I enjoyed a good conversation the other night on ethics as it applies to mental health treatment. As often happens after a good exchange, I came away from it wanting to enrich my understanding of some of the issues we talked about. Saul Bellow once said, 'how can I know what I think until I see what I write. With this in mind, here's some thoughts.
Ethical decisions are complex and nuanced. In making decisions we are often faced with myriad options. I'm reminded of the image on a television screen. There are an almost infinite array of colors and hues visible on the screen, yet all of this complexity is created by only three primary colors. These colors are fundamental dimensions. Perhaps if we can find a few dimensions that characterize the essence of mental health decision making, we can use them as channel markers to orient ourselves in complex and subtle decision making. This leads me to ask, what are these dimensions in medical, and in particular mental health ethics?
Let me propose the following:
Do no harm and it's corollary, be constructive
Avoid self indulgence
Respect and encourage Autonomy
Respect and protect privacy.
These four dimensions are concepts that we can use to govern our decision making. At the same time, like concepts embedded in a constitution, they are ambiguous and open to interpretation. This is unavoidable but hardly diminishes their utility, and in fact is the basis for why reasonable people can differ in their ethical calculus.
Let's put these ethical dimensions to the test with a simple but practical example. Consider the abrupt transition during the pandemic to using virtual technologies for sessions with patients. We made the transition rather suddenly, and now after two years, we are at a point of merging back to in office with face to face visits. During this transition time we are asking, should I get back into the office? Using this example as a template, let's apply our ethical concepts to try and answer the question.
First, the obvious. At the outset of the pandemic clinicians flocked to virtual tools in order to avoid harm. As the pandemic got underway it was clear that in most circumstances virtual visits were an effective way to interact with patients. Still, at times we met some patients in office when the risk of not having the patient physically present exceeded viral exposure (being constructive). In our clinic, this might have been when a patient needed urine drug screening for their safety (avoid harm), or in some cases, when patients simply did not have a private space to access counseling (being constructive).
Attempts to optimally use new technologies (being constructive) led to our wish to optimize the virtual experience. I read, for example, that voice quality was more important than video in online interactions, and so took time to research microphones.
Most of us also thought through the issue of privacy (privacy). We sought out secure platforms as well as means to securely send out appointment reminders and otherwise communicate with patients. As the pandemic wore on, there began to appear a small but significant literature looking at the cognitive impact of virtual tools. One remarkable article addressed the issue of fatigue. The idea was that online visual tools such as Zoom create a subtle desynchronization of sound to lip movement that, though beyond the threshold of conscious awareness, could lead to fatigue and distraction on the part of either therapist or patient. Awareness of subtle differences between virtual and live interactions enhanced ones clinical nimbleness (be constructive).
Now, as we transition out of the pandemic back to live encounters the issue of 'self indulgence' comes to the fore as a governing principle. It is remarkably easy and comfortable for therapists to see patients online from the home office. We can tell ourselves, why not, virtual mediums are not bad. However, I think studies will eventually show that as a tool for counseling virtual visits are not quite as effective as face to face interactions. These days I tell my patients that they are getting 75 cents on their dollar when they see me virtually versus the 100 pennies they deserve when they come into the office. Do I really want to be cheating my patients for my personal comfort (self indulgence)?
While the above example of the ethical issues surrounding online visits is somewhat trivial, the example nevertheless illustrates how we can use a relatively small number of ethical dimensions to guide an enormous variety of clinical behavior.
For each of the dimensions mentioned at the beginning of this essay there are obvious violations: we should not have intimate relations with our current or former patients. We should pursue continuing education in our respective disciplines in order to maintain the highest standard of care. We should avoid extra-therapeutic interactions, such as business deals with our patients. We avoid gossiping about patients and strive to protect their privacy.
On the other hand, there are very subtle challenges to good ethical behavior: is it justified in certain instances to treat someone with medications, 'off label?' What are the boundaries that constitute self indulgence? Is accepting a small gift during a holiday appropriate, is it okay to reciprocate a hug?
There is a term in common parlance, 'micro-aggression,' that describes offenses we might offhandedly make in social encounters. We can borrow this term and for the purpose of ethics morph it into the phrase 'micro violations.' It is inevitable that in governing our clinical behavior we will micro violate from time to time. Just as when driving a car we continuously correct little deviations to stay on course, so too in our clinical work it is our awareness of micro-violations that allows us to to guide sound ethical behavior. By being aware or our channel markers, we are thoughtfully negotiating complex decision making. If I get into a sidebar conversation with a patient around aspects of his or her work or hobby that might fascinate me (self-indulgence) I might be getting of course? A little voice in my head signals I'm near a channel marker. By listening to this voice I give myself I can redirect my behavior. A single micro-violation is unlikely to be consequential, yet by being aware of such deviations I am guided to be my best clinical self.,
We can conclude with an analogy. In malpractice suits, defendants tend to be held more accountable for not considering the complexity of a situation, than for thinking through a given situation and guessing wrong. Similarly, in making ethical decisions we are going to disagree at times, but we should all agree that the best decisions are made in the context of thoughtfully measuring specific decisions against a framework of basic, pre-established, concepts, concepts that I am calling channel markers.