Professional Ethics and Boundaries

Professional Ethics and Boundaries

Introduction

In the last several decades, advances in psychiatry have made it possible to treat mental disorders that were previously unamenable to successful intervention. There has been a dark side to this progress, however, because futuristic anticipation of subduing disease and forcing nature to surrender her secrets has led many practitioners to outrun their headlights. Like technical sorcerers of science fiction confusing promise with reality, we are in dan-ger of being lulled into an intellectual arrogance that can cause us to forget what it means to be professionals. One manifestation of this process has been the defensive reliance by clinicians on reductionistic explanations for complex and multidetermined disorders, combined with a neglect of the important role of trust and empathy as a curative factor in treating mental disorders.

A bewildering potpourri of treatment options and methods for financing healthcare present psychiatrists with other sources of confusion. Patients’ health and safety often depend upon our ability to make rapid clinical decisions regarding diagnosis and to utilize an optimal psychotherapeutic or psychopharmacologic approach. The psychiatrist’s dilemma is similarly compounded by conflicts between the cost-determined restrictions of managed care and the sacred promise to advocate primarily for patients’ welfare.

Building a cooperative and trusting relationship with patients has always been an essential factor enabling clinicians to foster the healing process. In ancient times, when there were few specific remedies available, physicians relied on a highly in-tegrative view of the sick person. For example, ancient Egyptian medicine did not make a special distinction between soma and psyche in considering physical and mental disorders, and therefore attached no special stigma to the mentally ill (Okasha and Okasha, 2000). Similarly, the Rabbinic sage and physician Maimonides (1135–1204 AD) (1944), relying on scriptural and clinical wisdom, taught that both physical and mental illness resulted from imbal-ances in somatic and mental processes, and that physical health and mental health are interdependent (Gorman, 2001).

In most instances, modern technology augments but cannot substitute for a trusting doctor–patient relationship. Patients seek-ing medical care must suspend ordinary social distance and criti-cal judgment if they are to allow physicians to enter their physical and psychological space. While neither the law nor medical ethics relieve patients from taking an active responsibility for treatment outcome (American Medical Association, 1993), society places a greater burden upon the healer – a mandate to act with the spe- cial care and vigilance expected of a fiduciary (Frank and Frank, 1991; Simon, 1987) or of a Common Carrier  as a precondition for granting licenses to practice.

As we review, the ability to sustain a profes-sional attitude and to practice within a set of coherent boundaries forms the foundation of proper psychiatric treatment, regardless of theoretic orientation or treatment modality. An understanding of psychiatric ethics plays a vital role in the psychiatrist’s ability to keep proper boundaries because these values provide a stable beacon in the cognitively perplexing fog that so often pervades the treatment situation.