Divided Loyalties in Mental Healthcare
DIVIDED LOYALTIES IN MENTAL HEALTHCARE•••
Physicians have traditionally understood their primarily loyalty as being to the patients they serve. This tradition goes back to at least to the time healers left behind their shamanistic roots, some twenty-five centuries ago. So important is this sacred commitment that it is enshrined in Hippocratic Oath, with which physicians and the public often identify the medical profession. The relationship between physician and patient is understood as a fiduciary relationship, meaning it is based on trust. Other healthcare professions—and indeed other professions—have modeled their self-understanding on this sort of promise to benefit those served.
Situations do arise in which physicians and other professionals experience divided loyalties—divided between allegiance to the patient and allegiance to some other interest. This has traditionally been spoken of as "the dual-agent (or double-agent) problem." A physician or therapist is a dual agent, for example, if he or she owes an allegiance to an employer as well as the patient. In situations of divided loyalties the integrity of a physician's judgment or action may be compromised. Classic examples of this occur when a physician (especially a psychiatrist) works for the military or for a state or federal institution, where confidences cannot be guaranteed. Increasingly, physicians and other providers find themselves asked to serve the broader interests of society; that is, the interests of populations rather than individuals. This is especially true for those working for large organizations, such as health maintenance organizations (HMOs), managed-care organizations, or nationalized health services. In these situations, the physician must recognize an obligation to society, making it more difficult to buffer the unique concern for each individual patient.
From the moral point of view, most dual-agent situations are best seen as cases of conflicting loyalties or clashing duties. The doctor must choose one duty over another (Macklin, 1982). Perhaps most problematic are situations in which the patient assumes (because of the weight of the professions' patient-centered ethic) that the doctor is working for the patients' best interest. A psychiatrist in a prearraignment examination might be able to elicit more information then a police interrogation simply by presenting a trusting demeanor. But if the message is not "I am here to help you," then the purpose of the examination should be directly stated. An administrative evaluation in a student health service should clearly state, "You are being evaluated at the request of the dean, who will receive a report of my findings." A health professional should not give the impression that everything a person says is confidential if that is not the case.
While cases in psychiatry and mental health have received the most attention, this attention has increased awareness of the problem of divided loyalties in virtually all areas of healthcare. A quick literature search for "divided loyalties" on the Internet returns results from the following specialties: nursing (Winslow; Dinc and Ulusoy; Chao; Tabik, 1996), ophthalmology (Addison), sports medicine (Sim), occupational medicine (Walsh), physical therapy (Lurie; Bruckner), military medicine (Howe; Camp; Pearn; Hines), transplant medicine (Bennett; Tabik, 1994), clinical researchers (Miller), aviation medicine (McCrary), infectious diseases, obstetrics (Plambeck), student health and those doing administrative evaluations and disability evaluations (Lomas and Berman), and house physicians and residents (Morris; La Puma), as well as psychiatrists, forensic psychiatrists and physicians, and child psychiatrists and pediatricians. Issues of privacy, especially the privacy of medical records, cut across all disciplines in the information age, as do issues of cost containment, reimbursement, and healthcare funding. While all these disciplines face situations of divided loyalties, perhaps nowhere is the conflict more dramatic than it is in nursing, where loyalties have undergone a transformation from loyalty to the individual physician for whom and with whom a nurse works, to the healthcare institution that employs the nurse, to patients more generally, and finally to the principles of medical ethics that inform the values of all professions.
Background and History
Divided-loyalty dilemmas have been most blatant in efforts at social control. Since mental healthcare often deals with deviance in behavior, its conceptions run parallel to society's conceptions of social behavior, personal worth, and morality. Thus, in certain situations, there may be great pressure for mental-health professionals to label patients on the basis of social, ethical, or legal norms, and not on clearly established clinical or laboratory evidence of psychopathology.
Doctors are influenced in their activity and judgment by sociocultural context, by the ideology implicit in their professional training, and by the economic and organizational constraints of the setting in which they practice. Their practice involves multiple and, at times, competing professional roles with different social and ethical requirements, but often with no clear definition of boundaries (Mechanic). The practitioner must always ask the crucial question: Whom do I represent and whom do I serve? History is replete with cases showing that the patient is not always the primary one represented.
Extreme cases put the more mundane cases into perspective. Psychiatrists in the former Soviet Union (as well as in other Eastern European countries and in the People's Republic of China) have come under scrutiny for hospitalizing political dissidents and labeling them psychiatrically impaired (Bloch and Reddaway). Physicians in the military governments of Latin American have (perhaps under coercion themselves) cooperated with the torture of political prisoners, a situation that also occurred in South Africa during the period of apartheid. Nazi physicians conducted experiments in concentration camps that would have previously been unimaginable, giving rise to the safeguards of informed consent now required (Drob; Lifton, 1976, 1986). Nazi doctors acted completely contrary to their own moral and professional commitments, serving the ideology of the state and not their patients. These historic lessons make the need to examine divided loyalties all the more urgent.
The use of psychiatry as an instrument of social control had a long history in the former Soviet Union. Soviet authorities chose to have dissenters from official governmental policy labeled with mental illness designations such as schizophrenia, "sluggish schizophrenia," or paranoid development of the personality. The labeling of persons as mentally ill is an effective way to discredit their beliefs and actions, and to maintain control over those persons of whom a government disapproves.
Although the situation in the former Soviet Union was extreme, there have been examples in other societies in which psychiatry has been used (or abused) to stifle nonconformity, serving the interest of someone other than the patient. Notorious examples include the poet Ezra Pound and the actress Frances Farmer, both of whom where involuntarily hospitalized for political extremism (Arnold).
In cases of controversial religious movements, distressed families have sought help from mental health professionals to "rescue" and "deprogram" their children from such groups or cults. The mental health professional may be caught in a divided-loyalty dilemma between family values and religious liberties, possibly medicalizing religious conversions and then treating them as illnesses (Post). On the other hand, vulnerable young people may be particularly susceptible to coercive group pressure, and mental health professionals have traditionally acted in the "best interest of the child" for autonomous growth and development.
The question of divided loyalty can readily arise in matters of confidentiality. Mental health professionals cherish confidentiality as a prerequisite for psychotherapeutic work, but what is an appropriate limit to confidentiality when a patient reveals plans that might endanger others? This question came dramatically to public attention in 1974, when Tatiana Tarasoff, a college student, was murdered. Lawsuits were subsequently brought by the student's parents against the university, the campus police, and the psychotherapist who had failed to warn Tarasoff of threats made against her life by a fellow student (and patient of the therapist) who had fallen in love with her and whose love was unrequited. The therapist had alerted campus police to the danger his patient posed, but they arrested him, found him harmless, and released him.
The military is an organization whose needs and interests may compete with those of the patient. In the military, mental-health professionals are committed to serving society by supporting their commanders in carrying out military operations (Howe). The psychiatrist who returns a soldier to mental health may be returning him to a battlefield where he could be killed. Robert Jay Lifton highlights this ethical conflict by showing that the soldier's very sanity in seeking escape from the environment via a psychiatric judgment of instability renders him eligible for the continuing madness of killing and dying (a perfect example of Joseph Heller's "Catch-22"). Even in military situations, mental health professionals retain obligations to their profession. Further, their clinical effectiveness requires that they give high priority to the needs and interests of the military personnel they treat. In most cases, the mental health professional's ambiguous position in military medicine as a dual agent allows the person to believe that he or she is participating in both the care of patients and the public interest (Howe).
The prison system has also been the setting for a variety of divided-loyalty dilemmas. The professional may be called upon to evaluate an accused person's competency to stand trial. If treated, the person may become competent to stand trial, but left untreated the psychosis may prevent the person from participating in his or her own defense. In capital cases this can be a matter of life or death. How does a physician understand this obligation to the patient when providing treatment, particularly antipsychotic medication that may ultimately lead to conviction and death?
Conflicting obligations can easily arise in situations where doctors ask their own patients to participate in clinical research. While most doctors comply with their primary obligation to deliver the best possible care to their patients, the demands of adhering to a strict research design can create obligations that compete with those of giving good medical care. The research-oriented physician must maintain special ethical vigilance to assure that the patients' interest comes first, a vigilance that is reinforced by external review of research consent procedures.
Ethical Analysis and Resolution
A first step in resolving divided loyalties is to think of loyalty as an attachment or allegiance to a person or cause, and to see it as expressing a coherent meaning that unifies one's personal and professional conduct (Dwyer). Loyalties develop with the assumption of roles and relationships both inside and outside of professional practice. The professional's identity is connected with the primary role of restoring the patient to health. In approaching a divided-loyalty dilemma, it is necessary to articulate and reflect on the meaning of one's commitments in order to determine how these commitments ought to be ordered or reconciled in a particular case.
A basic principle of medical practice is that health professionals should be loyal to their patients and be advocates for them. This commitment does not always avoid conflict. For example, even when health professionals devote themselves exclusively to the good of the patient and show no allegiance to other persons or causes, conflicts may still arise between what the professional sees as good treatment and what the patient wants and sees as good treatment.
The roots of the confidentiality concept are essentially ethical and not legal, and from the earliest days of medical practice, respect for the patient's confidences has been considered an important part of the obligation owed by the physician to the patient. Communications told in secret and in trust have been guarded and respected. In a situation such as the Tarasoff case, however, while acknowledging the desirability of maintaining patients' confidences, one sees a strong competing ethical obligation. When a patient intends harm to another person, or when information is required for the adjudication of a dispute in court, physicians are faced with the claim that societal interests should take precedence. While absolute confidentiality is no longer the expectation, arguments for protecting and extending confidentiality, even in the face of competing demands, remain strong. The arguments usually rest on both ethical and utilitarian grounds and center on the moral good reflected in protecting private utterances. The arguments relate to the belief that confidentiality promotes desirable goals, such as encouraging potential patients to seek medical care and allowing patients to unburden themselves and provide all the information essential for the doctor to help them. In a healthcare system such as that in the United States, the practitioner's relationship to the patient is fiduciary—that is, he or she acts for the benefit of the patient. Can modifications be made that do not compromise the fiduciary relationship? Can the doctor–patient relationship be extended to support affirmative duties not only to the patient but also for the benefit of third parties? Ralph Slovenko, an attorney-psychologist, answers this question in the affirmative, stating that a psychiatrist's loyalty to the patient and responsibility for treating the professional relationship with respect and honor do not negate responsibilities to third parties, to the rest of the profession, to science, or to society. Slovenko goes on to say, however, that how these other duties are accepted, how the patient is kept informed, and how the patient is cared for when other duties are carried out can either introduce or help to avoid a divided-loyalty dilemma.
Joan Rinas and Sheila Clyne-Jackson recommend a forthright stance in preventing dual-agent dilemmas. They argue that the mental health professional has obligations to all parties with whom he or she has a relationship. These duties include notifying all parties of their rights, the professional's specific obligations to each party, potential and realistic conflicts that may arise, and limitations in knowledge and service. If, on exchange of this information, the mental health professional concludes that he or she is not the appropriate one to provide the requested service, the patient or the third party should be referred to a professional appropriate and qualified to perform the desired function. Participants in a Hastings Center symposium on double agentry made a similar set of recommendations for addressing divided-loyalty dilemmas (Steinfels and Levine).
The answer to what appears to be a divided-loyalty dilemma in court cases may rest on a particular type of disclosure. Where the psychiatrist is functioning as a friend of the court, the primary loyalty is not to the patient but to society as embodied in the judicial system. In such settings, the doctor–patient relationship does not exist in the traditional sense. Both doctor and patient must understand this from the outset. Divided-loyalty dilemmas are prevented when the psychiatrist advises all parties involved that the relevant materials they provide will be used in the court proceedings and that he or she is functioning as a consultant to the court (Goldzband).
Divided loyalties are becoming more prevalent due to efforts at cost containment and the rationing of health services. Society is demanding that healthcare costs be controlled. In response, careful protocols are being developed as to what services can be given, and for how long they can be given. These cost-containment methods may interfere with what patients realistically need to remedy their health problems, and can therefore compromise the ethical principle of doctor as patient advocate. Ruth Macklin emphasizes that whether doctors cut costs voluntarily in treating their patients or are required to adhere to policies instituted by others, their ability to advocate vigorously for their patients' medical needs is weakened. When rationing becomes a factor in physicians' treatment decisions, such as which patients will be admitted to the hospital and for how long, physicians are forced into a divided-loyalty conflict. Further, the care obligation embraced by medical ethics cannot be accomplished without permitting a physician to strive for "a robust patient–physician relationship, patient well-being, and avoidance of harm" (Wolf, p. 38).
Conflicting responsibilities, contradictory goals, hidden scenarios, and unsigned contracts existing in the changing world of both the patient and the professional serve as reminders that ideal resolutions may be unattainable in many divided-loyalty dilemmas. Professionals must be very sensitive to the possibility that they may become double agents in the routines of their everyday practice with its many ambiguities and subtleties.
Further, review and examination of dual-agent issues should be a continuing obligation of mental health professionals, for that is one way to prevent these issues from disrupting the doctor-patient relationship. These are issues that often come before professional ethics committees, which keep them alive through education, codes, and professional discipline.
In cases of divided loyalties, physicians and other health professionals should give the patient their primary loyalty, and other allegiances should be subordinated to that of the patient. Where this is not possible, any conflicting allegiance should be explicitly disclosed. The goal of maintaining trust is essential for the therapeutic relationship, and anything that erodes that goal diminishes not only the therapy or the treatment, but also the therapist and the profession he or she represents.
james allen knight (1995)
revised by allen r. dyer
laura weiss roberts
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