Background and History

Divided-loyalty dilemmas have been most blatant in efforts at social control. Since mental healthcare often deals with deviance in behavior, its conceptions run parallel to society's conceptions of social behavior, personal worth, and morality. Thus, in certain situations, there may be great pressure for mental-health professionals to label patients on the basis of social, ethical, or legal norms, and not on clearly established clinical or laboratory evidence of psychopathology.

Doctors are influenced in their activity and judgment by sociocultural context, by the ideology implicit in their professional training, and by the economic and organizational constraints of the setting in which they practice. Their practice involves multiple and, at times, competing professional roles with different social and ethical requirements, but often with no clear definition of boundaries (Mechanic). The practitioner must always ask the crucial question: Whom do I represent and whom do I serve? History is replete with cases showing that the patient is not always the primary one represented.

Extreme cases put the more mundane cases into perspective. Psychiatrists in the former Soviet Union (as well as in other Eastern European countries and in the People's Republic of China) have come under scrutiny for hospitalizing political dissidents and labeling them psychiatrically impaired (Bloch and Reddaway). Physicians in the military governments of Latin American have (perhaps under coercion themselves) cooperated with the torture of political prisoners, a situation that also occurred in South Africa during the period of apartheid. Nazi physicians conducted experiments in concentration camps that would have previously been unimaginable, giving rise to the safeguards of informed consent now required (Drob; Lifton, 1976, 1986). Nazi doctors acted completely contrary to their own moral and professional commitments, serving the ideology of the state and not their patients. These historic lessons make the need to examine divided loyalties all the more urgent.

The use of psychiatry as an instrument of social control had a long history in the former Soviet Union. Soviet authorities chose to have dissenters from official governmental policy labeled with mental illness designations such as schizophrenia, "sluggish schizophrenia," or paranoid development of the personality. The labeling of persons as mentally ill is an effective way to discredit their beliefs and actions, and to maintain control over those persons of whom a government disapproves.

Although the situation in the former Soviet Union was extreme, there have been examples in other societies in which psychiatry has been used (or abused) to stifle nonconformity, serving the interest of someone other than the patient. Notorious examples include the poet Ezra Pound and the actress Frances Farmer, both of whom where involuntarily hospitalized for political extremism (Arnold).

In cases of controversial religious movements, distressed families have sought help from mental health professionals to "rescue" and "deprogram" their children from such groups or cults. The mental health professional may be caught in a divided-loyalty dilemma between family values and religious liberties, possibly medicalizing religious conversions and then treating them as illnesses (Post). On the other hand, vulnerable young people may be particularly susceptible to coercive group pressure, and mental health professionals have traditionally acted in the "best interest of the child" for autonomous growth and development.

The question of divided loyalty can readily arise in matters of confidentiality. Mental health professionals cherish confidentiality as a prerequisite for psychotherapeutic work, but what is an appropriate limit to confidentiality when a patient reveals plans that might endanger others? This question came dramatically to public attention in 1974, when Tatiana Tarasoff, a college student, was murdered. Lawsuits were subsequently brought by the student's parents against the university, the campus police, and the psychotherapist who had failed to warn Tarasoff of threats made against her life by a fellow student (and patient of the therapist) who had fallen in love with her and whose love was unrequited. The therapist had alerted campus police to the danger his patient posed, but they arrested him, found him harmless, and released him.

The military is an organization whose needs and interests may compete with those of the patient. In the military, mental-health professionals are committed to serving society by supporting their commanders in carrying out military operations (Howe). The psychiatrist who returns a soldier to mental health may be returning him to a battlefield where he could be killed. Robert Jay Lifton highlights this ethical conflict by showing that the soldier's very sanity in seeking escape from the environment via a psychiatric judgment of instability renders him eligible for the continuing madness of killing and dying (a perfect example of Joseph Heller's "Catch-22"). Even in military situations, mental health professionals retain obligations to their profession. Further, their clinical effectiveness requires that they give high priority to the needs and interests of the military personnel they treat. In most cases, the mental health professional's ambiguous position in military medicine as a dual agent allows the person to believe that he or she is participating in both the care of patients and the public interest (Howe).

The prison system has also been the setting for a variety of divided-loyalty dilemmas. The professional may be called upon to evaluate an accused person's competency to stand trial. If treated, the person may become competent to stand trial, but left untreated the psychosis may prevent the person from participating in his or her own defense. In capital cases this can be a matter of life or death. How does a physician understand this obligation to the patient when providing treatment, particularly antipsychotic medication that may ultimately lead to conviction and death?

Conflicting obligations can easily arise in situations where doctors ask their own patients to participate in clinical research. While most doctors comply with their primary obligation to deliver the best possible care to their patients, the demands of adhering to a strict research design can create obligations that compete with those of giving good medical care. The research-oriented physician must maintain special ethical vigilance to assure that the patients' interest comes first, a vigilance that is reinforced by external review of research consent procedures.

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