Ethical issues in Psychiatry

ETHICAL ISSUES IN PSYCHIATRY

PRESENTER – DR.SRIRAM.R, FINAL YEAR MD POSTGRADUATE IN PSYCHIATRY

CHAIRPERSON – DR.CATTAMICHI VINILA, SENIOR RESIDENT IN PSYCHIATRY

ORGANISATION INTRODUCTION RELEVANCE OF ETHICS TO PSYCHIATRY GOALS OF PSYCHIATRIC ETHICS SOURCES OF ETHICS OBJECTIVES OF PROFESSIONAL ETHICS

Psychiatric diagnosis. Informed consent. Voluntary and involuntary treatment & hospitalization Confidentiality. Respect for the patient and his human rights. Third party responsibility. Psychiatric research.

A CODE OF ETHICS FOR PSYCHIATRISTS REFERENCE

INTRODUCTION Ethics is as old as the art of healing itself. The earliest code of medical ethics was given by Hippocrates in 5th century BC. Ethics has been derived from the Greek term ethikos, meaning “rules of

conduct that govern natural disposition in human beings”. In simpler terms ETHICS means principles of right conduct. Encyclopedia Britannica – “ethics as a systematic study of the ultimate

problems of human conduct ”. Ultimate problems are concerned with the concepts of right and wrong,

morality and similar other issues.

INTRODUCTIONAccording to standard text books of Psychiatry, Ethics means customary or nature - the study of standards of conduct and

moral judgment . Customary pertains to the social component of ethics. Nature emphasizes the actors own character as an important component.

Need for medical ethics is becoming more & more important with the rapid advancement of medical knowledge.

Today ,organ transplantation, euthanasia, & artificial prolongation of life are issues on which clear ethical guidelines are required.

INTRODUCTION In 1970 the American Psychiatric Association, for the first time, appointed a

committee to develop a code of ethics.

In 1977, the World Psychiatric Association -- code of ethics which is known as the "Declaration of Hawaii".

Indian Psychiatric Society adopted its ethical code in 1989.

RELEVANCE OF ETHICS TO PSYCHIATRY

Line of demarcation between normal & abnormal is hazy & psychiatric diagnosis & treatment can be easily questioned.

Treatments aim at modifying behaviour, perceived as an implied threat because the psychiatric treatment occasionally may be utilized for controlling behavior for certain vested interests.

Psychiatric practice involves close relationship between the patient & the therapist, which can lead to intense transference which may be maliciously utilized.

RELEVANCE TO PSYCHIATRY

Psychiatric pts may not fully in contact with reality, they might consent to or become party to decisions which are not ultimately to their benefit.

Example - A manic patient may give a blank cheque to the therapist or he may ask the therapist to communicate certain things to others which are not in his best interest.

GOALS OF PSYCHIATRIC ETHICS

Deliver competent, compassionate, & respectful care. Deal honestly with patients & colleagues. Act within the boundaries of law. Respect the rights & autonomy of patients. Be responsible to the community and society.

SOURCES OF ETHICS

Law: ethics & law are closely related but not synonymous.

Religion : many ethical decisions have their roots in religion.

Professional associations and their guidelines.

OBJECTIVES OF PROFESSIONAL ETHICS

To provide guidelines of conduct among the professionals themselves. Referral from one therapist to another, giving comments on the opinion of another

professional, and charging consultation fee from co professionals & their families.

To formulate guidelines in dealing with the patients, their relatives and third parties

THE VARIOUS AREAS INCLUDED ARE THE FOLLOWING -

OBJECTIVES OF PROFESSIONAL ETHICS

Psychiatric diagnosis. Informed consent. Voluntary and involuntary treatment & hospitalization Confidentiality. Respect for the patient and his human rights. Third party responsibility. Psychiatric research.

PSYCHIATRIC DIAGNOSIS Certain schools of thought have doubted the existence of the discipline of

Psychiatry.

Thomas Szasz believes that it does not make sense to classify psychological problems as diseases or illnesses, and that speaking of "mental illness" involves a logical or conceptual error

Humanists raised objections, pointing out that dissenters in the various political systems are labeled as mentally sick.

All these raise the basic question regarding the boundaries of mental illness.

PSYCHIATRIC DIAGNOSIS WHO published the ICD-10 making the diagnoses precise & more acceptable.

APA -- 5th revision of its diagnostic system published the DSM – IV.

Both diagnostic systems are compatible with each other puts to end the controversy of psychiatric diagnosis.

PSYCHIATRIC DIAGNOSIS

However, One should not equate a psychiatric diagnosis with legal insanity or it should

not be used as a defense for reduced responsibility.

Large number of psychiatric diagnoses do not fulfill the legal conditions required for insanity.

Only for clinical purposes, as it provides a reasonable guideline regarding etiology, management & prognosis.

INFORMED CONSENT Till recently, after seeking consultation, psychiatrists generally decided

treatment which they felt to be best in the interest of patient. This method of medical practice is known as medical paternalism.

Human rights of the patient should be reasonably protected & the patient should be informed about the nature of illness & treatments available, so that he/she can partake in the decision-making process.

Consumer protection movement compels the medical profession to provide a detailed information for their own safeguard.

INFORMED CONSENT It has the following constituents –

A. Information to be provided by the treating physician.B. Competence of the patient to comprehend the information

provided.C. Freedom to choose.

INFORMED CONSENT

A.Information to be provided by the treating physician:

Nature of the disorder. Prognosis of the disorder without treatment & with each of the alternative

treatment methods. Treatment options available. Reasons for specific treatment being offered & drawbacks of the same. A specific statement that the consent could be withdrawn whenever the patient

wishes so.

INFORMED CONSENT

A. Information to be provided by the treating physician:

Cons of this/Practical problems faced –

Informing a patient of mental illness and the exact prognosis of the illness at the initial stage may give rise to distress & may sometimes lead to adverse consequences.

Information of treatment options, like drugs & ECTs, may not be fully understood by the patient to make decisions on the basis of certain prevailing biases and prejudices against each of these treatment methods.

INFORMED CONSENTB. Competence of the patient to comprehend the information provided.

Competence in this context refers to the patient's ability to understand the nature & severity of his presenting problems, and his/her need of suggested therapeutic help and its limitations.

Whether a mentally ill person is likely to possess such as ability has been debated for a long time by several researchers.


Psychiatric patients may not have insight and hence, are not able to give consent for their treatment.

Even if they give consent it may be for wrong reasons, e.g. a manic patient may challenge the doctor to give all the drugs that he has. Such consent has no meaning.

Before giving consent, patient should fully comprehend the information provided & should be able to decide on the course of treatment in an understanding manner


Assessing competence –

Whether he/she is able to objectively understand that he/she is ill & requires treatment?

Can he/she understand the nature of each treatment option & their consequences?


Pt can be treated in an emergency even without the consent.The treatment of a stuporose or acutely excited patient should not be deferred on account of non-availability of the consent.Minors (below the age of 18 years) are not considered to be legally competent to give consent.Mental Health Act (1987) allows specified relatives to give consent for admission in mental hospitals & for treatment of pts on an outdoor basis. One should take such consent in writing & as soon as the patient is competent, his/her consent should be obtained.

INFORMED CONSENTC. Freedom to choose:

Informed consent a priori i.e. the person has freedom to choose from certain available options

In a country like ours with meagre psychiatric facilities & poor economic conditions, real options are however not truly available.

INFORMED CONSENTC. Freedom to choose:

The patients either do not have easy access to or if some how they reach a facility, they have to accept what so ever is available.

It is the duty of every mental health professional to educate and inform the affected person about the treatment modalities available to him and his right to choose them.

It is better to have a standard written information sheet, with an addition of a clause that the patient is at liberty to ask any further clarification or information.

INVOLUNTARY VS VOLUNTARY TREATMENT

As psychiatric patients do not consider themselves to be ill, they have to be hospitalized or treated against their will.

Patients are usually admitted as 'voluntary' or 'informal' patients, by obtaining their signatures on consent form without obtaining their real consent.

Szasz felt these as an unacknowledged example of medical fraud.


It is undeniable that most of the so called voluntary patients are coerced to some extent for accepting hospitalization.

Coercion may be from employer, family or medical personnel.

Patients demand discharge after a few days of hospitalization & they need to be persuaded to continue treatment.


Temporary hospitalization to regain sanity is a much preferable alternative to staying chronically sick

Peele, Chodoff & Taub state that "it is a perversion and travesty to deprive these needy and suffering people of treatment in order to preserve a liberty which is in actuality so destructive as to constitute another form of imprisonment.“

Any psychiatric patient can be taken to a court of law where the evidence of his being mentally sick can be produced, and order for admission can be obtained.


1% of the population suffers from serious psychiatric illnesses and needs hospitalization.

Meaning that around 8 million persons in India need to be screened by the overburdened judiciary.

Even if the judiciary is able to do the needful, there is an acute shortage of hospital beds and, therefore, it would be rather impossible to provide admissions.


A large number of such patients are treated as outpatients & the only available consent is that of the concerned relatives.

Mental Health Act (1987) provides for involuntary hospitalization with the consent of relatives, which to a large extent obviates the need of judicial order for every patient.

Some times, relatives seek hospitalization of the individual on account of malicious intentions, and the treating physician should be wary of this.


The Hawaii declaration of the World Psychiatric Association provides the following guidelines for such a situation:

"No procedure must be performed or treatment given against or independent

of a patient's own will, unless the patient lacks capacity to express his or her own wishes, or owing to psychiatric illness can not see what is in his

best interest or, for the same reason, is a severe threat to others. In these cases, compulsory treatment may or should be given, provided that it is

done in the patient's best interest and over a reasonable period of time, a retroactive informed consent can be presumed and, whenever possible,

consent has been obtained from someone close to the patient”


As soon as the above conditions for compulsory treatment or detention no longer apply the patient must be released, unless he or she voluntary consents to further treatment.

Whenever there is compulsory treatment, there must be an independent and neutral body of appeal for regular inquiry into these cases.

Every patient must be informed of its existence and be permitted to appeal to it, personally or through a representative without interference by hospital staff or by anyone else".

CONFIDENTIALITY

Anything learned during the professional relationship should not be revealed to others without the consent of the patient.

Records of the patient should be strictly safeguarded, so that no unauthorized person can have access.

Unauthorized person include any person other than the treating team & the family member on whose consent patient has been admitted

CONFIDENTIALITY

However after having achieved recovery, if the patient advises the therapeutic team that even the admitting family member/relative should not have access to the patient's record, his wishes should be respected.

The employers, insurance companies & other interested parties should be provided information after obtaining consent from the patient.

CONFIDENTIALITY

PROBLEMS ASSOCIATED –

When the information provided by the patient can be dangerous to others or himself, the dilemma of protective privilege vs public peril ARISES.

EX: if a patient informs his therapist that he is planning to kill Mr. X, should the psychiatrist inform Mr. X or the police, so that protective measures could be taken? Similarly, if a bus or train driver suffering psychosis poses threat to the public safety, should the psychiatrist inform the police or remain silent?

CONFIDENTIALITY

SOLUTIONS –

No simple rule of thumb present! Consider the nature & the severity of the risk involved, and then decide on an

appropriate measure which may cause least breach of confidentiality. Discuss with the close family members & a colleague to decide on an appropriate

action.

CONFIDENTIALITY

SUMMONING THE PSYCHIATRIST TO TESTIFY –

One should obtain the consent from the patient, and if that is not forthcoming, then one has to depose after lodging protest with the judge.

CONFIDENTIALITY

The confidentiality clause will require more careful monitoring as the new Mental Health Act has come into operation.

The records of the patient may be inspected by the "inspectors" at any time.

Some of these "inspectors" may not be professionally trained. Therefore, one must only record all the observations which seem to be relevant to diagnosis and treatment.

RESPECT FOR THE PATIENT AND HIS HUMAN RIGHTS

Each patient has to be respected as an individual and the aim of the treatment should be towards an early restoration of the functioning of the individual.

Nothing should be done which could be perceived as violation of human rights of the individual.

Unnecessary restraints, keeping a person in solitary cell, & afflicting physical punishment would be considered as highly unethical practices.

RESPECT FOR THE PATIENT AND HIS HUMAN RIGHTS

ECT is used sometimes as a punishment for unacceptable behaviour. Such practices should be condemned.

Each patient should have facilities for basic human rights like privacy, uncensored opportunities to communicate with others, & basic requirement of food, hygiene etc

Every treatment method should be in conformity with the basic human rights and aversive treatment methods which may inflict pain or torture have to be avoided.

THIRD PARTY RESPONSIBILITY

In the modern era, medical treatment has no longer remained within the confines of doctor-patient relationship.

Many external agencies influence both the content as well as the form of treatment.

In Western countries, insurance companies often provide funds for the treatment, likely to influence policy of hospitalization and its duration.

THIRD PARTY RESPONSIBILITY In India, where most treatment facilities are government-funded, the ability of drugs and

number of trained personnel could be the main factors affecting the decision making of treatment.

Pharmaceutical companies are also nowadays indirectly influencing the treatment decisions.

Ex;, the extensive use of II and III generation antidepressants, which are much costlier than the tricyclic antidepressants, is a result of the third party influence

This is largely a by-product of a spate of research and media articles glamorizing these drugs.

PSYCHIATRIC RESEARCH

Research is essential for the advancement of knowledge.

However, when research is involved with human beings, certain safeguards are a must.

Helsinki Declaration guidelines regarding the use of human subjects in research ARE AS FOLLOWS -

HELSINKI GUIDELINES1. Any research which is not likely to directly benefit the patient should not be undertaken.

2. No human subject should undergo research without adequate safeguards. The researcher has to be a protector of the interest of the patient.

3. Any patient, who is not able to give informed consent should not normally be included for purposes or research, unless such a permission has been sought from the concerned family member or relative.

4. While publishing research material, one should take care that the research publication does not violate confidentiality.


In India, much higher & rigorous ethical standards are required as there are few legislations for the professional service & the public gives carte blanche (unlimited authority) to the therapist.

A mechanism of inner controls has to be evolved to maintain a high standard of practice & to develop public confidence.


The Nuremberg Code is a set of research ethics principles for human experimentation set as a result of the subsequent Nuremberg Trials at the end of the Second World War.

The Nuremberg code includes such principles as informed consent and absence of coercion; properly formulated scientific experimentation; and beneficence towards experiment participants.

NUREMBERG CODE – TEN POINTS1) Required is the voluntary, well-informed, understanding consent of the human subject in a full

legal capacity.2) The experiment should aim at positive results for society that cannot be procured in some other

way.3) It should be based on previous knowledge (like, an expectation derived from animal experiments)

that justifies the experiment.4) The experiment should be set up in a way that avoids unnecessary physical and mental suffering

and injuries.5) It should not be conducted when there is any reason to believe that it implies a risk of death or

disabling injury.6) The risks of the experiment should be in proportion to (that is, not exceed) the expected

humanitarian benefits.7) Preparations and facilities must be provided that adequately protect the subjects against the

experiment’s risks.8) The staff who conduct or take part in the experiment must be fully trained and scientifically

qualified.9) The human subjects must be free to immediately quit the experiment at any point when they feel

physically or mentally unable to go on.10) Likewise, the medical staff must stop the experiment at any point when they observe that

continuation would be dangerous.

A CODE OF ETHICS FOR PSYCHIATRISTS

A committee comprising of Prof. JS Neki, Prof. DN Nandi, Prof. AK Agarwal, Dr. VN Vahia and Dr. JK Trivedi was requested to prepare the recommendations for a code of ethics for psychiatrists in India.

The committee prepared the following draft recommendations, which have been approved by the Indian Psychiatric Society at its Annual Conference in1989, held at Cuttack, Orissa (India).


PreambleEthics has been an essential part of the healing art. Ethical guidelines have been

prepared by international and national organizations for different groups of practitioners. Each country has its own social, economical and psychological compulsions which might make it difficult to translate and practice ethical codes of other countries. Hence, this body proposes the following ethical guidelines for the members of psychiatric profession in this country. These principles are intended to aid the psychiatrists individually and collectively, in maintaining a high level of ethical conduct. These are not laws but standards by which a psychiatrist may determine the propriety of his conduct or his relationship with patients, with members of allied professions and with the public.


Principles

1. ResponsibilityAs a practitioner, the psychiatrist must know that he bears a heavy social

responsibility because he not only deals with disturbed human behaviour but also to contend with intimacies of life.

As a scientist, he would serve the society through observation, investigation and experimentation, and well planned and ethically carried out research.


Principles

2. CompetenceThe maintenance of high standards of professional competence is (the)

responsibility of all psychiatrists in the interest of both the public and the profession. Psychiatrists are responsible for their own continuing education and should realize that theirs must be a lifetime learning.

As members of the profession, they will not violate ethical standards and, when such violation comes to their notice, will take steps to correct it.


Principles

3. BenevolenceThe interest of the patient and his health will stand paramount with them in their

professional practices. Personal interest would find but a secondary place.Financial arrangements will never contravene professional standards.Psychiatrists will always safeguard the interests of the patient and the profession.


Principles

4. Moral standardsThey will at all times be responsive to the moral codes and expectations of the

community they serve, and will not let their behavior in any way malign their profession.


Principles

5. Patient welfareThey will not treat a case that does not clearly fall within their competence. The

ones they accept, they will treat with the best of their ability and with the highest regards for the patient's integrity and welfare, as also that of the communities in which they work.

They will terminate the clinical or consulting relationship with the patient when it is reasonably clear to them that the patient is no longer benefiting from it.

In case of referral, they will continue to feel responsible for the patient's welfare until the responsibility has been formally transferred.


Principles

6. ConfidentialityThey will safeguard information about a patient that they have obtained in the

course of their clinical work, teaching or research in order to safeguard the patient's interest and protect him from social stigma, discrimination and harm.

They will treat this as a primary obligation and not reveal unto others any such information unless certain ethical conditions are met, or when there is clear and imminent danger to an individual or society and then only to the appropriate authorities or concerned co-professionals.


Principles

6. Confidentiality

Confidentiality of the clinical records will be meticulously guarded and identity of the patients will not be revealed even in scientific communication.

No data about a patient shall be ordinarily revealed to any agency without the consent of the patient or his family.


Recommendations Every person, who has attained the age of majority and who does not appear to

have lost the ability of reason, shall be assumed to be capable of giving consent.

A patient should be taken up for medical evaluation and treatment with his consent.

In case a patient, because of his mental illness, is unable to express valid consent, the psychiatrist may undertake to treat him with the consent of a person close to him, who appears to be clearly interested in the welfare of the patient.


Recommendations Exception to treat without consent would be an emergency situation involving an

immediate threat to the life or health of patient or others.

In research, the consent shall be obtained after satisfying the following: The consent is entirely voluntary. The patient can withdraw the consent at any stage. Withdrawal of the consent shall not affect the interests of the patient.

The decision to hospitalize a patient will essentially rest on the consideration of his welfare and will also take into consideration legal and administrative constraints as well as its social appropriateness.


Recommendations Psychiatric treatment shall be initiated only on clinical considerations and shall be in

accordance with scientific knowledge and professional ethics.

The patient's welfare should be the primary factor determining the choice of the treatment modality.

Should the specific modality not fall within the competence of a psychiatrist, he should refer the patient to a competent colleague.

The termination of therapy also shall be determined on clinical consideration. Treatment should not be permitted to continue unjustifiably or for materialconsideration.


Recommendations All treatment should be humane and never punitive.

No psychiatrist shall refuse to treat in an emergency.

Gift and gratifications from patients under treatment should not be accepted.

Any kind of sexual advance towards any patient is unethical.

In case of doubt or in situations where unconventional treatment procedures are contemplated, a second opinion must be obtained.


Recommendations It is unethical to force a contract upon a patient during treatment.

Even when a patient has been referred by legal or administrative authority or by the employer, welfare of the patient will remain of paramount consideration.

The patient should be informed of the purpose for which he is to be examined.

Basic human rights of the mentally retarded should not be subjected to unethical abridgement.


Recommendations Due ethical discretion should be exercised when advising such procedures as

sterilization.

In the interest of patient and the society, drug abusers who refuse to give consent may be treated with the consent of their relatives. Efforts have to be made to motivate them for accepting treatment voluntarily.

Ethical codes have to be implemented with sincerity. Ethical committees may be formed at central and zonal levels. Should consider complaints either from public or from fellow professionals and then, carefully investigate them.

REFERENCE

TEXTBOOK OF POSTGRADUATE PSYCHIATRY, SECOND EDITION. EDITORS – JN VYAS AND NIRAJ AHUJA

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Ethical issues in Psychiatry

Health & Medicine