarily due to excessive and disproportionate fear of dependence or abandonment/neglect (Barbosa,1997a), but equally due to guilt of overburdening the family, or to mere anxiety in the face of the actual process of dying. When, in these circumstances, the focus in on the patient’s right to refuse treatment or on accepting patients’ decisions at mere face value, one may be casting a shadow on vital emotional determining factors in the patient’s decision-making process.
If, on the one hand, acknowledging these difficulties may be important to help distinguish latent feelings from patients’ expressed feelings (Barbosa, 1999), which are often the matrix and the key point to the emergence of ethical problems, on the other hand, one should avoid the psychiatric tendency to medicalize or confer a pathology to all forms of decision-making. Naturally, there is a role for ethical aspects, for moral decision, and for values.
c) A psychiatric and ethical case, in which both play a very important role.
In some circumstances, psychiatric problems may be one of the important aspects of that particular situation, alongside ethical, legal, religious, economic, institutional, and other problems (Barbosa, 2010b).
Naturally, one of the prime responsibilities of a psychiatrist in ethical conflicts regarding medical treatment is to evaluate the patient’s capacity to make decisions, but also to correct diminished capacity (Cassel, 2001), and to treat reversible mental disturbances which, as they are relieved, may enable the whole process of informed consent.
Ethical issues in types of psychiatric intervention
- Treating individual psychological problems
- Evaluating decision-making capacity
- Restoring, improving, stabilizing decision-making
- Improving dysfunctional family dynamics
- Diagnosing and improving team, patient, family issues, and communication problems
- Using the psychiatrist’s capacity to involve other carers, if appropriate
- Recognizing and reducing cultural or religious incongruities
- Evaluating and optimizing the contribution of social or community players
Psychiatric interventions often lead to treatment decision resolutions (whether the patient is competent or incompetent) and to refusal of treatment, which was perceived as a psychiatric issue, and which is now beginning to be seen as an ethical issue. Preparation in this field is not always guaranteed by the training undertaken by health professionals (Barbosa, 1997; Preissman, 1999; Youngner, 1997).
António Barbosa (Professor of Psychiatry and Director of the Centre for Bioethics of the University of Lisbon; Co-head of the Consultation-Liaison Psychiatry Team at the Psychiatry Unit of Santa Maria Hospital)
cbioetica@fm.ul.pt
_____________________
Bibliography
Barbosa, A. (1984). Psychiatric intervention in the general hospital. Acta Psiquiátrica Portuguesa, 30: 43-47.
Barbosa, A. et al. (1988). Psiquiatria de ligação. Atendimento psiquiátrico num hospital geral. O Médico, 119, 1904: 337-382.
Barbosa, A. (1989). Psiquiatria de ligação em cirurgia. França de Sousa, J., Cardoso, G., Barbosa, A. (eds) Psiquiatria de ligação e psicossomática. Lisbon, Delagrange, 145-154.
Barbosa, A, (1997a). O doente em estádio terminal; Contributo para o ensino. Revista da FML. Série III, 2, 2:95-99
Barbosa, A. (1997b). Formação em psiquiatria de ligação no internato de psiquiatria. Acta Médica Portuguesa, 12:933-942.
Barbosa, A. (1999). Comunicação com o doente em estádio terminal.
in Gomes Pedro, J. Barbosa, A. (eds) Comunicar: na clínica, na educação, na investigação e no ensino (1ª ed.) Lisbon: Faculdade de Medicina de Lisboa, 69-77.
Barbosa, A. (2010a) Ética relacional in Barbosa, A., Neto, I (eds) Manual de Cuidados Paliativos (2ª ed.). Lisbon FML/ Centro de Bioética/Núcleo de Cuidados Paliativos, 661-691.
Barbosa, A.(2010b) Processo de deliberação ética in Barbosa, A., Neto, I (eds) Manual de Cuidados Paliativos (2ª ed.). Lisbon FML/ Centro de Bioética/Núcleo de Cuidados Paliativos, 693-721.
Binder, R.L. (2002). Liability for the psychiatrist expert witness. Am J Psychiatry, 159, 1819-1825.
Callahan, S. (1988). The role of emotion in ethical decision making. Hastings Center Report, June/July, 9-14.
Cassel, E.J., Leon, A.C., Kaufman, St.G. (2001). Preliminary evidence of impaired thinking in sick patients. Ann Intern Med, 134, 1120-1123.
Lederberg, M.S. (1997). Making a situational diagnosis: Psychiatrists at the interface of psychiatry and ethics in the consultation liaison setting. Academy of Psychosomatic Medicine, 38(4), 327-338.
Preisman, R.C. et al (1999). An annotated bibliography for ethics training in consultation-liaison psychiatry. Psychosomatics , 40:5, 369-379.
Steinberg, M.D. (1997). Psychiatry and bioethics an exploration of the relationship. Psychosomatic,38, 313-320.
Youngner, S.J. (1997). Consultation liaison psychiatry and clinical ethics. Academy of Psychosomatic Medicine, 38(4), 309-312.
A psychiatry of ethics – “Addiction as an illness” (evil is an error, and whoever chooses it is wrong about its true nature, whether as a result of ignorance or illness).
An ethics of psychiatry: “Illness as an addiction” (all illnesses, at least serious ones, due to the fact they cause pain and suffering, imply a type of mental disturbance that would make human beings incapable of discernment, rationality, and prudence).
The complexity of the relationships and problems involved in the practice of contemporary medicine (Barbosa, 1988, 1997b) often confers consultation-liaison psychiatry the role of a mediator between the perspectives of doctors, nurses, and patients and their families in particular clinical situations.
Consultation-liaison psychiatry is a field of clinical psychiatry that includes all psychiatry/psychology activities in non-psychiatric units at general hospitals. These activities take place at three levels: 1) clinical, including diagnosis, therapy, and prevention; 2) educational, that is, the psychological/psychiatric training of other technicians; 3) research. We have been developing these activities since 1987, the year the Liaison Psychiatry Unit of Santa Maria hospital formally started its activity.
The psychiatric aspects of bioethical problems are very common and go hand in hand with issues of a legal, economic, social, institutional, and religious nature (Lederberg, 1997). Consultation-liaison psychiatrists are traditionally, and on a daily basis, amply involved in clinical problems that often constitute true ethical consultations (Steinberg, 1997), and they are almost always well positioned to do so (Binder, 2002).
The main ethical issues in consultation-liaison psychiatry basically are:
1. Issues regarding the principle of respect for autonomy
Each patient is a competent being with intact human rights. The interruption of his/her human rights (hospitalization or treatment against the patient’s will) can only occur exceptionally and always aimed at the benefit of the patient.
When assessing the capacity of patients, the psychiatrist may also perpetuate past mistakes (considering all patients as being incapable, or certain types of patients, such as psychiatric ones, as incapable, or, quite the opposite, resort to rigorous, adequate and up to date criteria of a functional nature).
2. Issues regarding the principle of beneficence.
One of the most frequent conflicts between beneficence and autonomy is refusal on the patient’s part to start treatment, or his/her express will to cease treatment in progress prescribed by the medical team or doctor. This requires a psychiatric evaluation to determine whether the patient is able to make a decision and is not putting him or herself, or others, at risk as a result of this decision.
3. Issues regarding the principle of non-malificence.
Loss of confidentiality may avoid damage being done to others, but also problems deriving from the right to know, or not, the truth, from negligence, malpractice, and ignorance.
4. Issues regarding the principle of justice
Ethics based on non-discrimination, segregation or marginalization, avoiding hospitalization as “punishment”, as well as the distribution of scarce resources to avoid that the most vulnerable (the weaker, frailer, mental patients) suffer.
5. Issues regarding relational ethics
Interpersonal and inter-team communication difficulties, as well as distorted beliefs on the part of health professionals on what should be part of the realm of the ethical and what should belong to the psychological or psychiatric sphere (Barbosa, 2010).
6. Psychiatric Issues with incidence on ethical problems
Patients’ decision-making capacity may be disturbed by actual fear or resurgence of older fears, or may be caused by a defensive problem of denial (normal or pathological). For instance, when a surgery is refused, the majority of causes are of a psychological nature, such as fear, anxiety, negative previous surgical experiences or that took place at that particular hospital, mistrust of doctors, communication problems (Barbosa, 1989).
Another psychological factor that is often difficult to recognize is depression, because the patient with depression generally provides rational explanations for the choices made (Barbosa, 1984). It is important to evaluate feelings of abandonment, neglect, despair, of a meaningless future, or suicidal ideas. The depression aspects that most undermine patients’ capacity are distorted evaluations of themselves, of the world, and of the future. Sometimes antidepressant treatment may be useful to ascertain if depression is interfering with the patient’s decision-making capacity.
Main psychiatric aspects related to ethical difficulties
- Diagnosable psychopathology in any of those involved in the ethical conflict
- Personality styles and psychodynamic problems
- Family dysfunction
- Interpersonal conflicts between patient, family, and health professionals
- Conflicts or non-cooperation among the health intra-team
- Countertransference reactions on the part of health professionals with regard to patients, family, and other agents
- Disproportionate involvement or rejection on the part of the health team
Three types of situations that often occur in the practice of a consultation-liaison psychiatrist can be identified:
a) Pseudo-psychiatric evaluation when an apparent situation of a psychiatric nature disguises an underlying ethical problem.
Following an impasse in patient care due to a conflict of values (conflict between a patient’s family and the medical team about continuing aggressive and invasive medical interventions on a patient with a serious condition who is totally incapable), a request for psychiatric evaluation may be made. This type of situation deserves ethical consideration more than psychiatric evaluation of the patient’s decision-making capacity.
b) Pseudo-ethical evaluation, when psychiatric problems lie at the basis of an ethical problem.
This type of problem is particularly common in end-of-life treatment decisions, due to the importance of emotional aspects in decision-making processes (Callahan, 1988). An example is when patients wish to stop treatment or speed up death, primarily due to excessive and disproportionate fear of dependence or abandonment/neglect (Barbosa,1997a), but equally due to guilt of overburdening the family, or to mere anxiety in the face of the actual process of dying. When, in these circumstances, the focus in on the patient’s right to refuse treatment or on accepting patients’ decisions at mere face value, one may be casting a shadow on vital emotional determining factors in the patient’s decision-making process.
If, on the one hand, acknowledging these difficulties may be important to help distinguish latent feelings from patients’ expressed feelings (Barbosa, 1999), which are often the matrix and the key point to the emergence of ethical problems, on the other hand, one should avoid the psychiatric tendency to medicalize or confer a pathology to all forms of decision-making. Naturally, there is a role for ethical aspects, for moral decision, and for values.
c) A psychiatric and ethical case, in which both play a very important role.
In some circumstances, psychiatric problems may be one of the important aspects of that particular situation, alongside ethical, legal, religious, economic, institutional, and other problems (Barbosa, 2010b).
Naturally, one of the prime responsibilities of a psychiatrist in ethical conflicts regarding medical treatment is to evaluate the patient’s capacity to make decisions, but also to correct diminished capacity (Cassel, 2001), and to treat reversible mental disturbances which, as they are relieved, may enable the whole process of informed consent.
Ethical issues in types of psychiatric intervention
- Treating individual psychological problems
- Evaluating decision-making capacity
- Restoring, improving, stabilizing decision-making
- Improving dysfunctional family dynamics
- Diagnosing and improving team, patient, family issues, and communication problems
- Using the psychiatrist’s capacity to involve other carers, if appropriate
- Recognizing and reducing cultural or religious incongruities
- Evaluating and optimizing the contribution of social or community players
Psychiatric interventions often lead to treatment decision resolutions (whether the patient is competent or incompetent) and to refusal of treatment, which was perceived as a psychiatric issue, and which is now beginning to be seen as an ethical issue. Preparation in this field is not always guaranteed by the training undertaken by health professionals (Barbosa, 1997; Preissman, 1999; Youngner, 1997).
António Barbosa (Professor of Psychiatry and Director of the Centre for Bioethics of the University of Lisbon; Co-head of the Consultation-Liaison Psychiatry Team at the Psychiatry Unit of Santa Maria Hospital)
cbioetica@fm.ul.pt
_____________________
Bibliography
Barbosa, A. (1984). Psychiatric intervention in the general hospital. Acta Psiquiátrica Portuguesa, 30: 43-47.
Barbosa, A. et al. (1988). Psiquiatria de ligação. Atendimento psiquiátrico num hospital geral. O Médico, 119, 1904: 337-382.
Barbosa, A. (1989). Psiquiatria de ligação em cirurgia. França de Sousa, J., Cardoso, G., Barbosa, A. (eds) Psiquiatria de ligação e psicossomática. Lisbon, Delagrange, 145-154.
Barbosa, A, (1997a). O doente em estádio terminal; Contributo para o ensino. Revista da FML. Série III, 2, 2:95-99
Barbosa, A. (1997b). Formação em psiquiatria de ligação no internato de psiquiatria. Acta Médica Portuguesa, 12:933-942.
Barbosa, A. (1999). Comunicação com o doente em estádio terminal.
in Gomes Pedro, J. Barbosa, A. (eds) Comunicar: na clínica, na educação, na investigação e no ensino (1ª ed.) Lisbon: Faculdade de Medicina de Lisboa, 69-77.
Barbosa, A. (2010a) Ética relacional in Barbosa, A., Neto, I (eds) Manual de Cuidados Paliativos (2ª ed.). Lisbon FML/ Centro de Bioética/Núcleo de Cuidados Paliativos, 661-691.
Barbosa, A.(2010b) Processo de deliberação ética in Barbosa, A., Neto, I (eds) Manual de Cuidados Paliativos (2ª ed.). Lisbon FML/ Centro de Bioética/Núcleo de Cuidados Paliativos, 693-721.
Binder, R.L. (2002). Liability for the psychiatrist expert witness. Am J Psychiatry, 159, 1819-1825.
Callahan, S. (1988). The role of emotion in ethical decision making. Hastings Center Report, June/July, 9-14.
Cassel, E.J., Leon, A.C., Kaufman, St.G. (2001). Preliminary evidence of impaired thinking in sick patients. Ann Intern Med, 134, 1120-1123.
Lederberg, M.S. (1997). Making a situational diagnosis: Psychiatrists at the interface of psychiatry and ethics in the consultation liaison setting. Academy of Psychosomatic Medicine, 38(4), 327-338.
Preisman, R.C. et al (1999). An annotated bibliography for ethics training in consultation-liaison psychiatry. Psychosomatics , 40:5, 369-379.
Steinberg, M.D. (1997). Psychiatry and bioethics an exploration of the relationship. Psychosomatic,38, 313-320.
Youngner, S.J. (1997). Consultation liaison psychiatry and clinical ethics. Academy of Psychosomatic Medicine, 38(4), 309-312.
