Psychiatric Annals

Moral Direction and Misdirection for Residents in the Psychiatric Emergency Room

Roger C Sider, MD

Abstract

Emergency psychiatry is one oí ihe mosí difficult and exhausting clinical arenas that residents encounter. Frequently assigned early in their training, during night and weekend rotations when faculty, staff, and disposition resources are minimal, they are expected to assess critically ill patients quickly, sympathetically, und accurately. Further complicating the task are legal and administrative constraints which define the terms for involuntary admission and limit therapeutic options, it is no wonder that such exposure regularly evokes a combination of anxiety, anger. demoralization, and ultimately a survivalist mentality. To cope successfully, residents require two resources: growing clinical competence and a firm sense of moral direction. It is toward the development of the latter that this article is aimed.

THE NEW MEDICAL ETHICS

Much of medical ethics writing over the past 2 decades has had as its dominant agenda a fundamental reshaping of the physician-patient relationship by advocating a contractual model in which the physician is viewed as a purveyor of technical services with the patient [he client,1 This egalitarian, consumer model is used to secure the value of patient autonomy and is buttressed by appeals to "right to treatment." "right to refuse treatment," and the specification of informed consent asa sine qua non of ethical treatment. Implicit in this model arc the following assumptions:

1. Patients should be presumed to be the most suitable judges of their own best interests; therefore, they are the appropriate arbiters of decisions to accept or reject the physician's services. Even suicidal patients may be rational, in which case the ethical physician may be required to withhold involuntary hospitalization.

2. The primary moral duly of physicians is to respect the patient's autonomy by providing sufficient information about the patient's illness, prognosis, and risks and benefits of available therapeutic options to enable the patient to make an informed, valid decision.2

3. To provide care to a patient against his/her will (paternalism) is to violate a moral rule or principle, an action requiring moral justification.5

4. Patients are noi presumed to have a moral obligation to themselves, their families, their society, or their physician to accept needed care and treatment.4

5. Psychiatrists have a historical propensity, as members of a powerful, professional elite, to oppress patients who are often helpless and powerless.7 This is accomplished by assigning disease labels to socially deviant individuals who are then involuntarily committed for coercive restraint and treatment.

6. Psychiatrists cannot make ethical conclusions based on descriptive data because this violates the separation of facts from values insisted upon by current ethical theories under the rubric of the "naturalistic fallacy."

This proposed ethical restructuring of the physician-patient relationship has taken place within a broader social context that questions all authority except that of the state and which views with ambivalence or outright suspicion the treatments that psychiatrists prescribe. Some contend (hat the treatments are harmful, that ECT is brain damaging, psychopharmacologic treatment mind-altering, and psychological interventions behaviorally controlling.0 Others argue that physicians unconsciously wish to harm their patients. One critic has based a recent book on the assertion that "rules governing doctor-patient relations must rest on the premise that anyone's wish to help a desperately pained, apparently helpless person is intertwined with a wish to hurt that person, to obliterate him from sight."7

Although well-intentioned, these reformist changes have done considerable harm to patients, now documented in the lay as well as professional press.8 Of course, these changes also have had an impact upon physicians. First, these changes have tended to shift the moral focus of the physician's attention from what constitutes optimal medical treatment to whether the patient is competent and agrees with…

Emergency psychiatry is one oí ihe mosí difficult and exhausting clinical arenas that residents encounter. Frequently assigned early in their training, during night and weekend rotations when faculty, staff, and disposition resources are minimal, they are expected to assess critically ill patients quickly, sympathetically, und accurately. Further complicating the task are legal and administrative constraints which define the terms for involuntary admission and limit therapeutic options, it is no wonder that such exposure regularly evokes a combination of anxiety, anger. demoralization, and ultimately a survivalist mentality. To cope successfully, residents require two resources: growing clinical competence and a firm sense of moral direction. It is toward the development of the latter that this article is aimed.

THE NEW MEDICAL ETHICS

Much of medical ethics writing over the past 2 decades has had as its dominant agenda a fundamental reshaping of the physician-patient relationship by advocating a contractual model in which the physician is viewed as a purveyor of technical services with the patient [he client,1 This egalitarian, consumer model is used to secure the value of patient autonomy and is buttressed by appeals to "right to treatment." "right to refuse treatment," and the specification of informed consent asa sine qua non of ethical treatment. Implicit in this model arc the following assumptions:

1. Patients should be presumed to be the most suitable judges of their own best interests; therefore, they are the appropriate arbiters of decisions to accept or reject the physician's services. Even suicidal patients may be rational, in which case the ethical physician may be required to withhold involuntary hospitalization.

2. The primary moral duly of physicians is to respect the patient's autonomy by providing sufficient information about the patient's illness, prognosis, and risks and benefits of available therapeutic options to enable the patient to make an informed, valid decision.2

3. To provide care to a patient against his/her will (paternalism) is to violate a moral rule or principle, an action requiring moral justification.5

4. Patients are noi presumed to have a moral obligation to themselves, their families, their society, or their physician to accept needed care and treatment.4

5. Psychiatrists have a historical propensity, as members of a powerful, professional elite, to oppress patients who are often helpless and powerless.7 This is accomplished by assigning disease labels to socially deviant individuals who are then involuntarily committed for coercive restraint and treatment.

6. Psychiatrists cannot make ethical conclusions based on descriptive data because this violates the separation of facts from values insisted upon by current ethical theories under the rubric of the "naturalistic fallacy."

This proposed ethical restructuring of the physician-patient relationship has taken place within a broader social context that questions all authority except that of the state and which views with ambivalence or outright suspicion the treatments that psychiatrists prescribe. Some contend (hat the treatments are harmful, that ECT is brain damaging, psychopharmacologic treatment mind-altering, and psychological interventions behaviorally controlling.0 Others argue that physicians unconsciously wish to harm their patients. One critic has based a recent book on the assertion that "rules governing doctor-patient relations must rest on the premise that anyone's wish to help a desperately pained, apparently helpless person is intertwined with a wish to hurt that person, to obliterate him from sight."7

Although well-intentioned, these reformist changes have done considerable harm to patients, now documented in the lay as well as professional press.8 Of course, these changes also have had an impact upon physicians. First, these changes have tended to shift the moral focus of the physician's attention from what constitutes optimal medical treatment to whether the patient is competent and agrees with the physician's recommendations. Second, they have weakened the physician's primary therapeutic altitude of empathie caring for the best interest of his patient and replaced it with respect for the patient's autonomous choosing. Third, they have suggested that physicians should view a difference of opinion between themselves and their patients regarding the proper course of therapeutic action as a subjective difference of personal opinion. This results in an undermining of physicians' confidence thai their therapeutic recommendations are based upon solid moraf ground.

REGAINING MORAL DIRECTION

Amid the current confusion, il is important for residents to regain moral perspective. The ethos of medicine is a good place to begin. Historically, our profession has been grounded on three overlapping values - life, health, and relief from pain and su Hering. To be a physician is to be devoted to upholding these values on behalf of one's patients. That lile is good, that health is to be sought, and that pain and suffering are to be diminished where possible - these three ends provide the moral purpose for the doctor-patient relationship. Clearly, there are times when these goods may conflict with one another and with other worthwhile goals. But they are not to be discounted lightly, nor, if they are, can physicians give their endorsement. For this reason, ethical physicians have refused historically to be agents of the state in administering death penalties or Io facilitate the implementation of patients': selfdestructive wishes. Accordingly, residents in the emergency department are appropriately guided by these historical professional values.

Next, residents need reassurance that there are twin grounds for this ethical posture that are philosophically respected and a viable alternative to the current medical ethics. First is physicians' expert knowledge of human health and well function. This is not merely technical know-how, but is basically moral, informing the definition of human good. When faced with a sick, suffering patient, physicians' determination of what is good is informed by their knowledge of health norms. In a fundamental sense, the doctor can and does know what is best for the patient insofar as basic health values are concerned. McCormick argues correctly that life is a value thai, while not absolute, is requisite for other values.1' Second, physicians are importantly motivated to act in their patients' best interests because they empathically care for them. Treatment recommendations are ethically made in the context of a personal encounter with the patient. Here, the history is elicited, the personality of the patient assessed, and the nature of lhc illness described. Similarly, ihe patient's wishes and Tears are expressed. This elinical encounter properly evokes in the physician "therapeutic concern," the affective substrate formoral intervention. Because of this grounding i n knowledge and emotion, physicians can give therapeutic advice wiih suint confidence. Their recommendations are not merely subjective opinions, but informed determinations of the good for this patient at this time.

Further, although ethical care requires respectful attention to the patient's wishes and personal values, these do not, even in competent patients, necessarily trump physician recommendations. Patients present lo emergency departments in crisis, highly stressed, frequently regressed, and emotionally overwhelmed. Even while meeting strict criteria for competence, their judgment is often impaired. Frequently, they are not acting in their own best interest as evidenced by suicidal, impulsive, or reckless behavior. To care (or such patients by temporarily limiting their freedom to do serious damage to their relationships, their reputation, their finances, and/or their lives, is to act empathically and ethically. Residents should remember that the patient's freedom of choice is not the highest good, but rather an important value within the broader context of survival and healthful function.

Finally, residents need to be instructed that although they represent an imperfect profession and health eare delivery system, this is the case with all who must act responsibly in lhe real world. TIi e alternative to involuntary treatment with side effect-inducing pharmacologie agents in a suboptimal institutional environment may be no treatment and life or death on the streets.

CONCLUSION

In the psychiatry emergency room, residents can be ethically guided by their profession's historical moral commitment, their scientifically-based knowledge of what is good in terms of health values, and their empathie therapeutic concern for patients. Reformist agendas of civil libertarians and sume medical ethicists interfere with good care, thereby harming patients. Clinical work in emergeney psychiatry settings requires professional competence and a clear sense of moral direction. By understanding who they are and why they are there, residents can find moral direction and professional satisfaction despite the cross-currents of opinion that characterize our present social climate.

REFERENCES

1. Veatch R: A Theory of Medical Ethics. New York, Basic Books, Inc., 1981.

2. President's Commision for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research: Making Health Care Decisions: The Ethical and Legal Implications of Informed Consent in the Patient-Practitioner Relationship. Washington, D.C., U.S. Government Printing Office, 1982. pp 2-6.

3. Culver CM, Gert B: Philosophy in Medicine. New York, Oxford University Press, 1982.

4. Sider RC, Clements CD: Patients' ethical obligation for their health. J Med Ethics 1984; 10:138-142.

5. Brody EB: Patients' rights: A cultural challege to Western psychiatry. Am J Psychiatry 1985; 142:58-62.

6. London P: Behavior Control. New York. Harper & Row Publishers, 1971.

7. Burt RA: Taking Care of Strangers: The Rule of Law in Doctor-Patient Relations, New York, The Free Press, 1979, p vi.

8. Morganthau T. Agrest S, Greenberg Nf. et al: Abandoned. Newsweek 1986; 14:19.

9. McCormick RA: Life preservation and the incompetent, in Teichler-Zallen D. Clements CD (eds): Science and Morality. Lexington, Massachusetts, Lexington Books 1982.

10.3928/0048-5713-19860701-08

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