Ethical Challenges in Psychiatric Training and Practice

The American Journal of Psychiatry Residents’ Journal (AJP-RJ) offers a dedicated forum for medical students, residents, and fellows to share their research, commentary on pertinent topics in psychiatry, and reflections on trainee experiences. Our collaborative philosophy around peer review offers an excellent opportunity for trainees to hone their communication skills, which are critical in the practice of psychiatry.

The journal owes its success to the countless hours of organization and critical review put in by the editorial team. I have had the honor of being on the AJP-RJ editorial board for 3 years, and I find it remarkable that the journal is sustained by volunteer trainees from sites across the United States and Canada, brought together by a shared passion for psychiatry and scholarly work. This year, I look forward to taking on the role of editor-in-chief and celebrating the milestone publication of our 20th volume.

Scientific progress in psychiatry depends on many iterative processes; this of course includes peer review, one of our favorite tasks at the AJP-RJ. These processes are imperfect and at times inefficient, and they may even be downright frustrating, but in the long run, the disciplined scholarly pursuit of knowledge can serve to improve the quality of countless lives.

Similarly, the ethics of psychiatry also evolve in an iterative manner, all while interfacing with legal, political, and cultural forces. As psychiatrists, as we learn more about the realities of both the human condition and about mental illness, we hope that this knowledge is reflected in the aims, expectations, and regulations of our practice. Unfortunately, as suggested throughout this issue, the ethical frameworks of psychiatric practice may at times be forced to take a wrong turn at the expense of patients and providers. Thus, psychiatrists must be well versed in the ethical considerations of their practice and remain critical of both existing and emerging norms. I am therefore immensely proud that the 20th volume of our journal begins with a special issue dedicated to contemporary ethical challenges in psychiatry. It has been a pleasure to take the lead on this special issue; it showcases the fresh perspectives that trainees can bring to the field.

Legal and regulatory frameworks fundamentally shape which treatments are available to patients and how patients access them. Considering the overturning of Roe v. Wade just over 2 years ago, Arboleda presents a review of studies on mental health outcomes after induced abortion or after the denial of abortion (1). This review also draws attention to how restrictions on reproductive autonomy may specifically affect women with a serious mental illness. In their case report, Evans et al. show how legal restrictions around providing electroconvulsive therapy (ECT) to patients that lack decision-making capacity can delay the treatment of catatonia (2). Although such restrictions may be informed by historic concerns about ECT, contemporary practice should compel a reevaluation of such restrictions.

Regarding involuntary treatment, Kramer and Perkey review the consequences of the use of psychiatric holds when decision making is impaired by the patient’s nonpsychiatric illness (3). This situation is complicated by the definitions of mental illness, particularly with conditions such as delirium, dementia, and intoxication. The authors call for a multidisciplinary approach and consider the merits of establishing processes for medical holds to mitigate the inappropriate use of psychiatric holds. They also refer to potential new challenges with last year’s passage of California’s Senate Bill 43; Server provides a historical lens to the ethical considerations of this bill (4), while Hegarty explores the potential implications specific to involuntary treatment for individuals with substance use disorders (5).

Darnell and Hiromoto highlight the ethical challenges of mandatory reporting in a hypothetical scenario involving a patient with impaired reality testing who discloses a history of perpetrating child abuse (6). Similar scenarios are not an uncommon occurrence in psychiatry and can put clinicians in a difficult bind. To address such scenarios, Darnell and Hiromoto succinctly characterize the ethical and legal principles involved, and they offer policy suggestions that may help balance the interests of patient privacy, the patient-physician relationship, and the protection of vulnerable populations.

Although psychiatry involves many ethical challenges related to restrictions on services, autonomy, and privacy, issues can also emerge when existing restrictions are relaxed. With the current renaissance of research into psychedelics, the classification and restrictions of these substances will likely need to be revised. Recently, a scientific advisory committee of the U.S. Food and Drug Administration voted against an application for the approval of 3,4-methylenedioxymethamphetamine (MDMA)–assisted therapy for posttraumatic stress disorder (7), although additional applications for MDMA and other psychedelics are likely to follow. Limited precedent around the regulation of psychotherapy, a component of this most recent application, will continue to challenge regulatory bodies. Hartstein and Menon outline the role of risk evaluation and mitigation strategies programs in future applications and the implementation of psychedelic-assisted psychotherapy (8). Additionally, they consider the ethics of diagnostic pressure and off-label use that might follow potential approval. Prasad summarizes some of the major concerns around Canada’s anticipated expansion of access to euthanasia to individuals with mental illness as the sole underlying medical condition (9). The provision of this service by physicians and nurse practitioners is currently postponed through 2027; officially, this delay was attributed to logistics, yet many challenges to the legal and ethical principles involved continue to be brought forward. The expanded eligibility was intended to mitigate discrimination against individuals with mental illness, and Prasad identifies ongoing concerns around social vulnerabilities, suicidality, and the identification of irremediability in mental illness.

On behalf of the AJP-RJ editorial board, we hope that you find this issue informative to your learning and your practice. If you have any disagreements with an article in this issue or wish to offer supporting arguments, we always welcome comments for consideration as a Letter to the Editor. If you are looking to enrich your training by getting involved with the journal or have any questions about submitting your work for publication in the journal, we encourage you to reach out.