Ethical Challenges in Psychiatric Administration and Leadership

Abstract

As with all professional ethical principles, those in psychiatry have to evolve over time and societal changes. The current ethical challenges for psychiatric administration and leadership, especially regarding for-profit managed care, need updated solutions. One solution resides in the development by the American Association of Psychiatric Administrators (AAPA) of the first set of ethical principles designed specifically for psychiatric administrators. These principles build on prior Psychological Theories of leadership, such as those of Freud, Kernberg, and Kohut. Supplementing these theories are the actual real life models of psychiatrist leadership as depicted in the memoirs of various psychiatrists. Appreciating these principles, theories, and models may help emerging leaders to better recognize the importance of ethical challenges. A conclusion is that psychiatrists should have the potential to assume more successful leadership positions once again. In such positions, making the skills and well-being of all in the organization seems now to be the foremost ethical priority.

Appendix: Ethical Principles for Psychiatric Administrators: The AMA Principles of Medical Ethics, with Annotations Especially Applicable to Psychiatric Administrators

Approved by the American Association of Psychiatric Administrators October 28, 2000.

Preamble

The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. As a member of this profession, a physician must recognize responsibility not only to patients, but also to society, to other health professionals, and to self.

Annotation (1) for Psychiatric Administrators A psychiatric administrator will have a greater or lesser degree of responsibility for the well being of the work setting and for the lives of those employed in that setting. Thus, the psychiatric administrator will need to pay more attention to the needs of society and other health professionals than would the typical psychiatric clinician. When conflict exists between the needs of the organization or society and the needs of patients, the psychiatric administrator must be guided by an ongoing commitment to the needs of patients. If and when the psychiatric administrator can no longer follow these principles, resignation would be an ethical option.

Section 1

A physician shall be dedicated to providing competent medical service with compassion and respect for human dignity.

Annotation (1) for Psychiatric Administrators Knowing that the quality of medical services can be affected by a wide variety of variables, including the skills of clinicians, the organization of the delivery system, and the adequacy of funding, the psychiatric administrator will strive, though may not always succeed, to do what is possible to have competent mental health services in the organization. “Competent” does not mean ideal services, but rather refers to the average expectable outcomes given the current state of psychiatric knowledge and available delivery systems.

Annotation (2) Whenever competing ethical needs, such as under-funding or the survival of the organization, jeopardize the provision of competent medical services, the psychiatric administrator will strive to have the organization still provide the best possible services with compassion and respect for patients.

Annotation (3) Given the targeted patient population of the organization, the psychiatric administrator should not allow discrimination of patients based on race, religion, or other sociocultural characteristics. Likewise, staff discrimination should not be tolerated.

Annotation (4) To substantiate that competent psychiatric services are being provided, the psychiatric administrator should support and/or foster the development of relevant outcome studies and strive for continuous quality improvement.

Section 2

A physician shall deal honestly with patients and colleagues, and strive to expose those physicians deficient in character or competence, or who engage in fraud or deception.

Annotation (1) for Psychiatric Administrators To deal honestly with patients and colleagues, the administrator needs to try to be aware of the psychological factors that may prevent that. Such factors may include dependency, narcissism, and guilt. To monitor and help maintain such honesty, advisory committees and consultation with more senior administrators in other settings is advisable.

Annotation (2) The role of the psychiatric administrator in a system of care should be explicit to the public, patients, and clinicians. Effort should be made, via newsletters, meetings, or other mechanisms, to make the administrator known and visible.

Annotation (3) When an administrator who is a psychiatrist decides or chooses not to follow these ethical principles, an ethical course would be to try to make that publicly obvious in one way or another, such as not using “Doctor” or “M.D.” as part of their administrative title.

Annotation (4) Whenever incompetent or inappropriate behavior on the part of the clinicians or other administrators comes to the attention of administrators, the administrator must intervene.

Section 3

A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interest of the patient.

Annotation (1) for Psychiatric Administrators A psychiatric administrator should know and follow the laws relevant to the healthcare system, and strive to advocate for new laws that may improve or develop healthcare systems that can provide costeffective, quality care.

Annotation (2) The psychiatric administrator should not support policies, nor receive financial benefits based on such policies, that compromise quality of care.

Section 4

A physician shall respect the rights of patients, of colleagues, and shall safeguard patient confidences within the constraints of the law.

Annotation (1) for Psychiatric Administrators While psychiatric administrators may have an ethical right to obtain patient information that, in its aggregate, will help to monitor and improve outcomes, every effort should be made to inform patients and clinicians as to why and how such clinical information will be used. It must be clear that appropriate safeguards for the confidentiality of the information are in place, including the use of coding whenever possible. Especially given the importance of confidentiality for psychiatric patients, the potential benefits must outweigh the risks of less confidentiality.

Annotation (2) Aggregate patient data may be shared within the healthcare institution and publicly, but any presentation of a specific patient must protect confidentiality unless the patient willingly provides informed consent in writing.

Annotation (3) The psychiatric administrator must be cautious in the use of power, so as not to take financial, social, or sexual advantage of clinicians or patients.

Section 5

A physician shall continue to study, apply, and advance scientific knowledge, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.

Annotation (1) for Psychiatric Administrators A Psychiatric administrator should have appropriate training and evaluations relevant to the position.

Annotation (2) The psychiatric administrator should stay abreast not only of general psychiatric advances in knowledge, but also relevant administrative, political, and business knowledge that may influence the functioning of healthcare systems. Information relevant to others in the organization and to the public should be shared with them.

Annotation (3) In order to avoid conflicts of interest, which may compromise patient care, the psychiatric administrator should make available consultants, clinicians, or reviewers outside of the system to provide objective opinions, care, appeal, or review.

Annotation (4) Given both the unique as well as occasional overlap of skills and training of the different mental health disciplines, the psychiatric administrator should strive to make the most cost effective use of the apparent strengths of each mental health discipline.

Section 6

A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical services.

Annotation (1) for Psychiatric Administrators When psychiatric administrators are responsible for a third party influence on the doctor-patient relationship, such as in a community mental health center, state psychiatric hospital, or managed care system, the administrator should strive to select the best clinicians possible for the staff or network.

Annotation (2) Although a psychiatric administrator need not continue to provide direct patient care, if one does not do so, some mechanism should be found to help maintain empathy for the perspectives of clinicians and patients.

Annotation (3) When new environments, such as telemedicine or e-mail, are used to provide treatment, the psychiatric administrator should assess whether they are at least equivalent or better, with respect to benefits and risks, to traditional environments.

Section 7

A physician shall recognize a responsibility to participate in activities contributing to an improved community.

Annotation (1) for Psychiatric Administrators Whenever and wherever possible, the psychiatric administrator should try to address and reduce the stigma associated with psychiatric patients and disorders.

Annotation (2) Psychiatric administrators should use their knowledge and management of healthcare systems to improve the well being of our communities, but when communicating on societal issues, should be careful to clarify whether he/she speaks as an individual citizen, individual physician, or as a representative of an organization.