I want to thank you all for coming to this session. We are pleasantly surprised that we have members who have come in on the last day of the APA, so we really applaud you. We are very grateful for your presence. This is the latest we have done this meeting, this dilemma session. We always did it on Tuesday afternoon, but for some reason the scheduling was Wednesday at this time. We consider this a very important resource that we have for APA members. My name is Charles Dike. I am the Chair of the Ethics Committee. I've been for a few years. This is my last year as Chair of the APA Ethics Committee, and one of my colleagues here on the table will take over and introduce himself when the time comes. But I just want to make a couple comments about the Ethics Committee, and then I will have our members introduce themselves. The Ethics Committee is made up of APA members who have interest in this area of ethics, and our role is to serve as a resource for members. We get a lot of questions from members about different dilemmas they are struggling with in practice, and our task is to very quickly review the questions as a committee and make recommendations back to them as quickly as we can. It's oftentimes time, it's always time limited, and they want things right away. So we take that task very, very seriously in making ourselves available for members who have issues that they are struggling with. We also sometimes take on a larger role, like we see something that's really important, we might decide to do a resource document on those issues. And, you know, I'm going to start after introductions to talk about one of those resource documents. So we are active in that way. We also collaborate with other APA committees and many things that they are doing. Oftentimes they want an ethics lens on them to make sure that the work is ethical. And so whether it's the Council of Scottish Law or Communications or whatever the councils are, many times when they are doing work, serious work, they invite the Ethics Committee to participate to just cover that angle of ethics. So those are the main areas we cover, main functions we do. My belief is that everyone who's here is a member of the APA. We do not respond to questions from non-APA members. It's a resource for members of the APA. However, if we get a question from a non-APA member that is really important and interesting, while we would not respond to the non-APA member, we would take it on as a committee and create some kind of opinions for the membership. So if you want to know where the questions we've responded to over the years exist, they exist as opinions of the Ethics Committee there on the website. So if you go to apa.com.org slash ethics, apa.org slash ethics, you will see main... Psychiatry.org, I'm sorry. I'm sorry about that. Psychiatry.org. Psychiatry.org slash ethics, and you will see the opinions that we have. It's psych. No, it's psychiatry.org, because I'm like saying that word. Thank you. But if you do psych.org, it take you there, too. All right. And this session also is about you guys. This is really your session. It's about you guys coming up to that microphone over there and presenting the scenario or the ethical issue that you're dealing with, that you want us to think through and talk about, and we will just over here respond to them as best we can. So that's really what this is. We're going to spend a lot of time doing that. But before I continue, let me just ask my team here, do we... Sorry. The Ethics Committee has members of the Ethics Committee. We also have consultants to the Ethics Committee. And then we have APA fellows and APA Foundation fellows who are also assigned to the Ethics Committee, and all of us do work together. We really review the questions that come together. We make responses together. And so on and so forth. But on this particular Q&A session, the members, only the members of the committee are here to respond to them. We don't have all of them. A few of them could not come today, but we have enough to take on this session. So on my right, on my left, immediate left, if you can introduce yourself, please. You want us to do declarations as well? Pardon me? Conflict declarations. I will. Good morning. I'm Dan Anzia from the Chicago, Illinois area. I'm the retired chair of psychiatry at Advocate Lutheran General Hospital in Park Ridge, where I still do some residency teaching. I'm a member of the Ethics Committee. While I don't think it's likely to be relevant to today's discussion, my wife owns some stock in Merck and Amgen. Thank you, Dan. Good morning. I'm Catherine May from Washington, D.C. I'm in solo private practice and do both psychotherapy and psychopharmacology. And I have no conflicts to report. Thanks, Godfrey. Good morning, everyone. I'm Phil Candelas from Washington, D.C. I'm at St. Elizabeth's Hospital, a public sector hospital in Washington and a professor at George Washington University. I did my ethics training in Boston and at NIH. I have no conflicts relevant to the committee and I'll be stepping into Charles's large shoes in about a day. Thankfully, Charles will be staying on the committee to keep us on the right track. Thank you very much, Phil. So Phil is gonna be our next ethics committee chair after me. Phil and I have been on ethics committees for 150 years. We were together on the American Academy of Psychiatry and the Law Ethics Committee where I was chair for about seven years and then Phil took over as well for a few years and then we are back at the APA Ethics Committee. We also have, I think we have only one consultant here today, so if you can just stand up and you can actually introduce yourself as well. As we say in Nigeria, she's retired but not tired, clearly, clearly not tired. One of the most important things that I want to just alert you is we try to not respond to any questions where there might be conflicts, if there's an active something that might relate to some conflictual situations, we will not respond to it. I actually should introduce as well our counsel, APA counsel. You want to introduce yourself and then clarify what I was about to say about conflicts. Can you please come? Good morning, everyone. Good morning, everyone. I'm Collin Coyle, I'm APA's general counsel. And what Charles was saying is that we, the ethics committee primarily provides opinions for people in active practice and also... So what we don't want to do is have an active investigation question. So if your question pertains to an active investigation, if you hold it, and don't ask it here in this room. Thank you. See, that's why we need her. And we need a very active bench of lawyers to assist us in our ethics committee deliberations. And Colleen is absolutely fantastic in that area. One last thing I would say is that the ethics committee has an award that it gives out. It's called the Carol Davis Award. And that award is for articles that are ethics-based or ethics-related articles, either in journals, in a book, book chapters, and so on. So the best of one of those type of articles per year is really you earn a Carol Davis Award. The ethics committee members reviews many submissions and debate the submissions. And then after each one will be selected as a winner of the Carol Davis Award. If we don't get many that year, we don't think it's enough, we can delay it a year and then give the award next year. This year we're supposed to give one, but the recipient for the award today is not here. He won the award on the ethics of using psychedelics. I don't know if you guys have seen the resource documents on ethics and psychedelics that came out from here. But that was driven really by one. He was an APA fellow at the time. It was absolutely fantastic the amount of work he did. If you haven't seen the ethics and psychedelics paper and resource documents, I really recommend that you look at it. It's really well done, very comprehensive. And so he won the Carol Davis Award for that article. But he's not here today to receive it. I just want to encourage you also in your district branches and wherever you are, if you can submit any type of article that you've written that has to do with ethics to the ethics committee to see if you'll be eligible for the Carol Davis Award. All right. So how it goes is somebody will ask a question, and I will ask my committee members to respond to it. And each of them might respond, may not. I might add my response at the end of the day. But you can just kind of see just gently how the ethics committee works behind doors. Obviously, we don't have to respond right away if we are behind doors. We have spent more time really having significant debates and discussions, which you might not have as much here today. But just to give you a slice and a sliver of what type of deliberations we have. We also always like to have people from different specialties. We have child psychiatrists. We have forensic psychiatrists. We have private practice, people in public service. We have different members so that we can have a more robust discussion about an issue that a member brings in. Thank you very much. I was going to ask if I had forgotten anything. Have I covered everything? Perfectly. All right, thank you. Just state who you are, where you're from, and then the question. I'm Bruce Hirshfield from Sparks, Maryland. I'm in solo private practice, and I do some teaching. It strikes me that the residents I speak to, and they're a very high quality, are amazed when I tell them some of the ethical principles. And my question is, what efforts have made young psychiatrists, brand new members of the APA, for example, to tell them how they can stay out of trouble instead of waiting until they have a question about how to stay out of trouble? In 1986, 12 years after I finished my training, I prepared for the administrative psychiatry exam. And one of the sections there is forensics and ethics. And that was the first time I remember seeing the code of ethics. So what efforts are being made to put this on a basis where it's prevention rather than questioning when something begins to go wrong? That really is an excellent, excellent question. So let me start with who can take on this. Some programs actually have fairly robust ethics exposure for residents during training. George Washington University, for example, has a program. And I think both Phil and I have taught in that program. So I think it is very program dependent. And while some programs may not have the resources to invest in this, many programs do take ethics very seriously and ensure that their residents are exposed. And the APA also sponsors APA Ethics Fellows from the different leadership programs that they have. We've developed a whole mentoring program the last few years for those fellows who are interested in APA Ethics. They just wrote up this wonderful toolkit for trainees and early career psychiatrists that we have up on our website. So there are a number of initiatives that bring it to trainees. And while I'm not a training director anymore, if there's any training directors in the room, I believe there are at least a couple of the milestones that mention or allude to ethics. So there's some expectation or I don't know how much you'd say it was pressure on programs to introduce residents to both the opinions or the principles and annotations and our other documents like the commentary on ethics and practice. Let me just say that the breadth and the depth of ethics teaching in residency programs or medical schools are really lacking. It's spotty at best. So you have some programs where it's really rich. You have many programs that don't have anything. That's a real problem. And as you were asking the question, I began to ask myself, why is that so? Why can't we as the APA find a way to infuse these type of trainings into different programs? And I am part of the problem-based ethics organization, so a private organization that does ethics remediation courses for individuals who've gotten in trouble, all kinds of licenses. And I am always amazed that even those people who have had ethics training in medical school or residency, they've only had it once or so. And then they've forgotten about it completely. And 10 years later, things happen. And it's like, oh my god, this was always there. And I'm now in trouble. So yes, I think to infuse it into training, but also to find a way to make this a kind of a people have refreshers on these things. I think the ethics opinions are really important for when you have questions. But the principles and the basics of ethics, I think the teaching needs to be much more than it is now. It's really an important point for us to take on. Phil, this might be something we can look into, how to get this out for the training directors. Thank you very much. Charles, I just want to add one thing. If any of you have ideas that you think you would like to draw to our attention, you may do so after the meeting. We would be happy to entertain any thoughts that you have on this. Thanks, Katrin. Hi, thanks so much for having this open forum. I really appreciate that we can connect with you on this. My name's Sean Barnes. I am an outpatient psychiatrist at a county clinic in California treating severely mentally ill. I wrestle with this issue of telephone visits. So during the pandemic, we switched over to almost 100% telephone visits. And what that's done on the positive side is we went from having a no-show rate to from about 65% no-show to now like 10% no-show. So we get much more engagement with our patients. The downside is I'm often talking to patients while they're on a bus, on a train, in line at the store. There's all sorts of ethical confidentiality issues there. But leaving that aside, it is clearly a poorer level of care that I'm able to provide. But I'm able to provide it more often to people because they're showing up. The county clinic loves it because now that we have less no-shows, we're reimbursed more. So they're going to keep doing it. But I struggle with the ethics of that, balancing out the engagement versus the quality. What are your thoughts on that? Excellent question, and very topical as well. Yeah, I have a thought on that because that's something we've noticed in private practice too, especially emerging from the COVID period. And one possible approach to that is to require in-person visits intermittently so that you can keep a relationship with the patient and take advantage of the enhanced care that phone calls give between in-person appointments. And that's a juggling act. And it's not going to be the same frequency for each patient. But that has been one way of reintroducing in-person visits. The other issue is also that informed consent has to be a little bit better with those interactions. So if you're hearing them on a bus, if you're hearing them in a park, you need to be talking about the issues of confidentiality that you're talking about with the patients very explicitly. Because we're still responsible for the quality of that care, figuring out whether greater access is the same thing as better quality is up to you. And making sure that you're documenting that that quality is being delivered is still in your corner. It's still your responsibility. I would add only that while we haven't, nor would I expect that we would say that phone-only treatment is unethical. We haven't said anything like that, and I don't think we would. I think Dr. Candelas has just sort of highlighted the responsibility aspect for psychiatrists to be concerned not only with their connection with the individual patient or patients, if it happens to be a telehealth couples therapy, for example, but also with who else is in the vicinity and who else is in the room, and to kind of build that into the expectations and open discussion with the patient. And that comes in around the issue of informed consent and a psychiatrist has to worry about it even if the patient isn't worrying about it. Yeah, so this is an issue that I think most of us have experienced as well. And I believe I wrote about this in the ethics column, and I give a whole list of things to worry about and how to do it. The one case I encountered was the guy was driving an Uber and he was having a therapy session, some kind of discussion with myself, and I was alarmed. So informed consent is one thing. The other thing is safety, because you don't really know where they are, what they're doing. You want to be sure that they're safe. The third piece is you don't know who's with them. Sometimes it could be a traumatic, coercive relationship, and what they are saying to you is to please somebody who's there as opposed to what you typically have when you have a one-to-one with patients. So there are significant issues to worry about, but the only way to do it is to make sure that you start off a conversation by saying, are you alone? Is there anybody else? Can somebody hear you? This has got to be just you and me. Are you in a safe place? Are you, you know, just make sure you have some kind of pre-warnings that becomes part of your care in case something bad happens. You can say that I give, we went through all of these protections in order for us to start seeing them. I like the idea of coming in once in a while. I like the idea of also using video once in a while. So, you know, if they can, I understand some of our patients cannot, do not have access to video meetings, but, you know, you can work with them. You can be able to do that, actually, if you're really keen on some of that. So it's really, how do you protect the patient from themselves when they don't know that there are issues? And at the same time, recognizing that this has really improved connection, but you want the connection to be effective and ethical. So those are the protections that you think about when you're working with people like that. Thank you very much for that question. Hello. Thank you for having us. My name is Nicolas Padre. I'm a psychiatrist in California as well. I have prior practice, do some forensic work. My question is about disclosure and conflict of interest. And I think I would sort of introduce the question by saying I think there's a lot of pressure on psychiatry. There was recently a lot of articles about the conflict of interest with the authors of the DSM-5, for example. My question is, I have an impression when I go to talks that a lot of times the requirements are kind of like a throwaway comment. Like, you will have a speaker that will say something like, oh, I have, you know, ties to all those companies, but I won't get a sense of how are those ties relevant to the talk? You know, what are those companies involved with the content of the talk? What is the extent of the involvement? That goes for speeches at the APA or lectures at the APA as well as articles where it requires a lot of work on the reader or the listener to have to go back and look those things up. Like, how is this company involved in any way with the talk? I was just wondering, how did sort of the requirements that we have now came about? What are they? And is there any discussion of expanding them in the future considering the pressure on psychiatry to sort of keep things clean? Thank you. Yes, excellent, actually. Thank you very much. Yes, you can, anyone can start. I know you all can talk as well. You're the forensic psychiatrist. I'm a forensic psychiatrist, so I get to answer that. So this topic has an extraordinary history in professional organisations and medical organisations in particular, and most of the ones that I've worked with over the years have developed an entire structure for researching what competing interests are. Even the language has changed from conflict to competing so that all of us can try and figure out what it is that the influences are. On our work. So this is true for journals, it's true for us here. The kinds of things that we have to disclose to the APA when we join committees, and in particular the DSM groups, the oversight groups and the authorship groups. And you can request those directly from the APA, the standards. The other issue, the problem for medical organisations is that the prominent researchers and academicians who work at universities have some kind of partnership with private industry and the medical organisations in general, not to speak directly about the APA, but AMA, psychologists, College of Physicians, all of these I'm familiar with, have approaches that take into account all these different kinds of influences because everyone has them. So we hope that our leaders in medicine are involved in research in these partnerships with private industry and that we have the capacities to distinguish one conflict, one competing interest from the other. But it is up to us, it is up to us as readers, as consumers of the DSM and of consumers of the literature to try to make those connections. But this is an enormous issue, and in fact ethicists have been writing about it since I was an ethics student 35 years ago. So there are processes, there are expectations that our leaders will be involved in private industry and in other areas outside of academia and outside of public service, but there are mechanisms in place that are increasingly transparent, let's put it that way. Thanks, Phil. Any more? If you don't mind speaking on the microphone, you can come here. So APA actually has a separate committee called the Conflict of Interest Committee, which is a committee of the board, and it is chaired by the secretary of the board and composed of ethicists as well. And there is, and you can find these on our website, we do have a disclosure policy for conflict of interest, and it's any interest. We don't ask just for relationships with industry, we ask for conflicts that might be personal conflicts or conflicts with your research or conflicts with anything else so that the committee can evaluate where you're coming from. And we have a lot of information that we can share at our meetings of those things when some interest that you might have may impact your decision-making. But for the groups that dictate diagnosis and treatment, so our DSM and our Guidelines Committee, there's a much deeper dive into what you say your conflicts are to look at whether the interest that you have, whether that company can have any influence on the particular work that you're doing. So for example, does that company make a drug that deals with the type of illness you're looking at right now? So that's a much deeper dive that's done to make sure that it's within our guidelines. On the dollar amounts for conflicts, which are pretty low, it's $5,000. So after that, you have to disgorge any of the interest you might have with a direct industry conflict. So those are all on our website, but there is a group that does look at this, and they do take much deeper dives on things that impact diagnosis and treatment. Thank you very much, Colleen. But also, it depends on an honor system. And if I'm the one who's going to be presenting at the APA, and I'm talking about something that I'm interested in sertraline, I'm getting things from the drug rep, and I'm not disclosing it in my talk. So there's an honor system that is required from each and every one of us, because it's tightening now. The forms and the different requirements are tight, but we require that you also be honest in what you document. That helps. So we sort of agree that when you say you have no conflicts, or we agree that when you say you have a conflict with a particular agency, or I consult a particular agency, we sort of believe that you're saying that what you're talking about does not have a connection with them, because that's in the form. And if you've said no, then that means we sort of believe that this is correct. So that has got to be part of the work. That is a struggle. Is everyone going to be doing it that way? I don't know, but that's a requirement, and that's an expectation. But thank you very much. Hello. My name is Jacob Davidson. I'm a new attending at a county facility in Los Angeles. So when I started, I was told that there's an agreement between us and a large private group that I guess they can send some of their patients who they feel need ECT to be evaluated by us to sign off on some of the under-insured patients to get ECT and then follow back with their private psychiatrist. So recently I got a patient who was, I was informed needed ECT, treatment-resistant bipolar, treatment-resistant depression. When I saw them, my evaluation was it was more borderline and benzodiazepine use and medication non-adherence and not following up. So I told them I don't feel that this ECT is necessarily the right step. So I sent them back. I said I'd be willing to follow up and maybe that would be a consideration in the future but not immediately. Now I'm getting pushback from my non-clinical administrators and from the private group going like, why isn't this patient getting it? They're calling, they're demanding. So I guess what is our role for just rubber stamping other psychiatrist treatment plans? Excellent question again. Thank you so much. Something we have grappled with a few times. So if you guys can start. Well, I'll take a first stab at this. I think our ethical responsibilities for delivering competent and quality care to our patients are very fundamental. And if you believe you do a conscientious and as complete as necessary for the purpose assessment of the patient and believe that this treatment isn't indicated, then you would be ethically bound not to deliver it. And I think there's an ethical expectation that we resist competing pressures and interests that might push us to do things we don't think are correct clinically. Thank you. I think you've brought up a very present dilemma, especially as medicine becomes more commercialized. And I think it's important to keep in mind that yes, your primary duty is to the patient and to deliver a very good evaluation, but also to keep in mind that good men can disagree and clinicians often do disagree on diagnosis. And it might raise the question of whether or not you would wanna be in contact with the physician who made the initial diagnosis. Were they seeing the patient under different circumstances? And then you might find yourself possibly in the position of saying, I don't think ECT is the best treatment for you at this point in time. This is what I would recommend, but I understand that Dr. X had this other opinion and thereby not have a direct conflict with the other doctor, but really seek to find out more about the patient and how that other decision was made. So let me just say, let me point you to the APA Ethics Committee's commentary on ethics. There's a document. So I'm assuming most of you know the documents. One is the actual principles of medical ethics with special annotations applicable to psychiatry. Then there's these commentaries. The commentaries really address your question because it talks about how you work with organizations or industries or you are an employed psychiatrist in that kind of a scenario. What should you do? What shouldn't you do? Where are the lines? The pressure to carry things out in a different way beyond what you really want to do by different agencies can be driven by material motives, can be driven by financial needs, can be driven by all kinds of other things. And then the doctors who are there have immense pressure to go along with what they are pressing them to do for whatever reasons. So that's there. You can't, I know the way you're dealing with it is exactly how it should be. You're thinking it through. You're saying, where do I fall in this? Do I really agree with this? Because at the end of the day, that patient is depending on you, not the association, not the global organizations. What's your take on the treatment? And I do like the responses you've received so far. I mean, in terms of being humble, to try and say, what did my colleague, I mean, why are they saying that this is important? Because the last thing you want to be is to just have a blind eye and say, this is what I think. You want to check with your colleagues and humbly find out whether you might change your opinion based on that. But if at the end of the day, after talking to your colleagues and reviewing the case and everything, and you still believe that this is not what is appropriate at this time, you stand your ground. If on the other hand, you believe, because you might change your opinion based on those kinds of discussions, you do it. But then you have a discussion with the larger organization as to, you know, where you are and why you're making decisions you're making. But those pressures are there and they will continue to be there. And so it's really a topical area. I recommend that you look up the commentaries as well. Thank you. Charles, you inspire me to add that, you know, weighing risks and benefits is part of the art of what we do. But if you include the values of the patient there, it's like a trump card. So the patient values these things. I make the decision based on the patient's values. It's very hard for there to be criticism from your administrators or your colleagues. Thanks for you. Hello everybody. My name is Akash Verma. I am a psychiatrist as well. Pro is the tail end of my early career. And I am at Lehigh Valley, a great organization that's about an hour and a half west of here. There was a question that came to mind. I'm trying to formulate it. It kind of involves patient autonomy and benefits and what we can do. We had a patient who was on the consult service who had access to guns. We were trying to take them away and the family was trying to remove them, but wanted to make sure that it was legal to go to someone, or legal ethical permitted to go to someone else's homes and take someone else's property. We sure wanted to and the family eventually did so, but there's maybe that general question over, can we do so? Another example that maybe that comes to mind would be a patient eloping from the hospital will get called, especially if they have a psychiatric condition, to say, hey, is it okay if this person leaves AMA? Is the primary team's okay with that? And we will quickly conduct maybe an interview evaluation over the phone without ever talking to the patient saying, let's hold this person against their will. Is that bad or is that not bad? Technically, we've never been sued or we've never gotten in trouble for it, but these kind of ethical questions over patient autonomy benefits what we can do. If you could maybe comment or elaborate on whatever that means. So let me clarify, there are two questions there, right? The first is a patient who you're worried about their access to guns. And I'm assuming you're worried about that access to guns because of their psychiatric disorder. Places them at a place where you're worried for danger to others or danger to themselves. I mean, for the purpose of this question, it could be either or, but basically they have guns, we want them out and the patient is not gonna remove them. So you're worried about them, but they have guns and you want to take them out. That's one. The other is somebody has left the hospital AMA and the team is saying that they have the mental capacity to do that, but. Or a patient has donned their street clothes and is physically walking out of the building and no one is stopping them perhaps except for a service like psychiatry asking for a urgent capacity evaluation to keep them in the hospital. But we have not evaluated the patient face to face that day perhaps. And they are calling you to do a phone consult to decide whether they should keep the person or not? Well, the security service would probably argue if they don't have the right to hold someone that would be battery and they don't want to commit a crime against someone. So they're asking for our assistance in that moment. But this is not a psychiatric hospital now. This is a general hospital. This is a general hospital. All right. Thank you very much. Okay. So let's take the first one first and then the next one after. Which was the first one? First is somebody has access to guns. They don't want to remove their guns but people are worried about them and guns. Well, my sense is that as psychiatrists we're raising concerns. We're not in the position of being able to tell family members what they should do and what's okay for them to do. We're not in the position to give them legal advice about whether they'll get into legal trouble. We certainly wouldn't want to advise someone to do something that we're pretty sure is illegal. So I think the best we can do is to say I have concerns about this person having guns and it would be best if they did not have access to them. I would advise you to do whatever you can to help the patient by getting them into a safe place where their access may be more limited. So I'm just saying you give your advice and raise your concern but you don't really go to telling families how to handle it. Anybody else? Yeah, a number of things. I want to make sure that there's some kind of collaboration between you and the family and the patient. So I worry about our emphasis on autonomy. This is an issue in US medicine, has been for a generation. I like to use fidelity towards the patient and the relationship and the patient support system, the family, so if there's anything that you can do collaboratively, which we've done with these kinds of patients, hey, you know, your parents, your family, everyone's really worried about you, can we take those guns out of the house? Now being aware of, that's the ethics part of it. The legal part of it, which is a professional obligation, is about knowing what the jurisdiction's requirements are. So I went from Massachusetts to Washington many years ago. So I went from Massachusetts to Washington many years ago. I know what the standards are for decision-making capacity, imminence, dangerousness, that kind of thing, but DC interprets things differently. So you have to get to know what the parameters are within the jurisdictions and what your agencies, police, courts, will tolerate, fair enough. Extreme risk protection orders are another layer of this. So you have to know in your jurisdiction under what circumstances you can claim that mental illness and dangerousness require protection from guns. But ultimately, I think all of this yields to that nexus of mental illness and dangerousness and that you're quite safe to make those calls. And also, perhaps you as a treating psychiatrist are not in a position to go to the family home and take the guns, but if you're in an urban setting where there are psychiatric outreach teams that very often work collaboratively with patients and families and can possibly help bring the patient towards more of a decision to surrender their arms, or if you're extremely worried, extremely worried, direct them to law enforcement as a resource, but I have to say what you've raised is we really have very little knowledge or control of our patients' use of guns. Someone can surrender the key to their gun cabinet while you're worried about them and you have no idea if they have another key. And someone can surrender their guns and then have a friend go pick them up. So we have, in reality, very little control over what happens out in the real world. How many people here know of extreme risk protection laws in your state? It's also known as red flag laws. All right, so you really need to know what the red flag laws are for your own state because that will guide some of what you're saying. There's also a piece of risk assessment. So you're talking really about risk assessment and autonomy. Obviously, if the risk assessment shows you that this person is in danger, you make a different decision around what you do. Sometimes that decision would automatically trigger the removal of guns from their homes, depending on your state laws. In Connecticut, if you admit somebody in a psychiatric hospital, even if it's voluntarily, for six months, their guns will be taken away from them and then they can be returned later. So that's the, no, I'm just giving you, the other thing that can happen is, if that is not the case, this is the struggle, right? The case, the person does not have, you're not concerned, there's no, your risk assessment shows that the risk is not high or is, and the person has capacity for consent. Just like anybody else on the street, they can own guns like everybody else. The mere fact that they have a mental illness does not preclude them from having that. So you're making an assessment based on concerns, based on risks, and if the risk is high, then that might be all of what Phil and the rest have talked about, collaborating family, trying to figure out a way to engage them, to have a discussion, engage them in other services. It becomes really a negotiation-type discussion piece with the different agencies you have in your state and the individual. But the idea that an individual with mental illness has lost capacity to own guns is a problem. But it's the, how can they own it safely? And are there laws that allow you to be able to do more in your particular state? Is there anything else you wanted to add to that piece? Just, I'm from Pennsylvania, so the, we can only legally remove guns from the home through police assistance or anything through involuntary commitment. So even if a patient is voluntarily committed and had intention of using firearms, we cannot legally permit them. But I mean, it's a complicated case, or it's a complicated question. I'm sure many people have faced in combination also with the ethical perspectives of what the right thing to do is. And so I appreciate you all sharing your expertise. And the other one, just in the interest of time, the other one about somebody is living in the hospital, a general hospital, and suddenly they want psych consult to see, and this is always happens all the time. You know, if somebody says yes, they just keep treating. But once you say no, let's get psych in quickly. The question for you is, can you do a real good assessment on the phone? You can't let people put you in a position where you're doing a shoddy job just to maintain the system. So that's really the question for you. The question is, does this individual have capacity to make the decision to leave the hospital, which every doctor can do. It doesn't have to be a psychiatrist. The doctor there can make that assessment, and then they can call you to come back later and decide whether, you know, review it again or not review it again. But they oftentimes will push this on residents or push this on any psychiatric person to avoid doing it, but any doctor should be able to make that judgment. But if you are on the spot, and you're being asked to do it, and you're gonna do a phone call, and you can, you just really need to ask yourself if that is what you consider an appropriate evaluation. And if it's not, why are you doing it? And that's a struggle. That might require discussion with the hospital. That might, you know, these things are never easy. That might require a lot of discussions with different people to make sure that we have a better way of doing this. But if, you know, I said, one saying I always say is everything is okay until it's not. You know, everything's going well until one day something happens. And then people will say, but you examined them. You told us to do this on the phone, and it's not usually your normal way. That becomes a real problem. I, did anybody want to add anything to this? Well, I was going to make the same point, I think, about that sounds like a position, being called up and say, Mr. X is walking out. Is it okay when I haven't evaluated Mr. X? I wouldn't want to be in that position. So I would try to take it up with the hospital in terms of its policies and procedures about how to handle these situations when in the usual manner of doing a psychiatric assessment, I haven't had a chance to evaluate the patient. Now, if you've been on a consult service and you've already evaluated the patient, well, then you may be in a better position to say, hold this patient until I can get back and reevaluate them. Or I don't know of reason that this patient should be helped. Now, if they have a psychiatric problem per se, and they leave, what I would do is ask mobile crisis teams to go and assess them. So this urgency, you have to do something right now. At least you can send mobile crisis teams to look at them and make it, they can then do a formal assessment. That's, I mean, I know that we're not quite capturing everything you're saying. No, I think it's, you know, patient autonomy is always an interesting question when, you know, kind of do the quote unquote right thing for your patients when sometimes that means being a little bit flexible with what you're able to do or what not to. And there are many gaps in the current systems and it's state dependent. So I just appreciate the perspectives. Okay. I appreciate your answering the question to the best of your abilities. Thank you. Thank you very much. Thank you. Sorry, next. I have to make a comment and then goofy question. Can you speak so people can hear you? Sorry. I have a comment and then I have a question. We've been through different residency training programs, fellowships or whatever it is. There may be some lectures regarding ethics and all that stuff, but I didn't remember what. I came into cross, I work with the community mental health system for the last 25 years or so. It's somewhere about 10, 11 years ago, a responsibility was given to do a consult service for from St. Louis, Missouri, to consult with the bigger organizations hospital. And our attending physician, one patient was admitted who was refusing care and the attending thought that she should be treated involuntary. I don't even remember what was the details. This patient had came from, because St. Louis is on the, just across the river from Illinois. So she had a judge's orders or she went through all those things. She had some chronic illness and she does not want it to be resuscitated. And if she's dying, let her die. And I thought that patient was in his sane mind. She had a chronic illness and she wanted to go. I had a conflict with the physician who got angry at me that if she does not want to care, why she come to the hospital? She shouldn't have came to the hospital. Of course, the family got concerned. Then I was sitting there at the nursing station. I kind of pulled my hairs and asked, is there any ethics committee here? So they say, yeah, we have an ethics committee. So we went to the ethics committee and that issue was sorted out. And they asked me, oh, we don't have a psychiatrist in our ethics committee. Would you like to join? So, and then over the years, they had learned that that hospital has a very good ethics committee, which have members like a couple of members of the board of the hospital, surgeons, and critical care people, some internists. So to solve the problems, they've met regularly. We used to meet like once every two months, and then later decrease it to once every three months. Difficult cases, some people are involved in those kind of acute situations. But I still think sometimes we come across certain things where we are like personally myself is not sure what to do, and we ask the risk management people. And we don't get any help from them. I'm not exactly sure why. And then another question what I want to ask, in the state of Missouri, if a lot of time and the patient is refusing care, wanting to be discharged. For example, this sick girl, 21 years old, substance user, admitted to the hospital with endocarditis. ID people think that if she won't receive the care, she would die. She needed to be have on antibiotics for an extended period of time. I asked psychiatry to see them, and my own question comes in, they wanted us to get her on involuntary on the medicine floor. And they always think, medicine people, that Missouri has a 96 hours hold for involuntary psychiatry hospitalization, and could not convince them, medicine people, that medicine people can also keep people on involuntary basis, considering the consults or whatever it is. So I want some more feedback from you guys that what could we have done in these kind of situations. OK. So first and foremost, ethics committees of hospitals are really important. And sometimes we forget that they exist in a hospital where we work. So it's really important to always check to see if you have. It also has an ethics committee where you work. And if they don't, it might be important to add stat one, so that at least you have a place where two heads or three heads are better than one when you have issues that you're dealing with. So that's a really important plug for ethics committee in the hospital, which you should probably participate in if you can. But the question really is about someone who has refusing care. They have acute medical problems brought on by psychiatric issues, in this case substance use. But they have acute medical problems, and they could die from the acute medical problems, but they are refusing care. Can we use psychiatric holds to hold the individual in the acute medical center? That's the question, right? Part of the question, because we are not putting them in a psychiatry unit, but they are still going to stay on the medicine floor. But they are asking psychiatry to commit them to the medical floor for medical illness. All right. Thank you very much. Any comments? A lot. Yeah, I'd have a lot too. Go ahead, you can start. Hard to know where to start, but everyone's going to pick me up after this. So the right to refuse treatment is enshrined in US law. It's supported by the ethics literature, by informed consent doctrine. And we're often asked to make decision-making capacity assessments for people at the end of life. That shouldn't be an issue. Not bringing people into the hospital for that. So there's a literature on that and a political viewpoint within ethics that the hospital is about care. It's about support. If you want to use hospice or other versions of it, that's fine too. But that's an old argument. That's an argument my mentors and teachers struggled with a long time ago that I thought we had solved. Ethics committees require some kind of training, as do consult liaison ethicists and the ethics committees that do these kinds of floor consults. So you might look into the new standards from places like the bioethics community, which are online, and they've developed over the last decades. So that's a few of these issues. Risk management consultation. Nothing wrong with talking to the hospital about what they think this means for the organization and the risks for the organization. But ethics committees and ethics consultants are focused on the patient. That's their primary responsibility. Again, nothing wrong with hearing what the hospital has to say or general counsel or the CEO if they're worried about it. But generally, those folks don't have votes on ethics committees, you may be aware. So a CEO, general counsel do not vote on the ethics committees that I'm familiar with. Training risk management decision. Oh, we published out of GAP, the Group for the Advancement of Psychiatry, a model for end-of-life interviewing so that you're not forcing people to take treatment or you're not abandoning them to their choices. That's another model that people are afraid of. I mean, we're afraid someone doesn't want treatment. We don't explore why it is that that's happening. We still have a responsibility to explore what the pressures are, what the burdens are from the patient's family, their community, from their insurer, what that may be. So GAP has a very nice piece just out last year on exploring decisions about end-of-life care that you might find interesting. Two comments to add to Phil's comprehensive answer. One is going back to the very beginning of your question where you said you got into an argument with the other physician who said she wouldn't have showed up at the hospital if she didn't want treatment. And there is a difference between treatment and care. Sometimes people come to the hospital wanting care and not treatment. And it's important for us to just keep that in mind as part of the decision-making process. The other is that there are no black and white answers in this. There are no algorithms that we follow for ethics. And that's why we have ethics committees, because these are very complicated questions that take into account all the variables for any given patient and why it's important to have different perspectives, not just one person making the decision, but a group of people who may look at it from very different angles. Are you okay? So the only comment I will add to that is, and I know this may be specific to substance use, and this may not actually be a satisfactory answer, but if somebody is using in a very dangerous way that has put their life at risk, many people do not know that there's a civil commitment. Sometimes, some states have it. I don't know if all states have it. There can be civil commitments for substance use disorders in a psychiatric hospital. That civil commitment, certainly in our state, gives more time, because substance use takes a lot more time. It's not like how many days you are civilly committed. You can be civilly committed for up to 160 days, sometimes, for persons in a... Right, so that's what I'm saying. Now, I'm getting to the reason why it might not be completely satisfactory, because you might interrupt that dangerous use for that period in a psychiatric hospital, but if they say, I still don't want medical care, you can't take them to the hospital and back. Now, if somebody is committed to a psychiatric hospital, they certainly can receive care in an acute-care hospital and come back to the hospital, like transfer for, say, if you have a heart attack or you have some issues that are acute medical conditions, you can have it in an acute medical hospital and come back to your state of civil commitment in a hospital. If somebody has endocarditis and they are saying they don't want care, but we think that the reason why is to go to use and the use is so dangerous now, we can certainly apply for civil commitment to a psychiatric hospital and then begin to engage them in a discussion while at the hospital, where they would be able to receive care in the emergency. It's not a negotiation and a discussion, but at least they are removed from the environment, the serious environment, initially, while you're engaging them in a discussion about whether they would like to take medical care. They might still say, I'm not gonna go take medical care. You can't force that on them, but at least for a period of time, you can remove them from the offending substances that they are using and hopefully begin to engage them in treatment for substance use disorders that will help decrease the need for dying. So I'm just broadening the discussion. It's not satisfactory, but at least it might provide an initial place for people to take a breath and kind of hold on and see what next we can do at this point. Okay, thank you. My name is Svetlana Dimitrava. I work for the VA in West Virginia. My question is about hiring family members for a larger organization, like in a private practice, very often family members work together, but what are the ethical principles about and the nepotism in hiring family member in the same division, for example, and what are the ethical principles about that? So this is just about staff now. This is not a patient care issue. Not a patient care issue. So hiring staff, different family members to be in the same unit or the same hospital system. Not the hospital system, the same division. The same division. So they work together. Yes. Working together. Supervisor employee relationship. All right, thank you very much. Go ahead. Okay. What do you think? I'm not sure I understand the question. The question is, let me, I've seen this happen a few times where family members are in the same unit in a hospital. Say somebody and their sister or brother or even spouse might be working on the same unit, and yet there's a requirement of supervision, monitoring, and working together. Are there any conflicts and things like that? Really, what you're asking about. Supervisor employee. Right, right. So let me just, let me take this quickly. Look, it's a problem. It could be a problem. It's not always a problem. It could be a problem. And sometimes if you have a supervisor-supervisor relationship and it's a spouse, in most hospitals they try to separate you into different units because of real conflict. I mean, bad things can happen from that kind of a conflict where there's supervisor-supervisor relationships. But if it's siblings or other kinds of family relationships in a place, it really, especially only, becomes only a problem when there is a supervisory type relationship, even in those situations. Because people might begin to wonder whether you're holding some other people to account when you're not holding your family members to account. It could create some kind of bad blood in the system. But you can't really say family members cannot be on the unit. So it's really a question of exploring to make sure that those things are not happening. It's a question of the leadership of the hospital being aware and making sure that those kinds of conflicts do not arise. Having an open door where other staff can present their complaints and then taking those complaints seriously. So for other family members, that's what I would say for relationships that are intimate, husband-wife, it's very difficult to have that relationship in a hospital on a unit. Now if it's a large hospital system and they can work other places, that's fine. But on the unit, you might consider separating them to different units. And most hospitals take that seriously, actually. So, but it's not all of them, obviously that's why you're asking the question. But most hospitals take that seriously. Thank you. Did you want to add something? Yes. You know, the way I've seen this is that there are certain rules that are written into the contract. So people can't be responsible for each other's work or oversee each other's work. And the chair's department, the chair's office and or HR work collaboratively to make sure that these, that the two aren't reinforcing each other or voting with each other on faculty issues. So there's some elements of contract ethics that can affect this, but I've seen it written into contract so that someone will not have access to somebody else's supervision. Does that make sense, Charles? I think you've seen it. I've seen that too. I've seen that too. And the guides and rules as to how to work when you, I mean, I know of a case where people were working together and then they got married and automatically that meant they had to be separated from the unit because that was the rule of the hospital. And that made sense. So there are some rules that exist, but you have to look to see what exists and see whether it's being carried out and have a discussion about it. Thank you. I guess I have two kind of conceptual questions. One is regarding this issue of kind of fads in medicine and psychiatry, and we all know that happens. Frontal lobotomy is obviously in psychiatry, oxycontin, in pediatric bipolar disorder. They're very controversial issues that can happen. And the thing that's relevant now to me is this issue of adult ADHD, which whether it's a fad or not is unclear, but can become mainstreamed and kind of put into guidelines. And how do we ethically, if we disagree with something that ends up turning out to be a fad, but may or may not be, but patients come, the professional standard of care is one thing, guidelines are one thing, but you disagree with it. How do you deal with that kind of ethically? And I guess it's a general question, but I'm relating it maybe specifically to adult ADHD and the use of amphetamines, if a person is questioning that, whether that's a good thing. And the second question, again, is a conceptual question. Ethics is, to me, is like what we should do. That's the question, what's the right answer in terms of what we should do? But that could be different from a legal question of what we can do, and I guess that's often ethics and law are intertwined, but there is often a conflict there in just generally how we negotiate that. Sorry, I don't have a specific example for that, but. No, great questions, where are you from? Oh, sorry, from Toronto, Canada. Okay, so you practice in Toronto, Canada, okay. So there are two questions there. One is what's ethically permissible when you don't agree with a particular treatment recommendation or ideas or. Mainstream or the guidelines. Guidelines, you don't agree with that for a particular patient, and you use adult ADHD, but it could be other things, like benzos or whatever. You can be. Pediatric, but. Right, okay, and the other is that when laws and ethics collide, what do you, which, by the way, I have an article in Psych News on the ethics corner that addresses that particular question, but we can also talk a little bit about it here. So, first ones. So just to add a disclosure, I'm the chair of the APA Committee on Practice Guidelines, and the biggest concern around adult attention deficit disorder is that we don't have a guideline yet. The good news is that there are a couple of groups who are collaborating to work on a good guideline for adult ADHD that we hope will be coming out in the next year or so. It won't be the APA, but APA is collaborating. The question we've dealt with, and I'm not sure if this is the issue you're bringing up, is when patients are coming to you for treatment saying, I have adult, I have ADHD, and I want this treatment, usually stimulants, and you don't, you either believe they don't have it or you have reasons to doubt. And I think the advice we've given to people who are saying, I'm expected to see all these patients and I'm sometimes uncomfortable with being expected to meet the patient's requests or demands, and the advice we've given is to have a standard way of approaching it, to have a protocol for what kind of evaluation information you need to make the best judgment about them having ADHD, and so that you can feel comfortable when you're saying, yes, this merits such a treatment and I can prescribe it for you, or this doesn't meet the criteria. So it's to have a standard way of approaching it so that you're not kind of flipping a coin about whether to say yes or no. Let me, like to make it more specific, say 20 years ago, a patient came wanting oxycontin for pain management, and that was the standard of care and the key opinion leaders had all been promoting it, and that doctor was prescient and realized, oh, this probably wouldn't be a good idea. You would, how would you deal with, you know, I guess that's kind of the question in terms of dealing with if you feel like something is not a good idea but the standard of care is separate. Well, so I think that, I think he was answering some of it in a different way. One of the biggest issue is to have a blanket. I don't do X, I don't do Y statements, but at some point it becomes less the standard of care as what you have done as a physician to ensure that you're providing the care a patient needs. You know, so a patient comes, some other doctors have prescribed medicines for ADHD and you don't agree with that. The idea that I don't agree with this alone is not gonna help you. You have to do the same, your own assessment and review and come to a conclusion based on your own assessment and review that this is not the kind of treatment this person needs. You have to have your own full set, where the guy for the Oxycontin, you have to also make your own assessment and decide that this works or doesn't work. But having a blanket statement can be quite problematic. That's really the issue because when things happen, everyone wants to see what rigor you apply to come into your decision to not do something or to do something. I think that's what I done, that's part of what you were saying. Well, I was thinking further as you've been talking that I don't think this standard of care can ever be physicians must give patients who request X, X, whether they think it's the right treatment or good treatment for them or not, that can't be the standard of care. So someone arguing that the standard of care is to give people who say they have pain Oxycontin, can't be, can't be. The standard of care is that the physician does a competent assessment and weighs the risks and benefits and the medical knowledge and the literature and makes a judgment. Yeah, I think also, we've all had patients who've come to us with ADHD diagnosed by Vogue magazine or Reddit, because they've done a screen and come in. And I think it's important to remember not all of them are drug seeking. For some of them, it is kind of revelatory to do these things. But also, that the treatment for ADD isn't simply medication. That it's a broad-based plan involving some behavioral approaches, time management approaches, executive functioning. And so that when you doubt a patient has ADD, there are things you can do without immediately dismissing them, to really explore a little bit about whether actually they do. And women are traditionally underdiagnosed with ADD, and it may take them years to reach a diagnosis. So I think it's important to keep in mind that not all treatment is medicine. And that as psychiatrists, we really have to assess many more aspects of an individual patient before resorting to $5,000 worth of testing. Yeah. Let me retreat to the conceptual stuff, because you started this as a conceptual issue. And this is a matter of the state of our knowledge, right, as a profession, and how it evolves, how the standard of care evolves. Which again, puts the responsibility on us to recognize what makes up the standard of care. Because I mean, it's our guidelines, it's textbooks, the literature, and that's why we have to keep up with it. It's also why we have to be familiar with research methods, so that we understand the strength of one study over another. And I should tell you that the APA guidelines are guided by epidemiologists, so we borrowed one to help us with the forensic literature. So in the rating of the studies and the ratings of the research, there is very strong support, consultation for professional guidelines. But of course, they evolve, which is why we want them updated every five years or so. So understanding of research methods, the standard of care, and how the state of knowledge evolves is a very important question that we have to, this is why we have to keep up with the literature, go to the APA meetings, read the guidelines, that kind of thing. Finally, the distinction of ethics and law is huge for ethics committees, right, because as you say, we have to decide what one ought to do, which is a broad range of possible behaviors, as Dr. May has pointed out. But these are different things, right? Ethics and law, law is about resolving disagreements, it's about decisions that are often very clear-cut, one thing or another, someone's competent or not, disabled or not, they're very, you know, guilty or not. But we're allowed to work in these gray areas, which is why Dr. Dike is emphasizing this element of your assessment and making sure that your judgment and your understanding of the science is what governs the, the care. Thank you, I appreciate it. But I know that we have about 10 to 12 minutes, I want to make sure we cover everything. The one quick thing about law and ethics, illegal behaviors may not be unethical, unethical behaviors may not be illegal, or how do you say, ethical behavior may not be illegal. They are not the same, there are some places where they cross, but the law trumps the ethics, unfortunately. If you're practicing in a state and they tell you don't do X, and you say, well, my ethics say I should do this, you know, you might get in trouble. You know, there are some areas where the APA, the, you know, the only illegal behavior that the APA says is ethical is if they, if you are protesting the maltreatment of psychiatric patients in an area where they ban protest, you know, they might put you in prison, but it's not ethical. So, I mean, you just need to make sure you don't cross the laws of your state, and if you have to cross the laws, you really need to make a sober reflection and talk with people. Even if it's ethical to do it, but it's illegal, you have to really be careful around those areas. There's a lot more we can say about this, obviously, we don't have enough time for that. Thank you so much for the question, and yes, please. So, I'm Matt Majeski, I'm from New York City, I'm a hospitalist for the Mount Sinai system, and part of the ECT team. I want to go back to the example of ECT that the gentleman brought up. It sounds like you've just recently finished your training, and you're being asked by the county to be a gatekeeper for ECT, which is, I don't know if that's a role that you want to assume or feel comfortable with, but I can say that what sometimes happens in ECT practice is clinicians will throw up their hands, and they'll say, well, we've tried everything we can think of, and it hasn't worked, the patient isn't better, so let's do ECT, and that's the wrong way to think about it. It's best to remember the specific indications and things that ECT doesn't work for. ECT does not help personality disorders, it doesn't help substance use disorders, it does help major mood disorders, with and without psychotic features, schizoaffective disorders, schizophrenia, and catatonia. Now, sometimes patients with personality disorders have a comorbid mood disorder, and that's where the ambiguity comes in, but anyway, I just wanted to offer that comment. Thank you very much. Thank you. Hi, good morning. My name is Alyssa. I'm finishing up my child psychiatry fellowship at Stanford, and I'm actually currently sit on both of the Children's Hospital and Adult Hospital Ethics Committees there. I'm staying on as faculty with a dual appointment in psychiatry and ethics, and I previously worked as a public defender after law school, so I have some background in law and ethics as well. You woke up. You woke up. Yes, yes. My question is sort of a systemic level question about whether the APA Ethics Committee or whether you all as individuals have thoughts about ethical issues that may come up in hospital settings that are sort of above the level of patient-centered or patient-facing care, issues that have to do with how the teams interact with each other, issues that have to do with how hospitals make systemic policies around the law and around things that may have been practiced for years or even decades that maybe folks have ethical qualms about or ethical components. Do you have an example to give? I have a lot. I have a lot. Let's give one example. One example. Okay. Well, one good, well, so there's a lot of team-based examples where sort of like essentially a patient will be being cared for by multiple different teams in the hospital, and the teams may have a disagreement about how to address that care even though there's not really an ethical issue that comes up. There are also issues like at Stanford, let's say, where there's sort of this split between the adult and children's hospitals, which is a, from a legal perspective, which is a split that doesn't really make a lot of sense. And so, for example, kiddos, let's say in psychiatry, if they're hospitalized in an emergency room, they're actually embedded in the adult hospital. And because of that, there are certain laws around legal holds and things like that that are applied to the kids because they're in an adult hospital setting that otherwise wouldn't because they're minors. And nobody's ever really addressed that on a systemic level. So I'm sort of interested in these bigger sort of systemic issues. We have a robust ethics consult service. We oftentimes come in and consult on patient-related treatment issues and, you know, individual ECT, things like this. But what do you do about these sort of bigger systemic issues at play? Who is the right sort of body to address that stuff? And how do we think about that as psychiatrists and as ethicists? Thank you very much. Anyone want to take that? We do have guidance in the commentary on multidisciplinary teams and organizational psychiatry. There's a literature on organizational psychiatry. Again, it still is a focus on patient care. I've got to say, I'm medical director of a hospital, so these systemic issues on how you interpret data, how you influence the community to do certain things or the mayor's office to give you more funding. So I think that there is guidance out there, and I'm glad to talk about that more. So the issue of system-based issues, adult and children and hospitals, a lot of those are, I don't really know the specifics because one of my roles is I'm the chief medical officer in Connecticut Department of Mental Health and Addiction Services. So I obviously oversee a lot of psychiatric hospitals for adults, but we're oftentimes holding to the child system as well. So I'm not sure I understand fully. Maybe you and I can talk some more about that. I can tell you how we, you know, those things might apply. Ethics definitely looks at the individual, but there's also systemic ethics. There's a hospital ethics. There's a, you know, different kinds of ethics, organizational ethics. And all of them come to play in what you're talking about. And how do we as psychiatrists, how do we get involved in organizational ethics, in systems ethics, in hospital ethics to change some of these ideas? I think I'm really a supporter of somebody getting involved in those areas. But you and I can talk a little bit after this. Thank you very much. Yeah. My name is Raymond. I'm from Northern California. I don't have the same question as the lady doctor just ahead of me, but it is a philosophical question. I'm not interested in legal discussions. I've been part of our district branch ethics committee for two decades. And I'm curious what you folks think in terms of the direction that we might go in terms of the ethical discussions for the next decade, maybe. Thank you very much. Thoughts? I was chair of the Washington Psychiatric Ethics Committee for many years. And I've been heartened that there's been a drift in discussion from individual cases and to more general as we now have fewer ethics complaints and have become more of a resource for physicians in the area. It's been really heartening to have broader-based discussions. And I think that DB ethics committees, to the extent that they have the resources in terms of time and talent, can be very vibrant resources in their communities. And I think inviting members to come to you with questions and being a resource for them and also permitting free discussion about these issues within a DB can be very helpful. Thank you. Go ahead. I think that the focus or the items that garnered ethics attention have clearly evolved over time and continue to evolve. Currently, members are facing and raising a lot of questions about things that they see immediately on the horizon. Currently, using technology and apps in their practice. Coming soon, how is artificial intelligence going to affect the practice of psychiatry? Our members are already having questions and formulating questions, and I'm sure it pays us to think. And as we see other things come up, to try to think ahead about the implications. I know that's a general answer, Raymond, but there are lots of things on the horizon. Yeah, and I think the question required a general answer, actually, because you're talking about what things are on the horizon. What should ethics committees be addressing at this point? I do like the ideas that my two colleagues have put forth, the two different ideas. I mean, collaborative care models are coming up. Big companies are buying up psychiatric practices. Practices are closing and getting to the hospitals. What does that mean for us? What does it mean for the patients? So these are the areas that are really out there now that people are trying to figure out how to engage in them, and where the ethics lines are going to be drawn in these areas. So, but it requires a lot of education on our part to really learn about these things, because I'm still learning about these new things that are coming up, and just trying to understand them first, and then understand how they are going to be the ethical implications of all of them. So this is a time for education for all of us, I think. Thank you. Hi. My name is Rashida, and to provide a little context to my questions, I am a non-US IMG, meaning that I did not train at all in the US. I practice in the Bahamas, and so it's a small country made up of many islands. I actually live on the main island, New Providence, which is a population probably of about 200,000 of our 400 and some thousand in the country. And I also started working recently, less than a year, in the one private hospital system that we have in the country. There was no psychiatric service prior to them bringing me on in August of last year. Not really, I don't get the impression that they're really interested in developing a department, but just trying to fill some very basic needs in the time being. So I have three questions, and you can just point me to resources if that is preferable because we don't have time, but gifts and accepting gifts. So small community, you know, gifts and giving gifts is very culturally appropriate. I know that there is a standard that we should not accept gifts at all, but for example, a few years ago, I had a private patient that actually left a fruit basket at the front desk for me. I wasn't expecting it. She didn't tell me that she was sending it, but I did take it, and I thanked her for it when she asked me about it. So I just wondered if there are cultural exceptions. Also, seeing family members, so again, in this new system, I do not have control over my scheduling at all, so I have just recently, I had a patient that I've been seeing for the last year, and I ended up through just not knowing, ended up seeing her father and then mother, but found out at the end or during the sessions that this is who I was seeing. So how, you know, how do we go about doing that? Again, I keep in mind that it is a small, there are maybe 10 of us for the country, so the pool of psychiatrists is very small, and then the third is seeing associates who work in the same system, so I was very against this even before I started, but they have kind of forced me to agree to see associates that work in the same system, even though I tell them it's very uncomfortable, and my first case was extremely uncomfortable because she was uncomfortable with the process. She was very open and forthcoming, but it created a lot of negative sequelae after the assessment was done, so I just kind of need some guidance on how I can guide them about having a psychiatric service, seeing people in the system. So three excellent questions, and we're going to try and capture all of them because they are relevant, and really the issue is when you practice in a small community, whether it is in the Bahamas or in small rural Georgia or some other small areas, they all apply, so that's the question. Three things, one, accepting gifts, what's appropriate, what's not appropriate, treating family members, different family members, and treating colleagues, so you can take all of these. I'm going to very quickly address that. One, you have to ask yourself the question, is it more hurtful for me to reject this gift if it is a small gift, and because sometimes our relationships with the patients aren't psychoanalytic, we can't investigate what the meaning of the gift is, and certainly in many cultures, giving small gifts is appropriate, and so you really have to ask yourself, would I be causing harm by rejecting this, and you might accept it and then share it with the nursing staff or if that was appropriate. Okay, number two was seeing family members, and particularly in small communities, this happens all the time, if there's only one psychiatrist covering an entire large geographic catchment area, inevitably you see family members, and also sometimes the family is the patient, not the individual, and it is beneficial in that instance to see family members, but be very clear about the boundaries and how you see them. And the third one was, oh, colleagues, yes, and I think probably all of us are asked from time to time to see a colleague, either within a system or in a close, and it is not inherently unethical, again, if you're very clear about the boundaries, what you can and cannot do, what confidentiality issues there are, and certainly I would be very alarmed if I had to enter data into an electronic record that might be accessed by other people. So those are my quick answers. Any other quick answers? We can expand on these answers after this, by the way. Any other quick answers? Okay, that way? All right, so the only thing about gifts, first of all, any time you're doing anything for a patient, you want to ask, who's benefiting from this? If at any point in time you are benefiting from it, that's a problem. So gifts, small gifts, no big deal, but a little bit, again, it depends on the person, because what might be small for you might not be small for somebody else, but in the case where somebody dropped a bag, I would accept and thank them, but then tell them that please, because they might not feel under pressure to continue to do stuff like that. You never know how patients are interpreting your behavior. So once you accept that small food basket and thank them, you just let them know that ethically I'm really not, you know, it's, I'm not allowed to accept all of this. This was nice, but please try not to do that next time. Let's talk again, you know, just accept it, but give them some roadmap next time to be able to say no if they don't want to, which sometimes they might want to do that, but now worry that who knows what this is going to mean. So you just give them that feedback. For family members, again, it's a small place. The issue is it's not unethical to treat even your immediate family member. The only thing that is required from ethics is that you do exactly what you do for everybody else. You create a record, you examine them the way you can, you ask the same type of interviews. The problem is if it's an immediate family member, you're asking about sex with somebody or you're asking about all, so that those kinds of things make your assessment perhaps problematic, which is why people might say don't do it, but if you can keep records and do everything exactly how you do for everybody else, then that's acceptable. But for multiple family members, it really becomes about barriers and boundaries. It's very difficult to make sure that they don't cross, and sometimes the other patient might say, are you treating me this way because of what my dad said to you, and that becomes a whole different issue. The question of can you socialize with them in a small community, because everybody's there. Your children are in the same school with them, and so these are things that you really need to be mindful about. But again, the time is up, and we can talk some more about this. I want to take a second to thank you all so much for your participation and attention. This has been helpful.

ethical dilemmas

psychiatry ethics

patient confidentiality

telehealth

conflicts of interest

informed consent

systemic hospital policies

patient autonomy

prescribing practices

adult ADHD

small communities

AI in psychiatry

ongoing education