Ethical and legal issues

Patients with factitious disorders create unique ethical and medico-legal issues, some of which will be described below. Confidentiality

If no meaningful doctor-patient relationship exists or can be established, it has been argued that the physician is not bound by ethical codes, and that drastic solutions such as keeping 'blacklists' and the use of a central register can therefore be justified. (22) Objections to these approaches include breach of doctor-patient confidentiality and possible denial of treatment for genuine illness. Anyway, the use of aliases and poor record-keeping reduce the effectiveness of blacklists. Furthermore, physicians who disclose information without patient consent may have to justify the decision to their licensing body. In the United States there is a consensus that disclosure should only occur where there is a specific risk to the patient and/or another party. In such situations a multidisciplinary staff meeting can help to develop treatment policy and share responsibility for difficult decisions (see above).

Invasion of privacy

The medical literature contains many descriptions of how the diagnosis of factitious disorder was established following a search of the patient's room or belongings. Some physicians, however, consider that such behaviour infringes patients' rights, and that no search should be undertaken without the patient's knowledge and consent. One way of avoiding this dilemma is to make it clear to the patient that factitious disorder is among the differential diagnoses, and then request permission for a room search. If needles or syringes are discovered during the course of treating the patient, the ethical issue of invasion of privacy does not arise.

Involuntary hospitalization or treatment

Because the patient with factitious disorder may engage in behaviour that leads to permanent maiming or even death, it has been argued that in such cases a compulsory order may be used to protect the patient from him- or herself. This will provide time for not only a more in-depth psychiatric assessment but also the development of a more trusting relationship with a therapist. This is a contentious subject, but some case reports do indicate that extended involuntary hospitalization may result in therapeutic progress.(23>

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