Legal Regulation of Psychiatry

Fiduciary Relationship: Psychiatrist-Patient

A fiduciary relationship comes about as a result of an undertaking wherein one person places trust and confidence in another which s accepted by both parties.  This results in a dependency of one party on the influence of the other.  An undertaking sufficient for a court to construe such a relationship exists may be little more than the giving of professional advice.  A fiduciary must act with utmost good faith for the benefit of the other. The fiduciary owes duties of loyalty, confidentiality, abstinence, neutrality, and competence.  Competence is a professional duty.  For the psychiatrist, it means to act as would an ordinary and reasonable prudent psychiatrist under the same or similar circumstances.  A breach of a fiduciary or professional duty creates an unreasonable risk of foreseeable harm.  If the harm occurs, a malpractice suit may follow.  Though not enforceable, a reasonable patient also has duties.  They are to provide accurate and complete information, cooperate with treatment within the bounds of informed consent, respect her physical integrity and the physical integrity of others, and to obey the law.

The psychiatrist-patient relationship is both fiduciary and professional as well as legal.  It comes into existence when a reasonable patient would think it did. Only then do legal duties attach.  These duties terminate when they are discharged, upon proper non-emergent notice, referral to another psychiatrist, or when the patient fires the doctor.  A psychiatrist respects patient boundaries; i.e. interacts verbally, avoids personal relations, avoids physical contact, maintains stable fee policy, uses appropriate setting and defined session length, avoids double agentry, respects the autonomy and self determination of patient decision making, and accepts no material reward from patient other than an hourly fee.  A psychiatrist does not act like an unfeeling machine, but remains aware that big boundary violations are preceded by little ones.  A psychiatrist is not required to accept all cases but has a duty to identify emergencies and refer appropriately.