The question of agency in psychiatry is an interesting one. To me, it's clear: I'm the agent of my patient, it's his best interest that I care about. But the odd thing is that society periodically asks me to assess patients for their interests.
Is my patient able to serve on jury duty? He tells me he's very anxious, in fact he's taking medications for anxiety, and he has some health issues, and everything about jury duty is hard here in the grand city of Baltimore. There's a daily stipend; it doesn't cover the parking fee. You have to negotiate downtown traffic, park in a garage, walk to the courthouse, and if you're put on a criminal trial, there is the fear (albeit the risk is perhaps quite small) that you or your family could be in danger if you vote to convict a gang member. The seats in the waiting room are uncomfortable, the temperature is always wrong --either way too hot or way too cold. Serving doesn't mean you'll ever be called to a court room, I've spent 8 hours in a freezing waiting room to then be dismissed at the end of the day. Okay, but here it's not the court asking, it's the patient asking -- but the point is that if I say someone can't serve, they get a free pass.
What about driving? Periodically, someone gives me a form to fill out for DMV regarding their safety to drive because they carry a psychiatric diagnosis . I'm not aware of any purely psychiatric diagnosis --with the exception of dementia --which leaves one unable to drive, and invariably the patients does wish to continue driving. Driving helps get to appointments and to obtain medications and food, among other things. Usually it's people with schizophrenia or bipolar disorder who show up with the forms. I have never witnessed any of my patients drive; if I did, I still wouldn't know how to judge; driver safety assessment is not taught in medical school. And many patients talk about having multiple accidents, unrelated to any diagnosis or substance issue (they're just lousy drivers) and they never show up with forms.
A difficult one is the people who show up with forms for clearance for a new job. If they are bringing me a form, it means they've told the employer or the human resource folks that they have a diagnosis. Often, it's my opinion that it would be in their best interest to at least try working --- work adds structure and meaning to a life, it often adds health insurance (a very good thing), and it adds money which allows for food, housing, medications, entertainment, and opportunities for fun, all of which improve mental health!
Sometimes, however, I'm not sure if my patient will be able to do the job --- like driving, I was not trained to assess the ability to work. Sometimes I can see there might be problems -- the patient misses appointments because they get too depressed to get up, or they have executive functioning issues where they simply don't organize their lives well ("Oops, I forgot I scheduled 3 appointments at the same time!"). But still, if they want to work, and if they can, it would be in their best interest. Now, obviously, there are some exceptions here where it's not in my patient's best interest to take a job -- for example if there's been a history of repeated suicide attempts or violent behaviors, then perhaps it doesn't make sense for me to clear a patient for a job if it requires that he carry a firearm. But mostly, it's more benign stuff and I've seen people who can't get to an appointment reliably, but can manage a job -- either they prioritize getting to work, or they have jobs that value performance more than punctuality. And many people negotiate successful work lives around substance abuse problems, especially if they can limit the substances to after-hours. And there, too, there is a check on the system that doesn't fall on me; jobs where sobriety is crucial usually include drug screening.
So what's my obligation here? The patient the wants the job. No one's life will be in danger if she fails, though with some people, job failure can be a huge emotional setback. The structure, purpose, and money will all be be good if the patient can manage to work. But there are these forms that I've been handed with a long check list of questions regarding the ability to perform tasks where I have no idea, or I suspect that, based on history, the patient may not be able to do --like show up, attend to detail, demonstrate organized thinking-- but I could be wrong, because I have been before, and a work setting is different from a psychiatric office. If I say I don't think the patient can perform, they don't get the job and they lose the chance to try.
In my head, it's a dilemma. There is no question that I am the agent of the patient and that I owe nothing to a patient's potential employer with whom I have no relationship just because they send a packet of papers. I want what's best for my patient, but as human being, if I have reason to believe the patient can't perform a task and I say they can, then I'm basically lying. None of it feels right.
Psychiatrists (and perhaps doctors as a whole) have ended up in these strange places. We often don't know if our patients can work, serve on a jury, drive, own a firearm safely, go to summer camp, or manage the stress of any given situation. New settings can be stabilizing or destabilizing. I'm not sure how we got to be the gatekeepers on such things.
So when I'm