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Sound ethical decision making is essential to astute and compassionate clinical care. Wise practitioners readily identify and reflect on the ethical aspects of their work. They engage, often intuitively and without much fuss, in careful habits—in maintaining therapeutic boundaries, in seeking consultation from experts when caring for patients who are difficult to treat or have especially complex conditions, in safeguarding against danger in high-risk situations, and in endeavoring to understand more about mental illnesses and their expression in the lives of patients of all ages, in all places, and from all walks of life. These habits of thought and behavior are signs of professionalism and help ensure ethical rigor in clinical practice. Psychiatry is a specialty of medicine that, by its nature, touches on big moral questions. The conditions we treat often threaten the qualities that define human beings as individual, autonomous, responsible, developing, and fulfilled. Furthermore, these conditions often are characterized by great suffering, disability, and stigma, and yet individuals with these conditions demonstrate tremendous adaptation and strength. If all work by physicians is ethically important, then our work is especially so. As a service to Focus readers, this column provides ethics commentary on topics in clinical psychiatry. It also offers clinical ethics questions and expert answers in order to sharpen readers’ decision-making skills andadvanceastuteandcompassionateclinicalcareinthe field. Laura Weiss Roberts, M.D., M.A. Depression affects nearly 15 million adults in the United States each year. As the second leading cause of disability, depression is an illness that profoundly affects quality of life for individuals and creates significant socioeconomic burdens for society as a whole. Depression is also an important risk factor for suicide, an outcome that claims approximately one life in the country every 13 minutes. The clinical care of depression combines an urgency of crisis with the deeply experienced and pervasive feelings of hopelessness and sadness among patients, raising many ethical issues related to the need for patient safety, the appropriate treatment of disease, and the restoration of individual self-agency. Againstthe backdrop ofmodern health care, where people receiving treatment for depression are predominantly seen in primary care clinics, recent developments in innovative therapeutics and methods of care delivery promise to raise manymore ethical questions than answers.Some contexts for ethical tension are inherited, such as the split-care model of pharmacotherapy and psychotherapy in the treatment of depression, whereas others are completely novel, such as mobile health care and integrated care systems in disease management. Elements of therapeutic boundaries and alliance are being challenged in these settings. Last, research in new treatment modalities with distinct repertoires of benefits and potential harms, such as deep brain stimulation, suggests a continued role for ethical discussion in years to come. In this commentary, we describe several clinical cases illustrating only a handful of these issues. We hope these cases pique our readers’ interest in the application of ethical principles topractice and highlight the importanceof ethical decision making in modern clinical care of patients experiencing this disorder.

Sound, ethical decision making is essential to astute and compassionate clinical care. Wise practitioners readily identify and reflect on the ethical aspects of their work. They engage, often intuitively and without much fuss, in careful habits—in maintaining therapeutic boundaries, in seeking consultation from experts when caring for patients with difficult or especially complex conditions, in safeguarding against danger in high-risk situations, and in endeavoring to understand more about mental illnesses and their expression in the lives of patients of all ages, in all places, and from all walks of life. These habits of thought and behavior are signs of professionalism and help ensure ethical rigor in clinical practice. Psychiatry is a specialty of medicine that, by its nature, touches on big moral questions. The conditions we treat often threaten the qualities that define human beings as individual, autonomous, responsible, developing, and fulfilled. Furthermore, the conditions wetreat often are characterized by great suffering, disability, and stigma, and yet individuals with these conditions demonstrate such tremendous adaptation and strength as well. If all work by physicians is ethically important, then our work is especially so. As a service to Focus readers, this column provides ethics commentary on topics in clinical psychiatry. It also offers clinical ethics questions and expert answers in order to sharpen readers’ decisionmaking skills and to advance astute and compassionate clinical care in our field. Laura Weiss Roberts, M.D., M.A. Psychiatrists who care for children and adolescents find themselves in ethical situations distinct from those of general psychiatrists who provide clinical care for adults. Children, by nature, are a vulnerable population who rely on the higher developed judgment of their caretakers, and often many more individuals are involved in the care of minors than in the care of adult patients. When issues of neglect or mistreatment of young peoplearise,legalimperativesareintroducedtotheclinicalcare situation. The distinct situations encountered in the psychiatric care of children and adolescents require greater awareness of ethical principles and how to apply them to fulfill optimal standards of care. A developmental perspective, mindful of a child’s ability to understand illness and treatment decisions, influences the role the child will play in his or her care. Ethical engagement of young people requires attention to their evolving capacity for autonomy, balancing selfdetermination with the need for nurturance. The natural drive for independence among adolescents invites situations in which risky behavior may be explored. These experiences may be shared with the psychiatrist but withheld from the parent, introducing many new dilemmas. A well-designed conversation between the patient, parent or guardian, and child and adolescent psychiatrist at the first clinical contact about the limits of confidentially will minimize or prevent problems, in terms of ethical practices as well as the therapeutic relationship itself, later in treatment. Carefully considering the pros and cons of disclosing personal information of the child or adolescent, along with imagining several possible outcomes, will help the psychiatrist decide when and how to pull other stakeholders into clinical care. An ecological approach may add to the understanding of apat ient’s habitat with all of the related stresses, resources, and stakeholders. Patients do not arrive with all of the people who are significant in their lives, and those who possess fewer interpersonal and familial supports often have greater needs—and sometimes generate more ethical concerns. On institutional and organizational levels, schools and mental health, government, and legal agencies add another layer of complexity that demands careful attention by the psychiatrist to serve the needs of the child while fulfilling obligations to others. APA (1) and the American Academy of Child and Adolescent Psychiatry (2) have developed ethical guidelines and resource documents that may be helpful in addressing issues in clinical practice and training related to the psychiatric care of children and adolescents. Ethical issues encountered in the care of children and adolescents thus are distinct and challenging. Engaging with young people in a manner that is informed by developmental and ecological approaches will help identify and resolve ethical dilemmas in their care. Multiple-Choice Questions