Ethical Analysis and Resolution

A first step in resolving divided loyalties is to think of loyalty as an attachment or allegiance to a person or cause, and to see it as expressing a coherent meaning that unifies one's personal and professional conduct (Dwyer). Loyalties develop with the assumption of roles and relationships both inside and outside of professional practice. The professional's identity is connected with the primary role of restoring the patient to health. In approaching a divided-loyalty dilemma, it is necessary to articulate and reflect on the meaning of one's commitments in order to determine how these commitments ought to be ordered or reconciled in a particular case.

A basic principle of medical practice is that health professionals should be loyal to their patients and be advocates for them. This commitment does not always avoid conflict. For example, even when health professionals devote themselves exclusively to the good of the patient and show no allegiance to other persons or causes, conflicts may still arise between what the professional sees as good treatment and what the patient wants and sees as good treatment.

The roots of the confidentiality concept are essentially ethical and not legal, and from the earliest days of medical practice, respect for the patient's confidences has been considered an important part of the obligation owed by the physician to the patient. Communications told in secret and in trust have been guarded and respected. In a situation such as the Tarasoff case, however, while acknowledging the desirability of maintaining patients' confidences, one sees a strong competing ethical obligation. When a patient intends harm to another person, or when information is required for the adjudication of a dispute in court, physicians are faced with the claim that societal interests should take precedence. While absolute confidentiality is no longer the expectation, arguments for protecting and extending confidentiality, even in the face of competing demands, remain strong. The arguments usually rest on both ethical and utilitarian grounds and center on the moral good reflected in protecting private utterances. The arguments relate to the belief that confidentiality promotes desirable goals, such as encouraging potential patients to seek medical care and allowing patients to unburden themselves and provide all the information essential for the doctor to help them. In a healthcare system such as that in the United States, the practitioner's relationship to the patient is fiduciary—that is, he or she acts for the benefit of the patient. Can modifications be made that do not compromise the fiduciary relationship? Can the doctor— patient relationship be extended to support affirmative duties not only to the patient but also for the benefit of third parties? Ralph Slovenko, an attorney-psychologist, answers this question in the affirmative, stating that a psychiatrist's loyalty to the patient and responsibility for treating the professional relationship with respect and honor do not negate responsibilities to third parties, to the rest of the profession, to science, or to society. Slovenko goes on to say, however, that how these other duties are accepted, how the patient is kept informed, and how the patient is cared for when other duties are carried out can either introduce or help to avoid a divided-loyalty dilemma.

Joan Rinas and Sheila Clyne-Jackson recommend a forthright stance in preventing dual-agent dilemmas. They argue that the mental health professional has obligations to all parties with whom he or she has a relationship. These duties include notifying all parties of their rights, the professional's specific obligations to each party, potential and realistic conflicts that may arise, and limitations in knowledge and service. If, on exchange of this information, the mental health professional concludes that he or she is not the appropriate one to provide the requested service, the patient or the third party should be referred to a professional appropriate and qualified to perform the desired function. Participants in a Hastings Center symposium on double agentry made a similar set of recommendations for addressing divided-loyalty dilemmas (Steinfels and Levine).

The answer to what appears to be a divided-loyalty dilemma in court cases may rest on a particular type of disclosure. Where the psychiatrist is functioning as a friend of the court, the primary loyalty is not to the patient but to society as embodied in the judicial system. In such settings, the doctor—patient relationship does not exist in the traditional sense. Both doctor and patient must understand this from the outset. Divided-loyalty dilemmas are prevented when the psychiatrist advises all parties involved that the relevant materials they provide will be used in the court proceedings and that he or she is functioning as a consultant to the court (Goldzband).

Anxiety and Depression 101

Anxiety and Depression 101

Everything you ever wanted to know about. We have been discussing depression and anxiety and how different information that is out on the market only seems to target one particular cure for these two common conditions that seem to walk hand in hand.

Get My Free Ebook

Post a comment