Psychiatrists, particularly those practicing in academic settings, are increasingly called upon to serve in roles of institutional and professional leadership (1). One effective medium for psychiatrists to serve as institutional leaders has been as members or chairpersons of organizational committees (2). Consultation-liaison psychiatrists have served as medical board or medical staff presidents (3), and academic psychiatrists have functioned as chiefs of staff, deans, and other high-profile positions in university and veterans affairs hospitals or affiliates (4, 5). Ethics committees are historically and conceptually apposite forums for psychiatrists (6). Although the knowledge base and skill set of psychiatric and ethics consultation are similar and overlap in important domains, there are also significant differences that require specialized training if the psychiatrist is to exercise effective leadership on an ethics committee (7). A brief history of the relationship between psychiatry and ethics committees will be presented in this article as a background for examining appropriate educational initiatives to prepare residents and early career psychiatrists adequately for productive involvement in ethics committees (8).
Psychiatrists in all practice settings confront ethical dilemmas. However, psychiatrists who specialize in consultation-liaison psychiatry or psychosomatic medicine are in a uniquely suited position to serve as leaders of bioethics committees because of their experience in the daily application of ethical principles. Psychiatrists involved in this subspecialty are called upon to make determinations of patients’ decisional capacity, give informed consent and refusal, and forgo life-sustaining treatments. They are highly visible and interact regularly with multidisciplinary staff about ethical issues in their roles as clinicians, teachers and administrators. In June of 2003, psychosomatic medicine became an Accreditation Council for Graduate Medical Education-accredited subspecialty of psychiatry, and in June of 2005, the American Board of Psychiatry and Neurology administered a board examination in the field for the first time. Ethical questions were a part of the board examination and all of the major textbooks in psychosomatic medicine have chapters on bioethics (9, 10).
Ethics committees arose in the 1970s and 1980s as the primary organizational means of managing ethical dilemmas stemming from the rise of technological medicine, the human rights movement, and landmark legal cases such as Quinlan and Cruzan (11, 12). Ethics committees received further legitimacy when the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) recommended that all JCAHO-accredited facilities have a mechanism to address bioethical dilemmas (13). That mechanism is frequently interpreted by the facilities as an ethics committee. Additionally, the federal government enacted the Patient Self-Determination Act in 1990, requiring any facility receiving federal funding, such as Medicare or Medicaid, to have in place the means to ensure patient autonomy (14). The number and scope of ethics committees have grown exponentially over the last two decades (15). In 1983, only 1% of all U.S. hospitals surveyed had an ethics committee; by 1999, a comprehensive study found that over 90% of hospitals had such an organization (16, 17). Preliminary results from an agency for health care research and quality study of ethics committees found that all institutions that are members of the Council of Teaching Hospitals have ethics consultation available (18).
From their inception, ethics committees were multidisciplinary in nature; however, physicians and nurses generally have constituted the majority of the membership, and often have served as chairpersons (17). Few regional or state surveys available separate physician membership according to specialty (19–22). Although psychiatrists have served as both members and chairpersons of bioethics committees for decades, no systematic effort had been made to determine the extent of psychiatric participation on these committees until 2005. Cohen (23) and the members of the bioethics subcommittee of the Academy of Psychosomatic Medicine (APM) performed the first quantitative survey of actual participation in that year. Of the 599 members that APM surveyed, 122 (20.4%) responded. Of these 122, 52% were actively involved with bioethics committees and had served or were currently serving. The duration of their tenure ranged from brief to 31 years and many had been involved for over 20 years. In addition, 12.5% of those who served on bioethics committees were leaders of their committees. An additional survey to determine the extent of psychiatry membership on ethics committees outside psychosomatic medicine is being planned.
A search of the bioethics subset of PubMed using the terms “psychiatry,” “psychiatrist,” and “ethics committee” resulted in only one article specifically dealing with these parameters. This article, written by Engel in 1992, indicated that psychiatrists added value to ethics committees because of their skills in character assessment, group process, and mental status examination, as well as their ability to facilitate communication, perform consultation, and contribute to education and policy-making (6). He argued that the perception of psychiatrists as “reflective, tolerant of ambiguity, humanizing, and approachable about moral aspects of health care” well suited them to serve as leaders of ethics committees (4). Several other articles were identified that discussed the relationship of ethics and psychiatric consultation and the role of psychiatrists on ethics committees (24–27). These articles describe the intrinsic attitudes, knowledge, and skills that psychiatrists, particularly those in psychosomatic medicine, bring to ethics consultation, and by extrapolation and extension, to ethics committees. We and authors of other articles emphasize that ethics and psychiatry are distinct fields, each with its own scholarship, methods, and expertise (27).
Lederberg (7), Perl and Shelp (28), and Leeman (29), among others, have pointed out the complexities involved when ethical issues present as psychiatric problems or vice versa. Lederberg presents the concepts of pseudopsychiatry consultations, where a psychiatric problem conceals a hidden ethical conflict, and pseudoethics cases in which ethical issues are the presenting problem but obscure underlying psychiatric issues (7). The following is an example of a pseudopsychiatry consultation. A psychiatry consultation is called to determine decisional capacity. The patient is a young university professor with AIDS who presents with an acute change in mental status, cognitive deficits, paranoia, agitation, and violent behavior. Neuroimaging demonstrates CNS lesions consistent with herpes encephalitis or progressive multifocal leukoencephalopathy. The patient has completed a durable power of attorney for health care, which names his partner as surrogate decision maker. The psychiatric evaluation determines that the patient is able to understand his illness and the need for diagnostic assessment and treatment but that the staff is overwhelmed with his intelligence, fearful of his impulsive behavior, and unable to reconcile this acting out with the possibility that he is really decisionally capable. The psychiatric consultant educated the staff regarding the neuropsychiatric effects of the patient’s condition but reinforced his ability and right to make his own decisions. Once the staff more fully understood the patient’s clinical situation, they were able to honor his autonomy.
An example of a pseudoethics case involved a 65-year-old man recovering from surgery for a small bowel obstruction. The patient began to refuse to take his medications and nutritional supplements and to cooperate with scheduled tests. An ethics consultation was requested in order to evaluate the patient’s ability to refuse treatment. The psychiatrist discovered that the patient felt the surgeons did not respect him enough to inform him of planned interventions and frequently interrupted his sleep and meals with rounds or appointments for diagnostic procedures. The patient’s desire to be informed and treated with dignity was communicated to the surgical team, and the consultant facilitated discussions around required care. Use of these traditional consultation-liaison skills enabled the patient and team to collaborate effectively.
The final example of a case presenting both ethical and psychiatric issues involves an HIV-positive bus driver with substance abuse who insisted he was no longer using substances but then affirmed both alcohol and drug use. The psychiatrist was faced with the simultaneous ethical obligations to protect the patient’s confidentiality and the safety of the public, a situation which represented a true, rather than disguised, ethical dilemma (30). In this case, the bus driver was not reported but was monitored closely. His urine samples were periodically scanned for cocaine and he was followed frequently by his internist and psychiatrist. The case was presented to both the hospital ethics committee as well as to risk management, and there was consensus that the psychiatrist did not have a duty to warn or report the bus driver's substance use since he agreed to obtain help for his addiction and to be monitored closely. The consultant or ethics committees team responding to all three types of consultations would be unlikely to separate the issues involved without both psychiatric and ethics expertise and the ability to distinguish and negotiate the two domains.
Psychiatrists who serve as chairs of ethics committees or who perform both ethics and psychiatric consultation must be attuned to the differences between their psychiatric and ethics work and scrupulous in respecting the boundaries of their respective roles so as to avoid even the appearance of dual agency. A common example that highlights the need to separate clinical and administrative functions involves a consultation meriting both an ethical and psychiatric judgment. In any case in which psychiatric diagnosis or treatment is relevant, the chair should consult colleagues to perform those functions and provide a report. Failure to do so constitutes a serious conflict of interest that will undermine trust in the objectivity of the chair and the ethics committee, which is crucial to its advisory function.
For instance, consider a case in which a paraplegic patient with antisocial personality disorder was repeatedly discharged from community placements because they could not manage his care. This patient was found positive for illicit substances on each admission and was abusive to staff while on the unit. The spinal cord team felt the patient must be decisionally incapable because he made such poor choices, and the team wished to have a guardian appointed who could place him in a suitable long-term care facility. Because decisional capacity was key to the patient’s right to exercise autonomy regarding his disposition, the psychiatrist-ethics chair requested that another psychosomatic medicine physician assess the patient’s decision-making abilities. The chair then led a small team of committee members who evaluated the ethical issues of patient’s rights, professional obligations, nonmaleficence, and respect for autonomy. The ethics committee recommendations incorporated all of the clinical and social aspects of the case, including the consulting psychiatrist’s assessment.
These complex cases raise an issue that increasingly occupies ethicists: who is competent to consult and what degree and type of training qualify an individual to serve on an ethics committee? (31). Empirical work on this question suggests that current criteria for membership may not be adequate. Hoffman et al. (32) conducted a survey of hospital ethics committee chairpersons. They found that less than a third had a formally trained bioethicst in that position, and 62% reported no formal educational background in ethics, although 62% had a medical background. Sixty-seven percent of ethics committees had membership criteria, but only 11.4% required any training or apprenticeship and only 8.8% required education in bioethics. Eighty-six percent of committees offered some type of education to ethics committees members, but 42% of this education was confined to providing readings in bioethics. Other didactic methods utilized were presentations at meetings, case reviews, journal clubs, and support for attending outside ethics programs. Physician members rated themselves higher in perceived ethics assessment skills than did other health care professionals, despite lacking formal education. This survey did not indicate whether psychiatrists were among the physicians serving on these committees (32).
To explore and address the issue of requisite qualifications for membership on ethics committees, the Society for Health and Human Values and the Society for Bioethics Consultation Task Force on Standards for Bioethics Consultation produced a position paper in 2000 on “Health care ethics consultation: nature, goals, and competencies” (33). The report identified basic and advanced knowledge and skills that ethics committees members should possess. Character traits were also set forth, but these do not have the basic/advanced distinction. Obviously chairs should endeavor to possess as many of these competencies in the advanced category as possible.
An examination of these core competencies suggests that a psychiatrist should acquire many of the basic attitudes and skills required in a good residency and fellowship-training program (33). Residency programs with especially comprehensive ethics education might even provide some of the knowledge and skills mandated for the advanced level. But it is unlikely that even the best fellowship training with the most comprehensive ethics education, such as that offered in consultation-liaison and forensic settings, would equip a psychiatrist with all the skills and knowledge necessary to perform competently as the chair of an ethics committee in a large academic medical center. Appendix 1 lists some of the most advanced competencies that would warrant specialized training.
In the past, psychiatrists have made important contributions to ethics committees as members, consultants, and chairs. The personalities, interests, and training of psychiatrists in academic environments often led them to self-select for involvement in ethics committees, to be recruited by their peers, and to be appointed by hospital administrators to serve as the chairs. Many of these individuals were without formal training in bioethics but developed considerable expertise through natural proclivity, clinical experiences, and self-directed learning which equipped them to serve admirably for many years. However, the subtle complexities of the psychiatric and ethical dilemmas and their overlap and interaction described here, suggest that such on-the-job training may be necessary, but not sufficient, to prepare a psychiatrist for ethics committee leadership. Formal and structured training in bioethics would seem in order for any psychiatrist intending to serve as the chair of an ethics committee for an extended period of time. There is an opportunity for residency and fellowship programs to begin to develop postgraduate level ethics education, especially for those trainees demonstrating an interest in and aptitude for clinical ethics. Appendix 2 suggests pedagogical methods to translate the core bioethics competencies into curricular objectives and strategies that could be incorporated into residency and fellowship training.
Though only a minority of psychiatrists will serve as chairs, those who do may wish to pursue additional avenues of professional ethics education even beyond those provided in a fellowship program (34). These include certificate programs in bioethics, advanced university degrees in bioethics or related fields, or clinical fellowships in ethics (Appendix 3). Residents interested in pursuing ethics as a field of specialization would benefit from a connection to mentors in the field, an opportunity to conduct research in the areas during training, and an intensive focus on ethics consultation during appropriate rotations and fellowships, such as the required third-year rotation in consultation-liaison psychiatry. A prologue to these more directed initiatives should be continued strengthening and enrichment of ethics training at all levels of psychiatric training. The overarching goal of these initiatives should be to prepare every psychiatrist to be able to recognize the differences between ethical and psychiatric issues, to proffer constructive responses to these issues in a clinical context, and to seek additional consultation when the complexity or sophistication of cases is beyond their level of expertise.