Ethical Issues Encountered in Primary Care

Anthony Zamudio, Ph.D.


Health Care reform offer psychologists’ cross disciplinary work opportunities with primary care providers, including  physicians, nurse practitioners, nutritionists, speech therapists, and occupational therapists, in addressing undiagnosed mental health problems often presented in primary care (McDaniel & Fogarty, 2009; Nordal, 2012).  Integrative health care settings, such as the medical home, can present ethical challenges (American Psychological Association Ethical Principles and Code of Conduct, 2010) in the areas of Informed Consent (3.10), Confidentiality (4.01), and Multiple Roles Relationships (3.05) when providing assessment, intervention, and interdisciplinary collaboration. 


Informed Consent:

The medical home is an integrative model rather than a “place” where physicians and other disciplines including psychologists work together to provide better continuity, coordination, communication, and quality in the management of patients’ medical problems (McDaniel & Fogarty, 2009).  In some integrative settings, all patients are routinely seen by the psychologist as part of a comprehensive physical and psychosocial assessment (Kelly & Cons, 2013).  The fast pace and urgent climate may not facilitate informed consent in a mental health evaluation and/or treatment.  Psychologists should remember that consent is not a one-time event but an ongoing process that requires updating and/or clarification even when a patient signs a general medical consent form acknowledging multiple providers and services (Hodgson, Mendenhall, & Lamson, 2013).  Patients need to understand that when a mental health provider is present, the patient may receive a mental health assessment, diagnoses, or treatment.


Maintaining Confidentiality:  

Ethical challenges arise when psychologists seek to maintain confidentiality with the diverse providers working in the medical home (Hodgson et al., 2013) and for patients when family/friends are present at the medical visits (Reiter & Runyan, 2013).  With secured electronic record systems created to maximize provider to provider collaboration and coordination of patient care, ethical conflicts can arise between the need to cooperate with other professionals (2.09), providing documentation (6.01), and minimizing intrusions on privacy (4.04) such as, patients’ request to limit their other provider’s knowledge regarding a sexual abuse history.  Breaches in confidentiality can also occur very easily from waiting room discussions with patients or hallway provider consultations due to time limitations, inadequate physical space, or when discussing medical findings and/or history in front of family/friends in attendance of a patient’s visit (Hodgson et al., 2013; Reiter & Runyan, 2013). 


Multiple Relationships:  

The medical home’s family-based services present challenges with multiple members of the same family being treated independently by the same provider.  Reiter and Runyan (2013) recommend the revision of APA Ethic’s code 10.02 for behavioral providers due to their inability to clarify at the outset which of the individuals are patients and the nature of their relationships in order to maintain patients’ confidentiality (4.01).  Staff and providers in personal crisis often value and may request a behavioral health consultation from the psychologists.   Kanzler, Goodie, Hunter, Glotfelter, & Bodart, (2013) address the complexity of these situations and provide eight decision making recommendations to approach ethical issues:

1.        Consider your context

2.       Consult your ethics code

3.       Determine risks/benefits

4.       Critically interpret/implement your code

5.       Consider different perspectives

6.       Identify other’s expectations

7.       Clarify your role

8.       Discuss your concerns


References available on request from the LACPA office, [email protected].