Authenticity and Autonomy in the Managed-Care Era:
Forensic Psychiatric Perspectives
Harold J, Bursztajn and Archie Brodsky
Wenger and Halpern's timely article perceptively identifies some major
clinical and ethical issues that arise when one confronts a medical
patient's refusal of a psychiatric consultation to evaluate his or
her capacity to make decisions. Indeed, this article takes on even
greater importance than the authors suggest when it is considered
in the light of the present-day preoccupation with controlling cost
that shadows medical practice. On the basis of Wenger and Halpern's
prescient discussion, we will analyze the effect of cost control
on the patient's capacity to make decisions and will propose applications
of this analysis for clinical practice, ethics, law, and public policy.
. . .
CONCLUSION
If the treating clinician can build an alliance with a patient, and the
psychiatrist performs his or her consultation in the best possible
way, there is no reason for the consultation to be, or to remain,
involuntary. Given sufficient time to build the alliance, the skilled
medical clinician can nearly always give a patient the support he
or she needs to accept a psychiatric consultation. In the rare instance
when an involuntary psychiatric evaluation is ordered, a psychiatrist
with the requisite training can nearly always elicit a patient's
willing participation. There is much to be gained, then, from educating
clinicians on how to make a psychiatric referral [19]
and from educating psychiatric consultants on how to turn an involuntary
assessment into a voluntary one.
The methods described here are intended for preventive as well as remedial
use; they apply not only to medical patients with psychiatric disorders,
but to any patient with chronic medical illness that requires heroic
measures that may traumatize a patient. In the current rush to control
costs via managed care, this insufficiently explored area of clinical
ethics can no longer wait to be addressed.
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