Authenticity and Autonomy in the Managed-Care Era:
Forensic Psychiatric Perspectives

Harold J, Bursztajn and Archie Brodsky

The Journal of Clinical Ethics
Volume 5, Number 3

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.

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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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