Physicians have traditionally understood their primarily loyalty as being to the patients they serve. This tradition goes back to at least to the time healers left behind their shamanistic roots, some twenty-five centuries ago. So important is this sacred commitment that it is enshrined in Hippocratic Oath, with which physicians and the public often identify the medical profession. The relationship between physician and patient is understood as a fiduciary relationship, meaning it is based on trust. Other healthcare professions— and indeed other professions—have modeled their self-understanding on this sort of promise to benefit those served.
Situations do arise in which physicians and other professionals experience divided loyalties—divided between allegiance to the patient and allegiance to some other interest. This has traditionally been spoken of as "the dualagent (or double-agent) problem." A physician or therapist is a dual agent, for example, if he or she owes an allegiance to an employer as well as the patient. In situations of divided loyalties the integrity of a physician's judgment or action may be compromised. Classic examples of this occur when a physician (especially a psychiatrist) works for the military or for a state or federal institution, where confidences cannot be guaranteed. Increasingly, physicians and other providers find themselves asked to serve the broader interests of society; that is, the interests of populations rather than individuals. This is especially true for those working for large organizations, such as health maintenance organizations (HMOs), managed-care organizations, or nationalized health services. In these situations, the physician must recognize an obligation to society, making it more difficult to buffer the unique concern for each individual patient.
From the moral point of view, most dual-agent situations are best seen as cases of conflicting loyalties or clashing duties. The doctor must choose one duty over another (Macklin, 1982). Perhaps most problematic are situations in which the patient assumes (because of the weight of the professions' patient-centered ethic) that the doctor is working for the patients' best interest. A psychiatrist in a pre-arraignment examination might be able to elicit more information then a police interrogation simply by presenting a trusting demeanor. But if the message is not "I am here to help you," then the purpose of the examination should be
DIVIDED LOYALTIES IN MENTAL HEALTHCARE •-
directly stated. An administrative evaluation in a student health service should clearly state, "You are being evaluated at the request of the dean, who will receive a report of my findings." A health professional should not give the impression that everything a person says is confidential if that is not the case.
While cases in psychiatry and mental health have received the most attention, this attention has increased awareness of the problem of divided loyalties in virtually all areas of healthcare. A quick literature search for "divided loyalties" on the Internet returns results from the following specialties: nursing (Winslow; Dinc and Ulusoy; Chao; Tabik, 1996), ophthalmology (Addison), sports medicine (Sim), occupational medicine (Walsh), physical therapy (Lurie; Bruckner), military medicine (Howe; Camp; Pearn; Hines), transplant medicine (Bennett; Tabik, 1994), clinical researchers (Miller), aviation medicine (McCrary), infectious diseases, obstetrics (Plambeck), student health and those doing administrative evaluations and disability evaluations (Lomas and Berman), and house physicians and residents (Morris; La Puma), as well as psychiatrists, forensic psychiatrists and physicians, and child psychiatrists and pediatricians. Issues of privacy, especially the privacy of medical records, cut across all disciplines in the information age, as do issues of cost containment, reimbursement, and healthcare funding. While all these disciplines face situations of divided loyalties, perhaps nowhere is the conflict more dramatic than it is in nursing, where loyalties have undergone a transformation from loyalty to the individual physician for whom and with whom a nurse works, to the healthcare institution that employs the nurse, to patients more generally, and finally to the principles of medical ethics that inform the values of all professions.
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