In Reply: It is generally recognized that editorial pieces lack the completeness and specificity of a traditional case study in ethics. I believe Dr. Moffic would have to acknowledge that a measured response to his many questions, most of which are on the level of factual clarification rather than ethical disagreement, would have extended well beyond the constraints of an editorial format.
Nonetheless, I found a number of Dr. Moffic's questions to reflect a certain intellectual hastiness in their formulation. For instance, a careful reading of the Taking Issue made it abundantly clear that the patient was not doing well on her discharge medication regimen and the reason she was referred to the primary care clinic was that she had no insurance for mental health care. As I have noted elsewhere (1,2), it is not uncommon for the poor and uninsured who have serious mental illnesses to seek care from public health departments, city-funded primary care clinics, and emergency departments, because they are unable to pay their way in the community mental health care system. In answer to Dr. Moffic's question, the patient was "accepted" by the primary care clinic because it was the only health care system she was able to access.
Although questions about why the physician assistant made such a "drastic change in the medication" and "who was supervising this sort of decision" may be relevant for pursuing a more complete clinical discussion of this case, they have very little ethical bearing on the decisions that resulted in her being sent to a primary care provider in the first place. The prior and more fundamental moral issue, which I underscored in my editorial, was related to why her case was not followed up by those who initiated psychiatric care and who have the most expertise and training to treat her severe mental illness. Because the editorials in Psychiatric Services are intended to reach community mental health providers, I chose to focus on the profession-specific obligations that are most relevant to our clinical practices. I would argue that Dr. Moffic's questions raise an entirely different set of issues and stray from the central, albeit limited, ethical issues outlined in the article.
In closing, I would like to comment on Dr. Moffic's query, "What did Dr. Christensen do to address the perceived ethical problem?" I think I did what the vast majority of my colleagues in community psychiatry would have done when confronted with a similar situation. First, I treated the person before me to the best of my ability. I then petitioned the community mental health center for additional wraparound services and care for this young woman, which led to her subsequent treatment by the agency's assertive community treatment team. Finally, I wrote an editorial piece intended for community mental health providers that highlighted profession-specific ethical obligations not to "abandon by referral" those who expect from us compassionate care and competent treatment for their devastating mental illnesses.
Although this clinical scenario may be complex, deriving from it the ethical connection between what "is" and what "ought to be" requires little more than basic moral reasoning.