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.