Medicolegal Issues

Dear patients: Letters psychiatrists should and should not write

Current Psychiatry. 2023 December;22(12):11-15,21,24 | doi: 10.12788/cp.0416

References

1. West S, Friedman SH. To be or not to be: treating psychiatrist and expert witness. Psychiatric Times. 2007;24(6). Accessed March 14, 2023. https://www.psychiatrictimes.com/view/be-or-not-be-treating-psychiatrist-and-expert-witness

2. Knoepflmacher D. ‘Medical necessity’ in psychiatry: whose definition is it anyway? Psychiatric News. 2016;51(18):12-14. https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2016.9b14

3. Lampe JR. Recent developments in marijuana law (LSB10859). Congressional Research Service. 2022. Accessed October 25, 2023. https://crsreports.congress.gov/product/pdf/LSB/LSB10859/2

4. Brunnauer A, Buschert V, Segmiller F, et al. Mobility behaviour and driving status of patients with mental disorders – an exploratory study. Int J Psychiatry Clin Pract. 2016;20(1):40-46. doi:10.3109/13651501.2015.1089293

5. Chiu CW, Law CK, Cheng AS. Driver assessment service for people with mental illness. Hong Kong J Occup Ther. 2019;32(2):77-83. doi:10.1177/1569186119886773

6. Joshi KG. Service animals and emotional support animals: should you write that letter? Current Psychiatry. 2021;20(11):16-19. doi:10.12788/cp.0183

7. Tarasoff v Regents of University of California, 17 Cal 3d 425, 551 P2d 334, 131 Cal. Rptr. 14 (Cal 1976).

8. Black HC. Liability. Black’s Law Dictionary. Revised 4th ed. West Publishing; 1975:1060.

9. American Academy of Psychiatry and the Law. Ethics guidelines for the practice of forensic psychiatry. 2005. Accessed March 15, 2023. https://www.aapl.org/ethics.htm

10. Gold LH, Davidson JE. Do you understand your risk? Liability and third-party evaluations in civil litigation. J Am Acad Psychiatry Law. 2007;35(2):200-210.

11. Schouten R. Approach to the patient seeking disability benefits. In: Stern TA, Herman JB, Slavin PL, eds. The MGH Guide to Psychiatry in Primary Care. McGraw Hill; 1998:121-126.

12. Appelbaum PS. Law and psychiatry: liability for forensic evaluations: a word of caution. Psychiatr Serv. 2001;52(7):885-886. doi:10.1176/appi.ps.52.7.885

13. Varkey B. Principles of clinical ethics and their application to practice. Med Princ Pract. 2021;30(1):17-28. doi:10.1159/000509119

14. Mayhew HE, Nordlund DJ. Absenteeism certification: the physician’s role. J Fam Pract. 1988;26(6):651-655.

15. Younggren JN, Boisvert JA, Boness CL. Examining emotional support animals and role conflicts in professional psychology. Prof Psychol Res Pr. 2016;47(4):255-260. doi:10.1037/pro0000083

16. Carroll JD, Mohlenhoff BS, Kersten CM, et al. Laws and ethics related to emotional support animals. J Am Acad Psychiatry Law. 2020;48(4):509-518. doi:1-.29158/JAAPL.200047-20

17. Strully KW. Job loss and health in the U.S. labor market. Demography. 2009;46(2):221-246. doi:10.1353/dem.0.0050

18. Jurisic M, Bean M, Harbaugh J, et al. The personal physician’s role in helping patients with medical conditions stay at work or return to work. J Occup Environ Med. 2017;59(6):e125-131. doi:10.1097/JOM.0000000000001055

19. Munyaradzi M. Critical reflections on the principle of beneficence in biomedicine. Pan Afr Med J. 2012;11:29.

20. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 7th ed. Oxford University Press; 2012.

21. Gold M. Is honesty always the best policy? Ethical aspects of truth telling. Intern Med J. 2004;34(9-10):578-580. doi:10.1111/j.1445-5994.2004.00673.x

There are some important protections that limit psychiatrists’ good-faith opinions from litigation. The primary one is the “professional medical judgment rule,” which shields physicians from the consequences of erroneous opinions so long as the examination was competent, complete, and performed in an ordinary fashion.¹⁰ In some cases, psychiatrists writing a letter or report for a government agency may also qualify for quasi-judicial immunity or witness immunity, but case law shows significant variation in when and how these privileges apply and whether such privileges would be applied to a clinical psychiatrist in the context of a traditional physician-patient relationship.¹² In general, these privileges are not absolute and may not be sufficiently well-established to discourage a plaintiff from filing suit or prompt early judicial dismissal of a case.

Like all aspects of practicing medicine, letter writing is subject to scrutiny and accountability. Think carefully about your obligations and the potential consequences of writing or not writing a letter to a third party.

Ethical considerations

The decision to write a letter for a patient must be carefully considered from multiple angles.⁶ In addition to liability concerns, various ethical considerations also arise. Guided by the principles of beneficence, nonmaleficence, autonomy, and justice,¹³ we recommend the following approaches.

Maintain objectivity

During letter writing, a conflict of interest may arise between your allegiance to the patient and the imperative to provide accurate information.^14-16 If the conflict is overwhelming, the most appropriate approach is to recuse yourself from the case and refer the patient to a third party. When electing to write a letter, you accept the responsibility to provide an objective assessment of the relevant situation. This promotes a just outcome and may also serve to promote the patient’s or society’s well-being.

Encourage activity and overall function

Evidence suggests that participation in multiple aspects of life promotes positive health outcomes.^17,18 As a physician, it is your duty to promote health and support and facilitate accommodations that allow patients to participate and flourish in society. By the same logic, when approached by patients with a request for letters in support of reduced activity, you should consider not only the benefits but also the potential detriments of such disruptions. This may entail recommending temporary restrictions or modifications, as appropriate.

Continue to: Think beyond the patient