Ethical considerations in diagnosis

The following notes are for the learning objective: Discuss ethical considerations in diagnosis. It is important to remember that when discussing a topic, it is essential to look at the question from various perspectives. So, for this question, it is best to consider three things:

  1. What is diagnosis and why is it important?
  2. Why might it be ethical to diagnosis a client?
  3. What might be ethical problems with diagnosis?

To start, diagnosis is an important aspect of mental health care. Diagnosis helps to connect clients (patients) with appropriate treatments, facilitates personal communication and helps the field to identify trends and carry out research.

There are several very general ethical considerations that could be discussed - for example, confidentiality of the diagnosis or the possibility of causing undue stress or harm because of a lack of understanding of the situation. There is also the question of confirmation bias, over-pathologization based on stereotyping or premature closure. There is also Scheff's (1961) labeling theory. It is recommended that you choose fewer ethical considerations and try to write in more depth, rather than identifying a lot of different considerations, but not writing very much about any one of them.

The problem with confirmation bias

One of the classic and most controversial studies done in abnormal psychology was done by Rosenhan et al (1971). Before reading more of this section, please read through Reconsidering Rosenhan.

As you can see, Rosenhan's study is highly problematic. However, it does show that when someone goes to a hospital and complains of a symptom, they are likely to be diagnosed. It should be noted, however, that the study in 1971 did lead to several improvements in the process and today this study would not lead to the same types of diagnosis.

In another study, Temerlin (1968) showed psychiatrists, clinical psychologists, and clinical psychology graduate students a videotape in which an actor portrayed an ordinary, mentally healthy mathematician who had read a book about psychotherapy and wanted to discuss it with a psychologist. Before watching the tape, clinicians were informed by a prestigious psychiatrist that the individual on the tape was “a very interesting man because he looked neurotic, but actually was quite psychotic.” After viewing the tape, participants selected their best-guess diagnosis from a list of 30 choices: 10 psychotic disorders, 10 neurotic disorders, and 10 miscellaneous personality types, including “normal or healthy personality.” A majority (60%) of the psychiatrists, along with 28% of the clinical psychologists and 11% of the graduate students, diagnosed the individual as psychotic. In contrast, none of the 78 participants in four control groups diagnosed this individual as psychotic.

This study appears to show the problem of "prestige effect" - that is, when a patient has already been diagnosed by someone respected in the field and a doctor confirms the diagnosis based on limited information. Notice that the conformity rate was highest among clinical psychologists. The study has been criticized for not representing a typical diagnostic situation. In addition, the participants were told to "guess." The study lacks ecological validity and is not representative of what happens in the diagnostic process.

Mendel et al (2011) carried out a more modern study of confirmation bias in diagnosis. Researchers gave a case study to 75 psychiatrists and 75 fourth-year medical students. Participants were asked to choose a preliminary diagnosis of depression or Alzheimer disease and to recommend a treatment. The vignette was designed so that depression would seem the most appropriate diagnosis. Participants could then opt to view up to 12 pieces of further information.

For the preliminary diagnosis, 97% of psychiatrists and 95% of students chose depression. After looking at the further information, 59% of psychiatrists and 64% of students reached the correct diagnosis of Alzheimer disease. Psychiatrists who did not use information effectively to diagnose and only looked at information that confirmed their original diagnosis were less experienced. Participants were more likely to make the wrong final diagnosis if they chose to view six or fewer pieces of additional information.

This study is interesting because it seems to indicate that confirmation bias is not as serious a concern as we would think. However, 40% of doctors confirming their original incorrect diagnosis is still pretty significant. But once again, the study is artificial. There was no patient examination and the participants were given only two choices for diagnosis. So, confirmation bias is a concern in diagnosis which needs to be addressed, but the research is questionable as to the extent to which patients are disadvantaged by the bias.

Task 1: Stigma and mental illness

Labeling theory is very similar to confirmation bias. A lot of the early research on labeling looked at how a previous label influenced the objectivity of the doctor in making a diagnosis. Later theorists questioned the role of labels on social rejection and stigmatization.

Before looking at the research, take a look at the following PSA on stigma and mental illness.

Do some research

What does the video mean that people with mental illness suffer from discrimination? Take some time to do some searching on the Internet to find out the exact nature of this discrimination in your own country. Come back to the group with the statistics that you find. Why do you think that this type of discrimination happens?

Labeling theory and the question of stigma

Scheff's (1966) Labeling Theory argues that if a person is diagnosed based on symptoms of "deviant behaviour," society's reactions to this label will produce additional pathology or behavioral disturbance that causes mental illness or makes it worse. Extension of this theory has argued that labeling leads to the stigmatization - that is, the social rejection - of people with mental illness.

A study done to support the theory was carried out by Langer and Abelson (1974). In this experiment, psychiatrists watched a video of a younger man talking to an older man with the sound removed. Half the therapists were told that the younger man was a patient; the other half, that he was a job applicant. After viewing the video, participants responded to a series of questions about the interviewee. If the viewers were told that he was a job applicant, he was described as attractive and confident; if they were told that he was a patient, he was described as defensive, aggressive and/or frightened.

As with the research on confirmation bias, this study is highly problematic. The situation does not reflect how diagnoses are made. The participants are being asked to make decision based on very limited data. The participants also assume that the label is correct. Labels are used in order to communicate important information. It is strange that this study is surprised that people use the labels that they are given. More importantly, this study does not demonstrate Labeling Theory has defined above.

The greatest challenge to labeling theory is that psychologists are unable to empirically demonstrate that social rejection is the result of the diagnostic label rather than the behaviour of the individual.

It is important to remember that most patients come for mental health care on a voluntary basis, seeking professional help. They seek treatment to relieve them of their distress. Diagnosis tends to start a process of treatment that minimizes the length and severity of a person's disorder. It appears that rather than increasing symptomology, in most cases labeling actually decreases it. Gove & Fain (1973) carried out extensive interviews with 429 former mental patients. The vast majority stated that diagnosis had led to an improvement in their social relationships. They had positive evaluations of their hospital experiences and they felt that they were better able to deal with their problems.) A small minority of the former patients (19) reported exclusively negative outcomes. However, there is no way to tell whether these negative outcomes were the result of diagnostic labels.

Gove & Fain argue that negative feelings about individuals with mental illnesses in an abstract way as seen in much of the research above, is far different from actually discriminating against a mentally ill person. In a classic study, LaPiere (1934) studied racial prejudice by traveling around the United States with a Chinese couple. Over the course of two years, they visited a total of 251 hotels, restaurants, and other business establishments, encountering racial discrimination just once. Six months after visiting, LaPiere sent a letter to the same hotels, asking whether Chinese individuals would be allowed as guests. Of the 128 responses he received, 118 said they would not. So, in most cases, prejudiced attitudes did not translate into discrimination. LaPiere, 1934).

Gibbons & Kassin (1982) found that labels actually lead to more acceptance of behaviour. They found that when children were labeled with disabilities, they were blamed and punished less than non-labeled children for the same negative behaviours.

Another argument against the labeling theory is rooted in doctor-patient confidentiality. How do co-workers, neighbors or friends find out about the diagnosis? Do people respond negatively to the individual because s/he shares a diagnosis? This is possible. But it is more likely that behaviours leading up the diagnosis had a greater effect on social rejection.

Finally, Link et al (1987) argues that a diagnosis may lead to social withdrawal by an individual because they fear social rejection. This is then leads to a self-fulfilling prophecy as they cut off their own social support networks which then leads to a feeling of rejection, and may actually increase symptoms. This demonstrates the importance for doctors to provide adequate information for patients upon receiving a diagnosis to strive to maintain social networks that currently exist.

Task 2: Checking your knowledge & thinking critically

That was a lot of information. Try to answer the following questions in order to test your understanding of the text.

1. What is meant by confirmation bias?

Confirmation bias is when you pay attention to information that agrees with what you already believe and discount (ignore) information that contradicts it. The argument is that once a diagnosis is made, it is less likely that a doctor will change his or her initial diagnosis as a result of confirmation bias.

2. What is meant by prestige effect?

Prestige effect is when a previous diagnosis, made by someone who is respected in the field, influences the judgments of a psychiatrist or other doctor.

3. What are two problems with research on confirmation bias?

The situations in which confirmation bias is tested is not naturalistic. The situations are abstract and lack any personal contact with the person that they are being asked to diagnose. This does not represent what happens in true diagnosis.

4. According to Scheff's original Labeling Theory, what is the direct result of diagnosis?

According to Scheff, diagnosis leads to an intensification of symptoms and a self-fulfilling prophecy which leads to a higher level of dysfunction.

5. What experimental design was used by Langer & Abelson? What was the independent and dependent variable in their study?

Langer & Abelson used an independent samples design. The independent variable was the label that was given to the younger male - either a job applicant or a patient. The dependent variable was how the participants described the male in the video.

6. What are two advantages of diagnosis (labeling)?

Diagnosis allows treatments to be prescribed. In addition, labels are short-cuts for professionals to discuss a patient. It is also a way for professionals to carry out research on mental health trends.

7. What is one concern that you would have about the interview study carried out by Gove & Fain?

The interviews were carried out on individuals who were "former" patients. The study is therefore retrospective and dependent on the memories of the participants. Peak-end rule says that we will remember best how things end. Additionally, it is possible that demand characteristics influenced the responses from the interviewees. For more information on Peak-end rule, see: The use of self-reported data

8. What is one concern that you would have about the study by Gibbons & Kassin?

In this study, the set-up was similar to those about confirmation bias. Although this appears to support the hypothesis of the researchers, it suffers from the same problems with artificiality.

9. Is there evidence that the mentally ill suffer from social rejection, stigmatization and discrimination?

Sadly, absolutely. The argument that we cannot demonstrate a cause and effect relationship between diagnosis and stigmatization does not mean that the mentally ill don't suffer from social rejection and discrimination.

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