Jennifer Radden is a Professor of Philosophy at the University of Massachusetts Boston, and Consultant in Medical Ethics at McLean Hospital. John Z. Sadler is the Daniel W. Foster, M.D. Professor of Medical Ethics and Professor of Psychiatry and Clinical Sciences at UT Southwestern. Together they wrote, The Virtuous Psychiatrist: Character Ethics in Psychiatric Practice, which presents virtue traits as habits, able to be cultivated and enhanced through practice. The book describes these “virtuous” traits and how they can be habituated in clinical training. In the excerpt below we learn why these traits are so important through a case-study example that has no obvious answer.
Some of the dilemmas and problems around patient autonomy that are so distinctively psychiatric can be most readily revealed through a case example:
An adult patient with paranoid schizophrenia has discontinued her antipsychotic medication and has threatened her aging parents at knifepoint because” they are the toxin people who want me to be a good girl.” Her parents obtained a mental illness warrant (court order) for a brief psychiatric evaluation, and you, her long-standing doctor, are familiar with the following clinical pattern. She will agree to resume taking her medication to stay out of the hospital, but not follow through with this commitment until involuntarily hospitalized and medicated back to her baseline nondelusional state. The patient’s parents are urging you to again seclude the patient without her consent. Moreover, the managed care reviewer who would permit reimbursement for care refuses to “certify” (endorse) hospital care because “the patient is willing to take medication as an outpatient.”
This case raises many questions. Most broadly, is this patient rightly seen as an autonomous person, a rational agent capable of determining her own interests, an informed consumer of medical services, and one able to enter into an agreement about taking medication as an outpatient? How, more generally, should the parents’ physical safety be balanced against the patient’s individual rights? Indeed, given the hardships of living with a schizophrenia sufferer, how should the parents’ interests and stake in this decision be ranked against the patient’s own? Ought the practitioner’s prediction of outcome be honored over the assessment proffered by the managed care reviewer? How do we regard the professional role conflicts imposed on the psychiatrist, who is caught between the goals of ensuring safety for the parents and the patient, maintaining the critical “alliance” with the patient necessary for any long-term therapeutic success, and using whatever means to reduce her dangerous, delusional thinking?
Some of these dilemmas and difficulties, or closely related ones, may have complements in other specialties of medicine; others have none, or at least very, very few analogies in other medical fields. An, as this example illustrates, these are quandaries amplified, rather than reduced, by managed care medicine.
The principles governing all biomedical ethics are undeniably useful for the practitioner dealing with cases such as this one. Clearly, the value of autonomy, a principle accepted not only throughout medical but throughout professional ethics, will have to be part of any deliberation over ethical conduct in such a case, as will that of beneficence. And, as is so often true throughout biomedical ethics, patient autonomy and beneficence appear to be in tension here, presenting a common quandary or dilemma for the practitioner. Even the commitment to the principle of justice might be seen to be implicated in this complex decision. The patient’s apparent rights – to refuse her treatment, and to be trusted and respected in her predicted bargain – might be seen to introduce one kind of obligation for the person treating her. But the principle of beneficence, reflected in the practitioner’s recognition that her patient’s decisional capabilities can be enhanced with medication, is also pertinent – added to which the impulse to help her and ensure the family’s safety has its own legitimacy. On balance, preventing the danger to others posed by the untreated patient may present itself as a duty stemming from the principle of justice. The ethical decision here can be portrayed as one of balancing, competing, and incompatible goods or duties, and it will be a difficult and weighty, though painfully familiar, one.
Leaving the analysis at this point, however, would be failing to acknowledge the extent that this case is typical, even emblematic, of psychiatric ethical dilemmas. What distinguishes our practitioner’s dilemma from conflicts around the value of autonomy within the rest of biomedical ethics is that the tensions seem more starkly etched here. The issue is not merely whether to honor the patient’s autonomy over the principles of beneficence, nonmaleficence, or justice, but whether the category of autonomy is applicable at all. Even when, with every appearance of self-interested rationality, the patient tries to bargain with her doctor, promising to take her medicine if in return she need not return to the hospital, the nature of her illness forces us to ask whether the attempted agreement is a genuine expression of rational processes and personal decision.