Ethical considerations in mental health care informed by research.

Mental health care professionals regularly encounter significant ethical challenges in their practices, but an empirical approach to these questions can yield practical, patientcentered answers. Ethical issues related to confidentiality, access to resources, and informed consent are among those most frequently addressed by psychiatrists and other mental health professionals. Few investigators approach psychiatric ethics from an evidencebased perspective, but Medical College of Wisconsin (Medical College) faculty and collaborators are leaders among them. By studying real practice scenarios, researchers can better understand ethical questions and develop pathways for the compassionate and principled care of patients. While privacy is an inherent expectation in all medical practice, the importance of confidentiality is pronounced in mental health care because of the stigma and potential prejudice embedded in societal attitudes. In rural communities, stigma can be an overwhelming barrier to mental health care since patients often feel ashamed and fear their psychiatric disease will become public knowledge in a small community. Safeguarding a patient’s confidentiality is often essential to maintaining a treatment program. Advances in genetic testing and increased understanding of the genetic basis of mental illnesses have produced other confidentiality questions regarding access to personal health information and how it is used. Whether an employer ever has the right to know if an employee or potential employee has a genetic susceptibility to a mental illness is an ethical question directly applicable to people’s lives and livelihoods. The same can be said for the ethical ramifications of using genetic information to evaluate insurance status. If confidentiality were not required, an insurer might be able to refuse a person coverage based on genetic risk for psychiatric disease. While personal beliefs and economics may influence differing opinions, empirical study is valuable for objectively guiding sound public policy. Also of ethical concern, the typical, existing insurance structure for mental health coverage affects access to care. Neuropsychiatric diseases have a clear biological and genetic basis, while other mental illnesses may only have biological consequences—for example, a divorce may contribute to symptoms of depression, especially if a biological vulnerability exists. Nevertheless, insurance tends to paint something as transient as coping with a life event with the same broad brush as something as severe and persistent as schizophrenia. Thus, practitioners may find themselves often needing to advocate for their patients to have access to resources. The ability of patients with mental illnesses to provide informed consent can be compromised by their disease, which raises another ethical consideration. Practitioners need evidence-based tools to fulfill this fundamental safeguard for patients with cognitive deficits. Psychiatric medications can have severe side effects and implications for patients’ daily lives. Yet, if a person’s ability to grasp that information is limited, health care professionals have a greater challenge genuinely engaging patients and empowering them to make good decisions. Meaningful research is a highly effective and equitable opportunity to address these chief ethical issues and many others. Laura Roberts, MD, the Medical College’s Chairman of Psychiatry and Behavioral Medicine, is a pioneer and nationally recognized leader in psychiatric ethics. Doctor Roberts founded the Empirical Ethics Group in New Mexico in 1996. Now headquartered at the Medical College, with membership spanning from Anchorage to