Sunday, June 18, 2017
A Circular Ethics Argument About Psychiatric Services
I attended the Minnesota Psychiatric Society MPS spring meeting yesterday. The current American Psychiatric Association (APA) President Anita Everett, MD was there and gave a presentation on ethics. The title of her presentation was Ethical Issue Management in Team Care. The conference was focused on collaborative care and innovative ways to extend psychiatric practice out into areas where there is little to no coverage. The afternoon was dedicated to an APA sanctioned presentation called Applying the Integrated Care Approach: Practical Skills for the Consulting Psychiatrist.
The central theme in Dr. Everett's presentation involved streamlining the 9 dimensions of the AMA code of ethics annotated for psychiatry to 4 dimensions from Principle of Biomedical Ethics. Those dimensions include beneficence, non-maleficence ("do no harm"), autonomy and justice. There was not a good 1:1 translation largely because in her formulation autonomy seemed to apply to patients but there was a question mark regarding physician autonomy. Some of the AMA/APA dimensions applied to two of the 4. For example, commitment to medical education was seen as applying to both beneficence and non-maleficence.
Dr. Everett is a community psychiatrist and has studied various community mental health centers. She makes the distinction between simple and complex systems and how applying ethical principles to complex system. She gave some examples of how this might apply like integrated care in a medical shared ACO and meeting a patient in a coffee shop as part of an ACT team intervention. She poses the the ethical analysis as a series of questions pertaining to the 4 dimensions.
The open discussion was instructive. There was a psychiatric administrator present who talked about the ethical issue of emergency department congestion. In his hospital there are 80 ED beds. There has a chronic problem with psychiatric patients stranded in the ED sometimes for days. The problem is basically a systems problem because most Minnesota acute care hospitals do not have psychiatric units, and very few (2 or 3) in the Metro area are equipped to treat patients with aggressive behavior. As a result practically all of the police and paramedic related acute admissions in a 5-county area are brought to this hospital. At the same time acute care beds in Minnesota are rationed to the point that there are fewer beds available than in practically all OECD countries including Mexico. One of the other attendees at the conference also made a statement consistent with what I have put on this blog many times: the state of Minnesota has systematically dismantled the state hospital system and came up with an inadequate secondary system that they no longer use. That participant was an expert in the state hospital system. In the meantime, individual counties have essentially eliminated supervised housing for people with severe mental illnesses. I really don't know what people expect when all of the resources to treat severe mental illnesses are rationed away and emergencies continue to happen. What occurs is a large steady state population of mentally ill people who are rooted partially on the street or in very suboptimal housing, inpatient units, the ED, or (worse case scenario) jail. In what was probably the most illogical approach to a solution, the ED reported the Psychiatry Department to the ethics committee for not solving the problem of ED congestion with psychiatric patients!
The ethical conflict in this situation was discussed from the perspective of turf (ED physicians versus psychiatrists) and patient autonomy. Physician autonomy was touched on only so far as the question of whether physicians need to sacrifice autonomy for the greater good. Does the sacrifice of autonomy lead to resources to treat more people in the long run? That argument was advanced by a managed care physician-administrator.
Any reader of this blog knows that I view ethics as basically political arguments. Most ethics seem relative to the political arguments that carry the day. For example if you think doctors aren't paying enough attention to costs and you are a health care administrator - make cost effective care the new definition of professionalism. In this case, it comes down to blaming psychiatrists for severely rationed services. The technical argument basically transfers blame directly away from the rationers to psychiatrists who are left with a huge problem. That ethical argument carries the compounding problem negatively impacting all of the ethical elements as outlined by Dr. Everett and leaving the psychiatrists in a totally untenable situation. It also illustrates how a dissection of a complex system - in this case the entire universe of mental health care in Minnesota - results in a ethical argument that only applies to one environment - in this case the emergency department. Even there it should be painfully obvious that these problems selectively apply to psychiatric patients. There is no backlog of patients with chest pain waiting for 2 or 3 days in the ED or being transferred to a remote hospital 200 miles away. All of the illogical approaches to psychiatric care that apply in the ED can be traced back to decisions by politicians - not the least of which is to hire managed care proxies to ration access to care. It is obvious that sacrifices in physician autonomy to managed care administrators has only made the problem far worse and not better.
In the state of Minnesota. there is no justice for psychiatric patients.
George Dawson, MD, DFAPA
Anita Everett, MD, DFAPA. Ethics in complex systems of care. Minnesota Psychiatric Society Spring Scientific Meeting. June 16. 2017.