Forensic Corner; Being a Double Agent
Lee H. Haller, M.D.
As a child, it is exciting to be a double agent, whereby
one gains the trust of the enemy, finds out their secret
plans, and then flees with that information to save
the good guys. For such bravery, the child-hero is richly
rewarded and celebrated. Such fantasies are an important
part of normal development, a means by which children
work through conflict and manage anxieties. As adults,
several of us are being given a real life opportunity
to actually become double agents. What follow are some
examples of how this may arise.
You are an employee of an HMO. As such, you owe a duty
to follow the directions and orders of your employer
who is your boss. When patients come to you, if you
present yourself as acting solely in their interest,
then you are acting as a double agent any time that
you make a recommendation to them that is determined,
to an extent, by the needs, wishes, or demands of the
employer rather than purely the medical needs of the
patient. Similarly, if you accept a contract with a
managed care company, which has a "gag clause" (i.e.
one which bars a physician from telling a patient that
the best treatment option is one for which the insurance
company won't pay), you become a double agent.
In both these cases, the psychiatrist has an ethical
dilemma and also a legal problem, that being a failure
to provide sufficient information for the patient to
give an informed consent. No matter what the setting,
parents have a reasonable expectation that when they
bring their child to a doctor, the physician will act
in the patient's best interest, by performing an appropriate
evaluation followed by recommending the optimum course
of treatment. To the extent that a physician is not
free to fully follow this course of action, it is imperative
that such conflict of interest be divulged.
The same concept holds true if the psychiatrist has
completed an evaluation and believes that two sessions
per week are optimal, but only has one treatment hour
per week available. For the doctor to recommend once
weekly sessions rather than fully disclose that twice
per week would be better, but would require seeing someone
else, is improper.
Here, again, the doctor is being a double agent. In
this instance, the other "master" who is being served
is his or her own economic interest. To the extent this
conflicts with the optimum course of treatment recommendation
and if the lesser course is suggested, then the conflict
of interest should be divulged as well. This is not
to say that it is always problematic to offer a patient
less than the optimal frequency of treatment. However,
if it is done so for the physician's benefit rather
than the patient's, then it is improper.
In short, being a double agent as an adult is not the
way to save the world, nor practice good medicine. Some
years ago, the Kingston Trio began a song with: "These
are the times that try men's souls. Citizens, here me
out. This could happen to you." Et tu, doctor?
Dr. Haller is in the private practice of forensic psychiatry
in Potomac, Maryland
AACAP
News/January-February 1998 |
