By Laura Guidry-Grimes

Trust is a precious commodity in clinical settings. Not only do healthcare professionals request an enormous amount of trust from patients the second they walk into the door, but patients expect to be trusted as well. The clinical encounter usually begins with the patient’s explaining why they want medical assistance and any source of pain, discomfort, or other feelings of illness. The patient is then asked about their medical history, social and environmental variables, and any other symptoms. If at any point the healthcare professional doubts what the patient is saying, the patient’s care could proceed in ways the patient does not understand or want. The healthcare professional’s doubt can lead to broken therapeutic trust and questions about the patient’s capacity as a decision-maker. This doubt could be justified, but what if it’s not? What if the healthcare professional’s doubt is actually hasty or overbroad? The clinician might not notice when they are withholding trust unfairly, but patients are frequently attuned to the ways their testimony is put aside or reframed. A patient who feels unfairly dismissed as a knower could understandably become skeptical of the healthcare team, which can, in turn, make the team more suspicious of the patient. Some patients, such as those who have psychiatric disabilities, are especially vulnerable to this cycle of distrust.

In my paper, I investigate one facet of this phenomenon: when patients with psychiatric conditions are assessed to lack insight.  When psychiatrists or other mental health professionals assess a patient’s level of insight, they are checking to see if the patient has proper awareness of their mental illness. The conceptual literature on insight contains a host of problematic vagaries and contradictions, and thus the empirical literature lacks a clear target when trying to determine which patient populations tend to lack insight, whether insight is stable or dynamic, and to what extent it is associated with severity of psychopathology (to name just a few of the empirical questions). Moreover, although there is wide acknowledgement in the literature that insight is a multidimensional and continuous construct, in clinical practice this assessment is usually marked with a single descriptor like “fair,” “poor,” or “good.” The details of what the patient does know or understand are often left undocumented, which can compound the patient’s vulnerability as a knower and as a decision-maker.

Although I believe that insight assessments can be valuable for understanding and advocating for the patient’s agential interests, I argue that these assessments carry hefty moral risks. Two central ethical concerns are that these assessments risk 1) marginalizing patients by setting unattainable ideals for self-knowledge and 2) minimizing the patient’s own perspective on their mental health. I offer recommendations for documenting and thinking through insight assessments, given these ethical concerns.

I started paying attention to insight assessments when I first started working in a clinical setting through a practicum offered by Georgetown’s Edmund D. Pellegrino Center for Clinical Bioethics and Philosophy Department. I have since observed numerous assessments in my role as a clinical ethicist, where I round weekly with the psychiatry consult service. In one of the cases that reached our ethics service (which I describe in the paper), an internist believed that his patient lacked insight into her bipolar disorder, which he believed was evidence that she lacked any self-awareness or understanding, so he involuntarily detained her to treat her heart and lung problems. One of the concerns with this case was that the internist assumed that a patient without sufficient insight into her psychiatric condition must lack insight into her medical situation more broadly, which meant that she could not have adequate capacity to be her own decision-maker. This sort of error is not inherent to insight assessments, but these errors are to be expected when the notion of insight remains conceptually vague and susceptible to idealization. There are no standardized bedside tools for clinical assessments of insight, which exacerbates the problem further.

One of my hopes for this paper is that it will encourage healthcare teams and ethics services to work together to educate themselves and others about insight, so assessments and documentation are as careful, detailed, and precise as possible. By acknowledging the difficulties in assessing insight, teams can guard against presumption and distrust. This could lead to more successful therapeutic alliances and more effective shared decision-making.

Paper title: Ethical Complexities in Assessing Patients’ Insight

Author: Laura Guidry-Grimes

Affiliations: Assistant Professor of Medical Humanities and Bioethics, University of Arkansas for Medical Sciences; Clinical Ethicist, UAMS and Arkansas Children’s

Competing interests: None