Ethics, Professionalism, and Forensic Psychiatry Comprehensive Exam Notes

Ethics and Professionalism

• Definition of ethical conflict: tension between what one wants to do vs. what is ethically right.
• Definition of ethical dilemma: clash of differing ethical principles/values.
• Professional ethics = morality + social norms + role‐specific parameters.

Professional Codes

• AMA – Principles of Medical Ethics.
• APA – Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry.
• Both exhort:
– Use scientific techniques.
– Self-regulate misconduct.
– Respect rights of patients, families, colleagues, society.

Four Basic Ethical Principles

1. Respect for Autonomy
   • Requires intentional action + adequate information + time.
   • Includes right to delegate decision‐making (guardian, proxy).
   • Example: psychotic young adult refusing antipsychotics—negotiated respect → eventually accepted meds.

2. Beneficence
   • Fiduciary duty to act for patient & society.
   • Paternalism:
   – Weak: patient lacks autonomy.
   – Strong: overrides intact autonomy for substantial harm prevention.

3. Non-maleficence
   • “First, do no harm.”
   • Adequate training, second opinions, active risk avoidance.

4. Justice
   • Fair distribution of benefits/burdens; reward/punishment.
   • Resource allocation models: greatest need vs. greatest individual impact vs. greatest societal impact.

Five High-Frequency Ethical Problem Areas

1. Sexual boundary violations.

2. Non-sexual boundary violations.

3. Confidentiality breaches.

4. Mistreatment (incompetence, double agency).

5. Illegal activities (insurance fraud, insider trading, etc.).

Sexual Boundary Violations

• Sex with a patient = unethical + illegal (rape, assault, battery, malpractice).
• Insurers exclude coverage.
• “Once a patient, always a patient” vs. time-limited prohibition—APA holds: sexual activity with current OR former patient always unethical (extends to family).
• Example: CA psychiatrist had 7-year affair, group sex, prescriptions → license revoked & fraud conviction.

Non-Sexual Boundary Violations

• Boundary-crossing ≠ violation unless exploitative / meets clinician’s needs at patient expense.
• Gift example: resident refused scarf → patient attempted suicide → need to explore meaning.
• Freud cigar anecdote—accepted gift then analyzed motive.
• Categories:
– Business: avoid business with patient/family; rural exceptions handled cautiously.
– Ideological: treatment decisions mustn't be swayed by clinician’s beliefs.
– Social: avoid friendships; don’t treat social friends (except emergency).
– Financial: fees, missed appointments, sliding scale, resentment, transparency.

Confidentiality

• Therapist duty; patient holds privilege in court.
• Violations harm trust, violate non-maleficence, and can be overridden for protection (duty to warn/report, child abuse, impaired professional).
• Endures after death; subpoena ≠ automatic release—judge can review in-camera.
• Teaching/research: disclose only necessary info, de-identify if possible.

Managed-Care Challenges

• Psychiatrists must:
– Disclose all treatment options (even if not covered).
– Appeal denials.
– Continue emergency treatment.
– Cooperate w/ utilization review w/ patient authorization.
• Case: Dr. A hides improvement to keep pt inpatient — deception harms trust, future care, policy reform; appeals preferable.

Impaired Physicians

• Causes: psychiatric/medical disorders, substance use.
• Ethical duty to report; State boards & physician-health programs.
• Treater should not monitor; independent monitor required.

Physicians-in-Training

• Delegation only with adequate supervision.
• Patients must know level of trainee.
• Trainees must know limits & seek help.

Physician Charter on Professionalism (2001)

Fundamental Principles

• Primacy of patient welfare.
• Patient autonomy.
• Social justice.

Commitments (selection)

• Lifelong competence.
• Honesty & error disclosure.
• Confidentiality.
• Maintain appropriate relations.
• Improve quality/access & allocate finite resources fairly.
• Manage conflicts of interest, self-regulate profession.

APA Table of Ethical Q&A (selected)

• Retirement ≠ abandonment if notice & referral.
• Bequests: accepting estate unethical; token gift possibly OK.
• Vaginal exams OK only if competent & doesn’t distort transference.
• Post-mortem confidentiality survives.
• Reporting: duty but assess risk/benefit; child abuse mandatory.

Military Psychiatry

• No absolute confidentiality under military code → may deter care; suicide rates spark calls for reform; many clinicians exercise discretion.

Forensic & Legal Issues

Medical Malpractice

• Civil tort of negligence; 4 Ds = Duty, Deviation, Damage, Direct causation.
• Expert testimony + guidelines establish standard of care.
• Intentional torts (battery, fraud) not covered by insurance.

Negligent Prescription

• Exceeding doses, polypharmacy, wrong indications, lack of disclosure, failure to monitor.
• Informed consent each med change; visits ≤ 6-month intervals at maximum.

Split Treatment

• Medication by psychiatrist + therapy by non-MD.
• Psychiatrist retains full responsibility; must communicate, hospitalize if needed.
• Fragmented care = substandard; malpractice trap.

Privilege vs. Confidentiality

• Privilege: legal right (patient) to withhold testimony.
• Jaffee v. Redmond (1996) federal psychotherapist–patient privilege.
• Military courts: no privilege.
• Subpoena duces tecum: produce records; can seek in-camera review.

High-Risk Scenarios

• Tardive dyskinesia: informed consent, monitoring.
• Suicide: foreseeability vs. preventability; thorough assessment, precaution plan.
• Violence: Tarasoff I (1976) duty to warn; Tarasoff II (1982) duty to protect (warning, hospitalization, police, medication).
– National standard even in states without statute.

Hospitalization Types

1. Informal (voluntary, can leave).

2. Voluntary formal (signed application; can leave).

3. Temporary (emergency, single MD, confirm within ~15 d).

4. Involuntary (danger to self/others; two physicians; legal rights, periods ~60 d; habeas corpus).
   – Parens patriae doctrine.

Rights

• Right to treatment (Rouse v. Cameron 1966, Wyatt v. Stickney 1971).
• Right to refuse treatment except emergency (O’Connor v. Donaldson 1976; Rennie v. Klein 1979; Rogers v. Okin 1981).
• Least restrictive alternative, visitation, communication, privacy, economic (fair wages).

Seclusion & Restraint

• Only when risk of harm & no less restrictive alternative.
• Written, time-limited orders; regular review.

Informed Consent

• Claims often added to malpractice; minors: parent consent except for specified conditions (STD, pregnancy, substance).
• Mature minor rule, emancipated minors.
• Essential elements: diagnosis, treatment nature, risks/benefits, alternatives, prognosis.

Child Custody

• “Best interests.” Presumption favoring mother eroding.
• Courts may remove children (neglect/abuse).

Competence & Capacity

• Testamentary capacity: know property, making bequest, natural heirs.
• Competence = task-specific; only judge decides.
• Durable power of attorney anticipates incapacity.

Criminal Law Interfaces

• Competence to stand trial: Dusky standard (consult lawyer & understand).
• Competence to be executed (Ford v. Wainwright). Ethical ban on physician participation.

Criminal Responsibility Tests

• M'Naghten (1843): unable to know nature/quality or wrongfulness.
• Irresistible impulse (policeman-at-elbow).
• Durham/Product rule (1954) – later abandoned.
• Model Penal Code (ALI): lack substantial capacity to appreciate wrongfulness OR conform conduct due to disease/defect.
• Guilty but Mentally Ill verdict = sentence + treatment.

Other Forensic Topics

• Emotional distress claims, concentration camp reparations.
• Recovered memory litigation – risk management principles (maintain neutrality, document, avoid suggestion).
• Worker’s compensation psych evaluations.
• Sexual exploitation civil/criminal/ethical consequences.

HIPAA Privacy Rule (selected patient rights)

• Written notice of privacy practices; acknowledgment.
• Copy of records (psychotherapy notes exempt).
• Accounting of disclosures.
• Authorization required for non-routine disclosures.
• Alternative communications; complaint mechanism.

Key Numerical / Mnemonic References

• 4Ds of malpractice: Duty, Deviation, Damage, Direct causation.
• Split-treatment malpractice risk: ensure ≤6-month med follow-up.
• Involuntary hold typical time limits: 15-day temporary; 60-day initial civil commitment.

Ethical & Practical Implications

• Balancing patient autonomy vs. beneficence/paternalism informs consent, involuntary care, deception to insurers.
• Duty to society vs. individual (justice) drives Tarasoff obligations, managed-care appeals, resource allocation.
• Confidentiality erosion (insurance, electronic records, military) challenges trust, demands transparency.
• Professionalism charter links ethics to lifelong competence, quality improvement, and social justice—embedding ethics in daily practice.

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