Wednesday, January 27, 2010

Psychiatric Ethics in Boston

While reading yesterday's Boston Globe over coffee I encountered two stories about courtroom trials that raise central issues in psychiatric ethics along with the legal matters the trials are about. Two in one day!

The Globe reported that Dr. Kayoko Kifuji testified in trial of Carolyn Riley, who is charged with murder in the death of her four year old daughter Rebecca. The prosecution alleges that Carolyn and her husband Michael, who will be tried separately, overdosed Rebecca with psychiatric medications, causing her death.

The issue in psychiatric ethics isn't murder, but Dr, Kifuji's prescribing major tranquilizers for Rebecca starting at age 2. Based on statements by Rebecca's mother, Dr. Kifuji diagnosed Rebecca as having bipolar illness, and prescribed strong doses of three powerful medications.

All I know about the case is what I've read in the paper. That a psychiatrist can (a) diagnose bipolar disorder in a two year old, (b) based solely on the mother's reports of behavior, without (c) extended inquiry into what was happening in the family or (d) additional information from day care workers and others, is, alas, (e) symptomatic of the current state of U.S. psychiatry. Forty years ago, at the peak of psychoanalytic thinking, mothers were confidently diagnosed as "schizophrenogenic' - that is, as causing schizophrenia by their cold, rejecting attitudes. Now we diagnose two year olds in a comparably confident manner.

What's needed is much more humility and curiosity. Humility about the limits of our knowledge. When I was in training my teachers assumed the truth of psychoanalytic explanations. Now we tend to assume the truth of neurological explanations. The real truth is that our understanding of complex phenomena is still rudimentary. As a result we need to be more curious to delve more deeply into the lives of the people we deal with - their biology, their psychology, and the social contexts in which the concerns are arising.

The other story concerns a malpractice suit brought by Ken and Danielle Lambert against McLean hospital and members of its staff, alleging responsibility for "wrongful deaths" of their 5-year-old daughter, Kaleigh, and 4-year-old son, Shane who were killed when Danielle's twin sister carried the children into traffic on Interstate 495 in a state of psychosis. (See here for a post about the events.)

Once again, my only knowledge of this case comes entirely from the media. The ethical issue that stands out for me involves confidentiality. Here's a relevant quote from the Globe:
The Lamberts told the Globe after the deaths that McLean psychiatrists had diagnosed Thibault with bipolar disorder in September 2007 and discharged her six days later after prescribing psychotropic drugs and recommending outpatient therapy. But, the couple said, doctors never told family members about the risk Thibault might pose to others or herself.

"Had they been warned of this potential," the Lamberts’ lawyer, Andrew C. Meyer Jr. of Boston, said yesterday, "they never would have allowed the children to be in her care that night."

...The Lamberts face significant obstacles in their suit, including confidentiality laws that limit what medical providers can disclose to third parties...
Psychiatry is not good at predicting danger, especially given that the tragic incident took place four months after Danielle Lambert's sister was discharged from McLean. What "interfered" with the Lamberts receiving any warning may well have been that clinical evaluation gave no indication of risk. In that case, concerns about confidentiality played no role.

But over the years I've seen innumerable situations in which mental health clinicians let an overly rigid understanding of confidentiality regulations trump common sense and thoughtful ethics. If clinicians believe that patients are dangerous to themselves or others, there are all kinds of ways of conveying relevant information to family members.

The best, of course, is to explain to the patient why one wants to convey the information, to discuss how best to do it, and to get permission to go ahead. Asking for permission can be done wimpishly - "may I talk with your XYZ?," dropping the topic at the first whiff of a "no," or vigorously - "I really think we should talk with XYZ about ABC," persevering in an effort to persuade.

It's also possible to give information indirectly. A clinician who is concerned about possible risk could say to a family member - "it's difficult to predict, but in illnesses like this there can be a risk of dangers..."

And, it's always possible to do what one thinks is right even if doing so violates the letter of the law. Society, and juries, expect clinicians to be devoted to the well being of their patients and relevant others, not simply to be slaves to regulations. I recall a number of situations in which I (a) was not able to get a patient's permission to convey information to someone else, (b) felt that doing so was in the ultimate interest of the patient as well as the third party, (c) told the patient what I was going to do, and (d) carefully documented my rationale. In most of these situations my patient and I remained on good terms, able to continue to work together.

In ethics discussions, it's common for students and seasoned clinicians to ask first - "what's the law about this situation?" My response is - "our job is to decide what we think the right thing to do is. Once we know that we can ask the lawyers - "how can we to [the right thing] most consistently with the law."

Ethics first. Then law.

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