Ethical and Legal Aspects of Psychosomatic Medicine

Article excerpt

Psychosomatic medicine, also known as C-L (consultation and liaison) psychiatry, is a subspecialty of psychiatry that deals with the interface of psychological, ethical, social, and legal issues arising in clinical medicine. This article addresses ethical and legal aspects of practice in this area utilizing a case-review perspective.

KEY WORDS: Consultation and liaison psychiatry, decision-making capacity, psychiatric ethics, psychosomatic medicine.

Psychosomatic medicine, also known as C-L (consultation and liaison) psychiatry, is a subspecialty of psychiatry that deals with the interface of psychological, ethical, social, and legal issues arising in clinical medicine. Due to the complex nature of this area of practice, authors, clinicians and ethicists have proposed principles and models to guide the treatment and management of complex issues. Beauchamp and Childress, in their work on bioethics, first published in 1979, defined four cardinal ethical principles in clinical care: nonmaleficence (an obligation to avoid doing harm), beneficence (an obligation to benefit patients whenever possible and to seek their good), respect for autonomy (the ability to make deliberated or reasoned decisions for oneself and to act on the basis of such decisions), and justice (fairness).1 Lederberg discussed a situational diagnostic methodology to define and address the different components of multilayered complex cases and systematically evaluate ethically important situations which includes: examination of patient and family issues (including any mental illness present in the patient or key significant others); staff issues; "joint" issues (e.g., family-staff relationships); legal/institutional issues, and ethical issues.2 Hundert proposed a model in which each of the basic values of liberty, justice and fairness that collided to create an ethical dilemma is weighed for the relative importance of each value and a moral action is therefore suggested.3

In practice, laws in local jurisdictions and individual aspects of each clinical case can further complicate the execution of proposed ethical guidelines and principles in the treatment and management of patients in the hospital setting. Physicians and specialists in psychosomatic medicine need therefore to be familiar with concepts related to decision-making capacity, advance directives, right to refuse treatment, informed consent, living wills, duty to warn, withholding medical treatment, patient autonomy, and confidentiality. Furthermore, practitioners must have knowledge of the laws associated with their local jurisdiction in order to make informed treatment decisions and recommendations for their patients. In the following sections, we will describe four case scenarios often encountered on our C-L service at the University of Pennsylvania. These examples will further illustrate some of the ethical dilemmas faced by psychosomatic physicians in their practice.

Decision-making capacity (Case 1)

Our psychosomatic medicine service was consulted to evaluate a 45 -year-old female who was admitted to the medical floor for abdominal pain due to alcoholic pancreatitis and was asking to leave against medical advice. The patient has had multiple previous admissions for this condition. The medical team informed us that she has been refusing to follow the team's advice and has been loud and oppositional. Upon initial evaluation, the patient was standing at the nurse's station, questioning us and demanding to be discharged right away. The patient continued to refuse to cooperate with the interview, stating that she has to go home to take care of bills. Her speech was noted to be pressured and her affect was angry. Although it was not known if our patient had any past psychiatric history, previous records mention a diagnosis of bipolar affective disorder by history, but no treatment for it. The patient denied any psychiatric diagnosis or treatment history whatsoever. …