"Through a glass, darkly": the clinical and ethical implications of Munchausen syndrome.
Patients who present repeatedly for care with medically unexplained symptoms raise challenges for the health system. One proposed strategy for dealing with such patients is the introduction of electronic medical records (EMRs) to identify these patients and thus limit the demands on resources their management involves. This measure may ultimately be appropriate but fails to consider equally critical core issues in psychiatric ethics. Identifying patients as "somatisers" invites a problematic relaxation of clinical vigilance, increasing the likelihood that an actual life-threatening medical problem will not be identified. Management of such patients requires regular, structured therapeutic contact with a skilled mental health clinician, that is independent of the patient's distress level. Psychiatric problems and medical problems are frequently seen as two distinct, unrelated categories. This is a false dichotomy, as mental health and physical health are interdependent. Given patient privacy considerations, EMRs would be unlikely to reveal the kind of sensitive mental health information needed for the identification and management of somatising patients in busy health systems. Cost-effective interventions for somatising patients' problematic behaviour, such as structured clinical intervention, antidepressant medication and cognitive behaviour therapy, are available at a fraction of the cost of EMR systems. Citing cost savings as a justification for violating the privacy of mental health patients compounds the manifest injustice these patients already face in the health system.
Robertson
Michael D
MD
Centre for Values, Ethics and the Law in Medicine, University of Sydney, Sydney, NSW, Australia. mrobertson@med.usyd.edu.au
Kerridge
Ian H
IH
D001315:Australia; D003219:Confidentiality / Q000941:ethics / Q000331:legislation & jurisprudence*; D004992:Ethics, Medical; D006801:Humans; D016347:Medical Records Systems, Computerized / Q000941:ethics / Q000331:legislation & jurisprudence*; D009110:Munchausen Syndrome / Q000191:economics; D028701:Patient Rights / Q000941:ethics / Q000331:legislation & jurisprudence*