Double agentry conflicts arise when psychiatrists have responsibility both to the patient and to the agent who hired him or her. This issue arises when treating patients in correctional settings or the military, police department, or fire department and in a personnel health service. For example, a psychiatrist may be called on to use his or her expertise to make a recommendation on fitness for duty. Some argue that psychiatrists must always act in the best interests of the person they are evaluating and that providing information to an employer that would lead someone to lose a job is inappropriate. This argument is impractical and is not supported by utilitarian ethics. If mental health professionals could not use their expertise to help organizations, the question of who is psychiatrically unfit to work might not be appropriately answered. Many who are competent to hold a job or return to their job would not be allowed to do so, and many who should not be working at a particular job would be. Moreover, helping someone to remain in a position when doing so places both the person and others at risk is not actually helping the person.

The principle of patient autonomy has central importance and, conceptually, is in many ways coextensive with the legal concept of competence. A patient makes an autonomous choice by giving informed consent when that choice is (1) intentional, (2) free of undue outside influence, and (3) made with rational understanding. Usually, when patients respond to a choice by saying, “Yes,” the desire to comply is assumed. However, that assumption may not be valid with a highly confused patient.

A boundary can be considered as crossing a line beyond which the patient is exploited. It gratifies the doctor’s needs at the expense of the patient. The doctor is responsible for preserving the boundary and for ensuring that boundary crossings are held to a minimum and that exploitation does not occur.

The issue of whether sexual relations between an ex-patient and a therapist violates an ethical principle remains controversial. Proponents of the view “Once a patient, always a patient” insist that any involvement with an ex-patient—even one that leads to marriage—should be prohibited. According to the American Medical Association’s Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry, “Sexual activity with a current or former patient is unethical.” Because of that, hugging a patient at the end of a session would most likely fall into that category. Similarly, accepting football tickets from a patient might be considered exploitative. However, when confidentiality is breached, it is not considered a boundary violation because a boundary violation involves the direct relationship between the doctor and the patient, whereas a breach in confidentiality involves a third party.

The medical profession overall is bound by rules of confidentiality, but these rules seem to apply especially to the field of psychiatry. Psychiatrists should never discuss their patients outside the office. Patients assume what they tell the psychiatrist stays inside the consulting room. Merely informing a spouse of the identity of one’s patient violates the ethical principles. Confidentiality survives even the death of one’s patient and is subsequently owned by the executor, not the psychiatrist. A confidence cannot be broken just because a patient died. A psychiatrist can break a confidence to give information to an insurance company as long as it is limited to only that which is needed to process the insurance claim. If informed, uncoerced consent has been obtained by the patient for segments of videotaped sessions to be used in conferences, these can be used. Anonymity must be maintained, and the patient must know the purpose of the videotape. The suspicion of child abuse does not warrant a break of confidentiality. The psychiatrist must make several assessments before deciding whether to report suspected abuse. One must consider if the abuse is ongoing, whether abuse is responsive to treatment, and whether reporting will causes potential harm. The safety of potential victims must be the top priority.

In Cruzan v Missouri Board of Health, the U.S. Supreme Court upheld the right of a competent person to have “a constitutionally protected liberty interest in refusing unwanted medical treatment

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