Ethical issues involved in the role of psychologists in medical settings.

Psychologists can be found working in various medical settings including general hospitals, physical rehabilitation centers, and chronic disease settings. It is estimated that over 10% of the American Psychological Association (APA) members work in medical settings, with an increase of 200 to 300 each year (DeLeon, Pallak & Heffernan, 1982). As this number continues to grow, there is an increasing need to focus on areas of ethical concern related to working in these settings. Important ethical concerns involve role delineation, working within the medical model, multiple responsibilities, and confidentiality.

Role Delineation

Role delineation is of primary ethical concern since it lays the ground work for the responsibilities and expectations of the psychologist. However, there is no consensus as to what constitutes the role of the psychologist in a medical setting (Schofield, 1976). Diverse terminology has been used to describe this role. These terms include health psychology, medical psychology, clinical psychology, and behavioral medicine (Korchin & Schuldberg, 1981; Wiggins, 1976). It is argued that this lack of clarity in definition of terms is more than semantic confusion. Asken states, "...(psychologists) can never be sure whether their interests and activities have or have not been included under one of these nonstandardized terms" (Asken, 1979, p. 66).

The psychologist in a medical setting often functions as part of a multidisciplinary team. This team usually includes a physician, social worker, speech pathologist, physical and occupational therapist. Although the team may view the psychologist as having a legitimate role, they may also condone the delivery of services of a psychological nature by other team members. This was demonstrated in a recent investigation of the psychologist's role in a physical rehabilitation setting (Remenyi, Thomas & Leonard, 1981). In this survey 111 team members were given questionnaires and asked to comment on role descriptions. The results indicated that the physician is viewed as the appropriate person to lead case conferences and to assess clients for brain damage, the occupational therapist to conduct group therapy and training sessions, and the social worker to counsel clients and families regarding their adjustment. In addition, the psychologist was identified as the most appropriate team member to perfrm the traditional duties of personality and intelligence assessment. The authors conclude that historical biases, customary practices, and perceived areas of expertise were reasons for these observations.

Working Within the Medical Model

Ethical awareness is essential when providing psychological treatment within the medical milieu. The hospital environment includes unique areas of stress which effect both the patients and treatment team members. For example, Kastenbaum describes the hospital setting as analogous to a Greek city-state with the fundamental similarities being, "...inequality among classes of people and the proliferation of regulations to govern everyday life" (Kastenbaum, 1982, p. 158). As a result of this unique hospital milieu, Kastenbaum believes that there is a lack of objective decision making. He states, "...certain classes of people earn their right to exist only by carrying out carefully specified intructions and tasks" (Kastenbaum, 1982, p. 158). Contributions to the problem include the stress of territorial team issues, issues of job burnout, outmoded methods of providing services, a constant budget crisis, administration's focus on public relations, and errors in professional judgment which are covered up (Kastenbaum, 1982).

Continued conflict between the medical model and psychological appraisal can place pressure on the psychologist to adhere to the medical milieu. This is of particular concern when working on a team which includes a physician as leader. The traditional medical model implies that the physician is the "expert", the patient is seen as having "diseased organs" which can be repaired, and "good patients" are those who comply with hospital staff (Elfant, 1984). In contrast to this, the psychologist is ethically responsible to work autonomously, regards the patient as being influenced by a variety of sources (such as environmental stress) and noncompliance with hospital procedure is seen as separate from symptomology (Weitlieb & Budman, 1979).

The literature shows consensus as to psychologists' objection to working on a team with a physician as absolute leader. Most psychologists object to, "...the notion that psychological services ought to be organized under the auspices and authority of physicians" (Hoffman, 1979, p. 571). That is, they object to being referred clients only when deemed appropriate by the physician. Pschologists prefer to have equally autonomy on the medical team. This includes having admitting rights and autonomy in writing orders for treatment of their patients.

Multiple Responsibilities

In working within medical settings, many times, treatment planning is accomplished through a treatment team approach. During treatment planning the psychologist must consider the influence effected on the team, medical setting, and patient. The psychologist has responsibilities to all of these parties. According to Monahan the priority of these responsibilities is, "...rarely the same across situations but may change with each intervention strategy and set of circumstances" (Monahan, 1980, p. 129). The psychologist in a medical setting is both an employee and healer. Therefore, in situations where obligations to an employer and patient are not consistent there can be a serious ethical dilemma.

The psychologist should understand the effect of multiple responsibilities in order to keep the best interest of the patient in mind. According to the APA psychologists should not be swayed by, "... personal, social, organizational, financial, or political situations and pressures that might lead to misuse of their influence" (American Psychological Association [APA], 1981b, p. 633). While the medical setting's coerciveness is subtle (Hoffman, 1979), there may be a focus on suppressing undesirable behavior of the patient (Flanagan & Liberman, 1982). For example, the institution may focus on the patient's compliance with traditional treatment and prefer that patients not "excite" other patients by becoming a model of noncompliance. In contrast, a patient may be reluctant to take the "good patient" or "sick patient" role. This resistance to comply with the "sick" role may be indicative of independence. In other words, a particular patient's acting out behaviour may be an indication of a good prognosis and improved long term adjustment (Hoffman, 1979).

Confidentiality

Another important ethical concern is that of confidentiality of documentation. Many times, psychologists are required to document all of their activities in a manner appropriate to hospital procedures (American Psychological Association [APA], 1981a). Limited awareness of confidentiality on the part of other hospital staff directly influences the management of this documentation.

Once psychological entries are made into the medical chart, the psychologist no longer has direct control over the information. Hospital staff may be unaware of the ethical implications involved in the confidentiality of psychological reports. This information can be exposed to a wide range of staff including administrators, clerks, technicians, statisticians, and others (Siegel, 1979). In addition, when the patient is discharged, the chart is frequently sent to the medical records department of the hospital. Requests for information are usually sent directly to that department. Psychological information can be forwarded to other professionals or institutions without the consent of the client or psychologist.

Strategies for the Future

In order for psychologists to adhere to an effective role delineation, it is essential that they be involved in hospital policy making organizations. These organizations are typically dominated by physicians. One example is the Joint Commission on Accreditation of Hospitals (JCAH) which forms policies which directly effect psychologists. For example, they suggest standards for referral and documentation. It has been stated that, "...organized medicine will never easily give up its hegemony over the delivery of health care services in the United States" (Zaro, Ginsberg, Batchelor & Pallak, 1982, p.1344). Nevertheless, psychologists have been persistent in their interactions with JCAH and have made slow progress in their attempts to gain equal status as a discipline (Zaro et al., 1982).

Education may help to alleviate frustrations encountered in understanding the medical milieu and its effect on ethical dilemas. For example, some suggest that psychology students have some exposure to a medical setting during their academic training (Matthews & Avis, 1982; Spear & Schoepke, 1981). The medical team's understanding of the psychologist's multiple responsibilities may foster greater cooperation in dealing with areas of ethical concern. One method of increasing understanding is the formation of a multidisciplinary committee designed to promote professional awareness of treatment team issues. This committee could operate at the hospital, state, or national level.

One strategy for overcoming ethical concerns involved in confidentiality is specific labeling for psychological entries in medical records. Cameron and Shepei (1981) found that stamping the psychological information "confidential" was unsuccessful. However, they found other methods of identifying this information more effective. One of these methods was to stamp the documents with "Not to be Copied or Released." Another was to include a notation in the chart indicating that information would be released following an appropriate request made directly to the psychologist.

Finally, some inroads to political activism by psychologists has begun. In 1982 the Association of Medical School Professors of Psychology was established (Thompson, 1987). This association is one attempt to address ethical concerns, yet more needs to be done. Until the time when an organized multidisciplinary understanding of ethical issues can be achieved, psychologists working in medical settings must continue to stand firm in upholding thier standards regardless of pressure to do otherwise.

References

American Psychological Association. (1981a). Specialty guidelines for the delivery of services. Washington, D.C.: Author.

American Psychological "Association. (1981b). Ethical principles of psychologists. American Psychologist. 36(6), 633-638.

Asken, M. (1979). Medical psychology: Toward a definition. Professional Psychology. 10, 66-73.

Cameron, R., & Shepel, L. (Eds.). (1981). Strategies for preserving the confidentiality of psychological reports. Canadian Psychology. 22 (2), 191-193.

DeLeon, P. H., Pallak, M.S., & Heffernan, J. A. (1982). Hospital health care delivery. American Psychologist, 37 (12), 1340-1341.

Elfant, A. (1984). Psychotherapy and assessment in hospital settings: Ideological and professional conflicts. Professional Psychology: Research and Practice, 16 (1), 55-63.

Flanagan, S. G., & Liberman, R. P. (1982). Ethical issues in the practice of behaviour therapy. In M. Rosenbaum (Ed.), Ethics and values in psychotherapy: A guidebook (pp. 207-237). New York: The Free Press.

Hoffman, I. (1979). Psychological versus medical psyhotherapy. Professional Psychology. 10, 571-579.

Kastenbaum, R. (1982). The psychologist and hospital policy: A report from the real world. american Psychologist, 12, 1356-1359.

Korchin, S. J., & Schuldberg, D. (1981). The future of clinical assessment. American Psychologist, 36 (10), 1147-1158.

Matthews, K. A., & Avis, N. E. (1982). Psychologists in schools of public health. Current status, future prospects, and implications for other health settings. American Psychologist, 37, 949-954.

Monahan, J. (1980). Who is the client? The ethics of psychological intervention in the criminal justice system. Washington, D.C.: American Psychological Association.

Remenyi, A. G., Thomas, s. A., & Leonard, R. (1981). Psychological services in rehabilitation. American Psychologist, 16 (3), 361-368.

Schofield, W. (1976). The psychologist as a health professional. Professional Psychology. 7, 5-8.

Siegel, M. (1979). Privacy, ethics, and confidentiality. Profesional Psychology. 10, 248-249.

Spear, J., & Schoepke, J. (1981). Psychologists and rehabilitation: Mandates and current training practices. Professional Psychology, 12 (5), 606-612.

Thompson, R. (1987). A call for medical school activism. The APA Monitor, 18(2), 9.

Weitlieb, S., & Budman, S. H. (1979). Dimensions of role conflicts for health care psychologists. Professional Psychology, 10, 640-644.

Wiggins, J. G. (1976). The psychologist as a health professional in the health maintenance organization. Professional Psychology, 7, 9-13.

Zaro, J. S., Ginsberg, M. R., Batchelor, W. F., Pallak, M.S. (1982). Psychology and JCAH: Reflections on a decade of struggle. American Psychologist. 37 (12), 1342-1349.

GERALDINE LUCIGNANO, Seton Hall University, McQuaid Hall, South Orange, New Jersey 07079.