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Who comes first: Patients or staff?

July 7, 2008
by H. Steven Moffic, MD
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This question might seem obvious at first glance, but don’t discount the vital role staff play in patients’ recovery

Behavioral Healthcare’s November 2007 issue profiled “Behavioral Health Champions,” and among them was Lawrence P. Noonan, CEO of A.W.A.R.E., Inc., in Montana and New Mexico. Beyond all of his leadership accomplishments, what really struck me was how he described his most vivid behavioral healthcare memory, which began, “The first day I worked in an ICFMR in Montana, on my first staff break, I was given a choice between helping the resident of the facility who was having an epileptic seizure in the hallway or helping the staff person who was having a seizure in the office.”

Before I complete Mr. Noonan’s quote, imagine what you would do in such a scenario. Or, if you actually have had a similar choice, what did you do? Is this an ethical dilemma like some of those questions designed and used to assess ethical decision making? One well-known mock scenario is whether you would pull a switch that would save five people but kill one, or do nothing and have all six die.

Mr. Noonan continued, “I helped the resident and called for help for the staff member. It was a tough choice.” I can understand why this choice might have been an early example of how his caring for patients was reflected in his actual behavior and a clue for why he received the award.

I’d like to think that I would have done the same thing. After all, as a physician and psychiatrist I was socialized to put the patient first. The American Medical Association’s Principles of Medical Ethics, revised in 2001, emphasizes in its preamble that “a physician must recognize responsibility to patients first and foremost....” If that wasn’t clear enough, Section VIII states that “A physician shall, while caring for a patient, regard responsibility to the patient as paramount.” Perhaps to counter the business and managed care intrusions on the practice of medicine, the 2001 revision places even more emphasis on the patient than the prior version’s preamble, which stated that the principles were only “developed primarily for the benefit of the patient.” Secondary responsibility is to society, colleagues, and self.

When I was an administrator, I developed the

Ethical Principles for Psychiatric Administrators for the

American Association of Psychiatric Administrators. Although these principles place more emphasis on “responsibility for the well being of the work setting and for the lives of those employed in that setting,” when that conflicted with the needs of patients, patients still needed to come first.




I am not as knowledgeable about the ethical principles of other behavioral health disciplines, but there seems to be a similar sentiment. For instance, the ethical standards of

NAADAC, The Association for Addiction Professionals, seem to parallel those of my field. Interestingly, the first ethical principle of the

National Association of Social Workers’ Code of Ethics states that “Social workers’ primary goal is to help people in need and to address social problems.” Although it is implied that the people in need are clients, would the staff member in Mr. Noonan’s scenario also apply?


Despite how Mr. Noonan’s decision fit the ethical principles I was familiar with, a nagging doubt persisted. Remember, he said it was a “tough” choice. In fact, the more I thought about it, the more I think it could have been the wrong ethical choice between two ethical goods. Why? Is it heresy to even question the principle of “patient first”?

All these ethical principles say we have some responsibility to colleagues, of course. Who else but us clinical staff to take care of patients? Don’t we all think that the better the staff, the better the care of patients/clients? And don’t all good administrators help us to do better work, or bad ones hinder it?

Logic then takes me to suggest that, just maybe, staff should come first and that, if I had time to think and not just react reflexively to the way I’ve been socialized, I might first try to help the staff member having an epileptic seizure.

I don’t mean that we should come first in a personal, narcissistic sense. Our priority should not be how much money we can make off our patients or how much renown we can achieve. No, I mean that everything possible should be done to help clinicians and administrators become as skillful as possible. I also mean that our own mental health must become a priority. Time to recoup during the day, mental health days off, not putting ourselves in dangerous situations with patients, and continuing education all should be a priority, not grudgingly available because they take time away from patient care.

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