Plastic Surgeon’s Ethical Guidelines to Therapeutic Discharge

OBJECTIVE: Therapeutic discharge is a well-known tool in psychiatry used to terminate a patient-physician relationship when interactions with the healthcare team contribute to the pathology of their mental illness. However, mental illness permeates into all specialties, especially plastic surgery where many patients experience body dysmorphia and other psychiatric illnesses that can compromise care. Here, we investigate the criteria under which therapeutic discharge is ethically permitted, and even recommended. METHODS: Principles of clinical ethics, informed by a review of the literature on therapeutic discharge, were applied to provide guidelines for navigating delicate patient-surgeon relationships. RESULTS: We have formulated ethical guidelines aimed at upholding principles of nonmaleficence, beneficence, futility, and patient non-abandonment in the setting of a non-surgical candidate, whose eligibility was impeded by psychiatric illness that directly threatened post-operative success. CONCLUSION: Guidelines for ending patient relationships are widely recognized. However, standard protocols can be ethically inappropriate in cases involving surgical patients with comorbid psychosis. Rather than terminating the relationship abruptly, physicians can prioritize maintaining a relationship with clear boundaries to mitigate fears of abandonment among patients and reduce the risk of further harm. Providing temporizing care until stabilization of the psychiatric condition is achieved often yields favorable treatment outcomes. Nonetheless, should these efforts prove ineffective, therapeutic discharge may become ethically justifiable and, at times, necessary to disrupt the cycle of maladaptive behaviors and safeguard the patient's well-being. CORRESPONDING AUTHOR: Leah Gudex, MD Candidate 2026. 926 Catherine St., Ann Arbor, MI 48104; [email protected]; 262-685-8800