Ethics Commentary: Ethical Issues in Bipolar Disorder: Three Case Studies

Sound ethical decision making is essential to astute and compassionate clinical care. Wise practitioners readily identify and reflect on the ethical aspects of their work. They engage, often intuitively and without much fuss, in careful habits—in maintaining therapeutic boundaries, in seeking consultation from experts when caring for difficult or especially complex patients, in safeguarding against danger in high-risk situations, and in endeavoring to understand more about mental illnesses and their expression in the lives of patients of all ages, in all places, and from all walks of life. These habits of thought and behavior are signs of professionalism and help ensure ethical rigor in clinical practice.

Psychiatry is a specialty of medicine that, by its nature, touches on big moral questions. The conditions we treat often threaten the qualities that define human beings as individual, as autonomous, as responsible, as developing, and as fulfilled. The conditions we treat often are characterized by great suffering, disability, and stigma, and yet individuals with these conditions demonstrate such tremendous adaptation and strength as well. If all work by physicians is ethically important, then our work is especially so.

As a service to FOCUS readers, in this column we endeavor to provide ethics commentary on topics in clinical psychiatry. We also proffer clinical ethics questions and expert answers in order to sharpen readers’ decision-making skills and advance astute and compassionate clinical care in our field.

Case 1

Ms. Genera is a 36-year-old woman with bipolar II disorder, first diagnosed in college, who is brought to the psychiatric emergency room by her boyfriend of 5 years. He is hoping that she will be admitted to the hospital “before she goes all-the-way manic.” He reports that she “almost lost her job last time!”

Over the past 6 weeks, he reports that Ms. Genera has needed “less and less” sleep, has been cleaning the house “around the clock,” and has “wanted a lot of sex even though she is really pissed off all of the time.” The patient states that she is “fine, more than fine, in fact.” She says that she has not been able to sleep “because of the neighbors.” She says that they talk loudly at night and that she and the baby will “fix that” because babies are “noisy at night too!” Her boyfriend is confused by this comment, saying that they have no children—“I don’t know why she says stuff like that. I know it’s the manic-depressive, but it is pretty crazy.” Ms. Genera states that her thoughts are like “O’Hare airport!” and that she has “no problem keeping up” with the different “planes coming and going.” The patient says that she stopped taking all of her medications about 3 months ago—“That lithium is really hard on me. I don’t like to take it unless I have to.” She has no history of alcohol or other substance use, no history of suicide attempts, and no history of dangerousness toward others.

On mental status exam, Ms. Genera is a neatly dressed, mildly overweight woman who appears slightly older than her stated age. She is cooperative with the clinical interview and asks that her boyfriend step out of the room when she is talking with the doctor. She is speaking quickly and loudly, with appropriate affect. Her thought form is linear. She denies hallucinations and reports no thoughts of self-harm.

Ms. Genera says that she has “Bipolar II, not Bipolar I—I don’t have it that bad. Never have. Yessirree, I am really good right now.” She does not want to be admitted to the hospital, despite her boyfriend’s request, but volunteers that she will go to an ambulatory care appointment with her psychiatrist on the next day.

1.1 Most states have provisions for involuntary psychiatric admission when a person has evidence of a mental disorder that causes “grave passive neglect” or the potential for harm to self or others. Which of the following is the most accurate statement regarding a psychiatric admission for Ms. Genera, in light of these criteria?

1.2 Which of the following diagnostic tests should be performed at the time of this evaluation?

1.3–1.7 Match the following actions by the psychiatrist with the most appropriate ethics term (each term may be used once, more than once, or not at all):

——1.3 The psychiatrist arranges to speak with Ms. Genera alone during the clinical interview.

——1.4 The psychiatrist respects the patient’s preference not to be admitted to the hospital.

——1.5 The psychiatrist recommends diagnostic tests to occur at the time of the emergency evaluation.

——1.6 The psychiatrist sits with the patient’s boyfriend to offer emotional support and “a listening ear” after the clinical interview with the patient is completed.

——1.7 The psychiatrist documents accurately in the electronic medical record the full set of concerns raised by the patient and her boyfriend.

Case 2

A resident in internal medicine with a well-established diagnosis of bipolar I disorder volunteers for a clinical trial that will test a new combination of medications and also involve two neuroimaging studies. The resident discusses the trial with his psychiatrist, who discourages the idea, stating that he has been concerned about the resident-patient, given the stresses of training and the severity of his illness. The resident responds, “Hey, Doc—get real! How often can you get $500—plus a brain scan, let alone TWO—free of charge?!” He decides to undergo screening for the clinical trial because he thinks he might benefit medically from an imaging test.

The resident knows that the trial will involve a washout period, so he decides to taper his medications in advance of the “official” enrollment date, 3 weeks away, which coincides with a planned vacation. Without medication, the resident becomes increasingly symptomatic. He has difficulty concentrating, becomes easily upset with team members, and develops progressively more erratic sleep. He was seen standing on the roof of the academic hospital and confided in a roommate that he was “tired of it all.”

Although he originally met criteria for the project, by the time of enrollment he had become too ill to enter the study. The psychiatrist-investigator permitted him to have the baseline neuroimaging study but did not allow the resident to progress to the full clinical trial. The resident returned to his apartment for his weeklong vacation. On the day he was scheduled to return to his training program, he did not turn up.

2.1 The psychiatrist-investigator designs a trial that excludes very seriously ill and potentially suicidal patients with bipolar I disorder because of concern about the risk:benefit ratio for participants. The psychiatrist-investigator’s decision is governed primarily by which of the following ethics principles?

2.2 The internal medicine program director chooses not to call the resident’s parents but, instead, arranges for campus security to go to the resident’s apartment when the resident does not show up for work after his weeklong vacation. The program director’s decision to explore the situation is governed primarily by which of the following pairs of ethics principles?

2.3 The clinical psychiatrist discouraged the resident-patient from pursuing the clinical trial but did not act to prevent it. The psychiatrist’s decision to behave in this way is governed primarily by which of the following pairs of ethics principles?

2.4 Informed consent for clinical research participation is based on the ability to communicate a choice, the ability to understand relevant information, the ability to render a rational decision, and the ability to appreciate the nature and significance of the decision. In this case, which of the following experiences of the resident-patient would demonstrate that he is unable to provide informed consent for the clinical research study?

Case 3

An 18-year-old male previously diagnosed with bipolar disorder is brought by his best friend to the emergency department of a rural hospital located near a ski area. The best friend reports that the patient “is completely wild—he just won’t stop—he’s going to kill himself on the slopes!”

The patient was first diagnosed when he experienced a “flat out manic” episode at age 13 years; he has been stable and doing well on lithium. He has a psychiatrist and therapist “back home,” although he will not provide their names.

The patient confided to his best friend that he “secretly” stopped his lithium recently, and the best friend states that the patient has been using alcohol. (“He says, ‘I like to get high while I’m high.’ ”) The patient is on vacation with his grandparents, two younger siblings, and the best friend.

The patient shows evidence of intoxication and is irritable but cooperative during the initial interview in the emergency department. His vitals are within normal limits and are stable. No abnormalities are found on physical examination.

While waiting to be seen, the patient appears to “sober up.” He is calm, pleasant, and respectful and thanks his friend and the emergency staff for helping him. He appears embarrassed. No abnormalities are found on mental status examination. The patient refuses a drug or urine test, and he refuses to allow the emergency physician to contact his grandparents or parents. The emergency physician calls a psychiatrist for consultation, which the patient declines.

3.1 The emergency physician abided by the patient’s decision to refuse laboratory testing, did not contact the grandparents or parents, and allowed the patient to decline the psychiatric consultation. The emergency physician’s decision to behave in this way is governed primarily by which of the following pairs of ethics principles?

3.2 The patient in this scenario declines a complete medical evaluation in the emergency room. What are the four necessary capacities for decisional capacity for informed consent or refusal of recommended clinical care?

3.3 If the patient had not sobered up but, rather, had developed confusion and combative behavior, on what ethical grounds could the emergency department have contacted his family for additional information?

Answers