Conflicts of Loyalty: Recognition Is Key

A conflict of loyalty exists when a person has a duty of loyalty to more than one entity and the interests of those entities diverge. A conflict of interest is a subset of conflict of loyalty and occurs when an individual’s personal interests create biases that may influence his or her professional actions or decisions. Even an appearance of a conflict of interest, whether or not tainted judgment actually occurred, should be avoided. Conflict of interest was addressed in earlier columns (see end of article); this column will discuss conflicts of loyalty as they may arise for psychiatrists, including some common examples and potential resolutions.

Conflicts of loyalty may occur when a physician serves on two committees for an institution, and the work of one committee is at odds with the objectives of the other committee or of the institution as a whole. For example, at a recent Colorado Psychiatric Society (CPS) Executive Council meeting, the institutional Policies on Advertisers and Exhibitors were reviewed. I was aware of a conflict between my loyalty to the CPS Ethics Committee, which may want to retain the old, more restrictive policies so as to prevent any appearance of allegiance to the pharmaceutical industry, and my loyalty to the financial health of CPS as a whole, for which a more liberal policy would be beneficial.

A similar conflict of loyalty may develop when a psychiatrist must balance institutional rules and patient preferences. For example, a psychiatrist employed by a mental health center may request an exception to the rule that a stable patient be transferred off a higher intensity treatment team because of the patient’s stated desire to remain on that team. In this instance, loyalty to the patient’s preference and respect for the patient’s autonomy to make treatment decisions are in conflict with loyalty to the institution’s procedures for maximizing efficient use of resources.

Another context in which conflicts of loyalty arise is when duty to a professional activity interferes with duty to family. A common scenario is the struggle over whether to return a phone call to a patient at the end of the day if that means the psychiatrist will be late to pick up his or her children from the aftercare program at school. We must abandon neither our patients nor our children.

How shall we manage conflicts of loyalty? In Professionalism in Psychiatry from APA Publishing, Glen Gabbard, M.D., and colleagues say that a physician’s primary loyalty is to the welfare of patients, with additional loyalties to the quality of medical education and the integrity of research. Secondary loyalties may be personal or institutional financial gain, professional advancement, fostering favor with another person, or other nonclinical interests. Identifying that one has a conflict of loyalties is the necessary first step in managing the conflict. Conscientious role separation and well-articulated policies and procedures may help psychiatrists avoid some conflicts. When a potential conflict arises, reflection and perhaps consultation to determine the best course of action are wise.

In the case of the CPS policy discussion, I announced my conflict of loyalty to the assembled officers of the society and asked them to consider my contributions to the discussion in that context. In the case of the mental health center psychiatrist, it is ethical to review with the treatment team the patient’s request, any compelling reasons to honor it and any potential consequences, rather than try to circumvent institutional policy through more surreptitious means. When duty to family conflicts with duty to patients, creative solutions sometimes present themselves. One of my personal physicians once returned a call at 8:30 p.m. Initially this was off-putting to me because my call had not been an emergency, and I didn’t intend to intrude into his personal time. I was relieved when he explained that he returned routine calls later in the evening so he could eat dinner with his young children. His solution to this common conflict felt respectful to both family and patient.

Conflicts of loyalty arise often in the daily life of psychiatrists. They are unavoidable. The psychiatrist’s task is to recognize these conflicts when they occur and to pause to consider a solution that preserves loyalty to the patient while balancing other interests and loyalties. Sharing the dilemma with the patient or other people involved in the conflict sometimes clears a path to successful resolution. ■

“Self-Justification About Conflicts of Interest” can be accessed here. “The Ethics of Profit and Conflict of Interest” is available here.