Crossing Boundaries

boundariesAn hour after I dictated a post about the complexity of working with patients with extreme moods. People whose moods may affect them so powerfully that a model of treatment that is purely based on the ethical principle of autonomy (I provide you with the information and you make the decisions about whether or not to seek treatment) doesn’t make senseI ran across an opinion article in the Journal of the American Medical Association (JAMA) that talks about the importance of the ethical principle of beneficence (kindness and caring) even when that principle may lead to behavior that violates the usual boundaries of the treatment relationship.

The author introduces the topic with this story –

It is 5 pm on Friday afternoon. After 2 hours on the telephone trying (and failing) to get her insurance plan to pay for her medication refill, I reached into my pocket and handed the patient $30 so she could fill the prescription. It seemed both kinder and more honest than sending her away saying, “I’m sorry I can’t help you.” While I hardly expected a commendation for such a simple act of kindness, I was completely surprised to find myself being reprimanded for my “unprofessional boundary-crossing behavior” after the resident I was supervising shared this incident with the clinic directors. This allegation of an ethics violation was not only personally painful; it also raised important, controversial, and timely questions about appropriate professional roles.”

I came at the topic from a different perspective.

I wrote a post about “Treatment as Punishment” that elicited a very thoughtful reply from one of the blog’s readers. [I encourage you to search for that post so you can find the reply]. Ever since I have been thinking about the issue of when, and how, to intervene when a person seems to be making very risky decisions as they escalate into full blown mania.

Intervene too early and you run the clear risk of being considered a “helicopter doctor” who is overcontrolling and, perhaps, punitive. Don’t intervene at all and your patient may end up dead.

In my experience there is a grey zone between a purely voluntary treatment relationship and a treatment relationship where the doctor steps in to prevent imminent harm or danger. Living in that grey zone is intensely uncomfortable because it involves constantly questioning one’s decisions (did I step in too early, did I make things worse?).

But I don’t see an alternative.