ETHICS IN PSYCHIATRY

Scenarios- How to go about???1. 60 year old elderly female from a poor back ground,

married, with a single girl child presenting in delerium. Attendee(patient’s daughter) could not comprehend the nature of illness or the treatment options available even after explaining many times. After two days of treatment she would not consent for any treatment despite deterioration in the patient’s condition.

2. A 28 yr female, a case of BPAD confesses about her series of extra marital relations during a past manic episode and is currently being threatened by one of those males demanding for a continuous relationship with the patient. The husband is apparently unaware of any of these.

Word ethics has been derived from the Greek term ethikos, meaning “rules of conduct that govern natural disposition in human beings”.

simpler terms means principles of right conduct

Encyclopedia Britannica – “ethics as a systematic study of the ultimate problems of human conduct ”. Ultimate problems the concepts of right and wrong,

morality etc.,

E-T-H-I-C-S

Historical:

The Charaka Samhita- 600 BC The Hippocratic Oath, devised about 400 BC the sixth century Hebrew Book of Asaph

Harofe the tenth century Persian physician, Haly

Abbas. The direct forerunner of modern codes, “the

Code of Institutes and Precepts”, (1803 AD) by the English physician, Thomas Perceval.

Psychiatric ethics is of a recent origin

In 1973 the American Psychiatric Association- First code of ethics in Psychiatry

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.

Rapid advancement of medical knowledge.

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

without adequate standards, self-regulation can degenerate into self-protection; and self-protection ultimately damages the profession.

WHY DO WE NEED MEDICAL ETHICS?

Ethics is much more relevant to psychiatry because….

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

The treatment aims at modifying behavior, perceived as an implied threat may be utilized for controlling behavior for certain vested interests.

Intense transference between the patient & therapist which may be maliciously utilized.

Psychiatric patients may not be fully in contact with reality, they might consent to decisions which are not ultimately to their benefit.

Ex:A manic patient may give a blank cheque to the therapist

Concepts: In psychiatry, by contrast to medicine, there

are a number of important prima facie connections between our diagnostic concepts and ethics

justification for involuntary psychiatric treatment

the insanity defence- ’mad but not bad’ Medical/Moral dimension:

psychopathic personality (a medical concept) and delinquency (a moral concept).

hysteria/malingering alcoholism/drunkenness.

• abuses of psychiatry: USSR-Delusions of reformism

Objectives of professional ethics

To provide guidelines of conduct among the professionals themselves.

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

1.  Psychiatric diagnosis.2.  Informed consent.3.  Voluntary and involuntary treatment &

hospitalization.4. Confidentiality.5.  Respect for the patient and his human rights.6. Third party responsibility.7. Psychiatric research.

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

The boundaries of mental illness. ???

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

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

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

1.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.

Because 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.

2.INFORMED CONSENT Medical paternalism: seeking consultation =

consent for treatment

NOW, a greater emphasis the patient's human rights the nature of illness treatments available take part in the decision-making process.

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

Constituents of an Informed Consent:

A. Information to be provided by the treating physician.

B. Competence of the patient to comprehend the information provided.

C. Freedom to choose.

A specific statement that the consent could be withdrawn whenever the patient wishes so.Liberty to ask any further clarification or information.

several practical problems.

Informing a patient of schizophrenia / BPAD

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

Competence of Patient: Competence in this context refers to the

patient's ability to understand the nature & severity of his presenting problems, and need of suggested therapeutic help and its limitations.

How to asses competence ? By asking a few questions on the information

made available to him. Whether patient is able to objectively understand

that he is ill & requires treatment? Can he understand the nature of each treatment

option & their consequences?

However, Pt can be treated in an emergency even without

the consent. Stuporose or acutely excited patient Minors (below the age of 18 years) Relatives

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 consent should be obtained.

3.INVOLUNTARY vs VOLUNTARY TREATMENT

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

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.

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

To be evaluated on the principle of beneficence.

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

Evidence for mentally ill in court of law Order for admission can be secured.

Problem : 1% of the Indian population (12 million) should be screened by the judiciary

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

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.”

The Hawaii declaration of the WPA “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.

Continued…

4.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

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.

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

Protective Privilege Vs Public Peril: EX: if a patient is planning to kill Mr. X, should

the psychiatrist inform Mr. X or the police, so that protective measures could be taken? Similarly, a bus or train driver suffering psychosis

poses threat to the public safety. Again, should the psychiatrist inform or remain silent?

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.

When courts summon 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.

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.

5.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. Ex: Restrains Keeping in Solitary cell ECT as punishment Pain or torture as aversive methods

6.THIRD PARTY RESPONSIBILITY 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 and sometimes provide treatment option guidelines.

In India Govt. funded availability of drugs & trained personnel might affect treatment.

Pharmaceutical companies undue importance on newer anti depressant much costlier than TCAs

7.PSYCHIATRIC RESEARCH Helsinki Declaration guidelines regarding the use of human

subjects in research. 1.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 the confidentiality.

Declaration of Madrid 1996-WPA

In India 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.

Some more points: Fees should be appropriate to the local conditions &

should not be increased without appropriate reason.

Gifts of any kind during the therapy are not permitted.

Any kind of sexual advance towards the patient is strictly prohibited

Ethics --- the relationship among psychiatrists themselves.

Entertain a patient only after a due referral from the treating psychiatrist.

Psychiatrists often do not react to the malpractices of their colleagues misguided notion disservice to the profession.

On the contrary, such black sheep in reality bring the profession to disrepute and their exposure in public would cleanse the profession.

Training the young:

Unfortunately, ethical issues are not given any attention in the undergraduate & postgraduate medical education.

Ethical issues should be discussed formally, so that young doctors are sensitized to the kind of problems they are likely to face.

Ethical practices are largely learned by the process of imitation and, as such, it is mandatory that teachers should themselves put up exemplary models for the young medicos.

IPS code of ethics for psychiatrists(1989) 1. Responsibility2. Competence3. Benevolence4. Moral standards5. Patient welfare6. Confidentiality

Principles in West:

1.Autonomy2.Beneficence3.Non-

maleficence4.Justice

Carry home message….

….summary

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.

One should be clear with…..1. Psychiatric diagnosis.2.   Informed consent.3.   Voluntary and involuntary treatment & hospitalization.4.   Confidentiality.5.   Respect for the patient and his human rights.6.  Third party responsibility.7.   Psychiatric research.

References 1. Vyas JN, Niraj Ahuja. Textbook of postgraduate

psychiatry, vol-2 : Ethics in psychiatry. 2nd edition. New Delhi : Jaypee brothers medical publishers;2008.

2. Michael G. Gelder, Juan J. López-Ibor, Nancy Andreasen .New Oxford Textbook of Psychiatry,Vol-1: Psychiatric ethics: codes, concepts, and clinical practice skills .London: Oxford University Press;2000.

3.Kishor.M, Vinay.H.R,Kiran Kumar.K,Lakshmi.V.Pandit.Glimpses of Psychiatry for doctors and medical students :Ethics & Medicine. 1st edition. Mysore: Tata Printing Press and Publications;2013.