ethics in psychiatry

1. ETHICS IN PSYCHIATRY
. MODERATOR: Dr. Shagufta Rahman
Assistant Professor of Psychiatry, IMH.
PRESENTER: Dr. Aditya.U
Post Graduate 2nd Year, IMH

2. INTRODUCTION
• Word ‘ethics’ - derived from Greek term ethikos, meaning “rules of conduct that govern natural
disposition in human beings”.
• Encyclopedia Britannica –systematic study of the ultimate problems of human conduct.
• Ultimate problems -the concepts of right and wrong,morality etc.,
• Professional ethics -appropriate way to act when in a professional role. Professional ethics
derive from a combination of morality, social norms, and the parameters of the relationship
people have agreed to have.

3. HISTORICAL ASPECTS
• Knowledge of ethical codes of historical importance, such as the Hippocratic Oath of
the 4th century BC and Percival’s Medical Ethics from the late 1800s, provide
perspective on the evolution of the standards of conduct for physicians.
• Psychiatric ethics is of a recent origin.
• In 1970 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.

4. BASIC ETHICAL PRINCIPLES
• Four ethical principles that psychiatrists ought to weigh in their work are respect for
autonomy, beneficence, nonmaleficence, and justice-Principles of Biomedical Ethics,
Beauchamp and Childress.
• Ethical analyses examine the interplay of these principles and seek to identify and
resolve when ethical principles are in conflict.

5. • Autonomy- The notion of self-rule; the capacity to make authentic decisions related to one’s body
. and mind.
• Beneficence - Doing good; the commitment to seek to bring about benefit.
• Compassion - Deep regard for the experiences and suffering of others.
• Confidentiality- A legal privilege associated with the right of privacy; the obligation not to disclose .
. information obtained from a patient or observed or gathered in caring for a patient.
• Fidelity - “Faithfulness” or loyalty to ethical ideals.
• Integrity - The notion of being whole or complete; the capacity to adhere wholly to the principles .
. of the profession.
• Justice- Equitable distribution of benefits and burdens in society.
• Nonmaleficence- Avoiding harm or injury to others.
• Respect for the law- The obligation to adhere to the law.
• Respect for persons- Fundamental regard for the dignity, sacredness, and value of the individual.

6. Respect for Autonomy
• Psychiatrists need to provide patients with a rational understanding of their disorder &
options for treatment. Patients need conceptual understanding ;time to think and to talk
with friends and family about their decision.
• Finally, if a patient is not in a state of mind to make decisions for himself or herself, the
psychiatrist should consider mechanisms for alternative decision making, such as
guardianship, conservators, and health care proxy.

7. Beneficence
• The expression of the principle is paternalism.
• Weak paternalism -acting beneficently when the patient’s impaired faculties prevent an
autonomous choice.
• Strong paternalism -acting beneficently despite the patient’s intact autonomy.
• Guidelines propose- beneficence to overrule patient autonomy; when the patient faces
substantial harm or risk of harm, the paternalistic act is chosen that ensures the optimal
combination of maximal harm reduction, low added risk, and minimal necessary infringement
on patient autonomy

8. Nonmaleficence and Justice
• Psychiatrists must be careful in their decisions and actions, ensure that they have had
adequate training for their doings, need to be open to seeking second opinions &
consultations, avoid creating risks for patients by an action or inaction.
• Concerns the issues of reward and punishment and the equitable distribution of social
benefits- include whether resources should be distributed equally to those in greatest
need, where they can have the greatest impact on the well-being of each individual
served, or to where they will ultimately have the greatest impact on society.

9. SPECIFIC ISSUES
• From a practical point of view, several specific issues most frequently involve
psychiatrists.
• Sexual boundary violations
• Nonsexual boundary violations,
• Violations of confidentiality,
• Mistreatment of the patient(incompetence, double agentry)
• Illegal activities (insurance, billing, insider stock trading).

10. Sexual boundary violations
• Sexual activity with a current or former patient is unethical.
• Sexual activity between a doctor and a patient's family member is also unethical.
• Ex: Medical Board of California Action Report (July 2006) of a psychiatrist who had a 7-year
affair with a patient who had schizophrenia. The physician’s license was revoked, and he was
also criminally convicted of fraud.

11. Nonsexual boundary violations
• Not all boundary crossings are boundary violations. A boundary violation is a boundary
crossing that is exploitative.
• Business:Almost any business relationship with a former patient is problematic, and almost
any business relationship with a current patient is unethical.
• Ideological Issues: -Any clinical decision should be based on what is best for the patient; the
psychiatrist’s ideology should play as little a part as possible in such a decision.

12. • Social: Problems often arise in treatment situations when friendships develop between the
psychiatrist and the patient. Such friendship should be avoided during treatment. Similarly,
psychiatrists should not treat their social friends except in emergency.
• Financial: For psychiatrists in the private sector, dealing with the patient about money is a
part of treatment. Issues surrounding setting the fee, collecting the fee, and other financial
matters are grist for the mill.

13. ETHICS IN MANAGED CARE
• i. Responsibility to Disclose- Psychiatrists have a continuing responsibility to the patient to
obtain informed consent for treatments or procedures. All treatment options should be fully
disclosed, even those not covered under the terms of a managed care plan.
• ii. Responsibility to Appeal- Physicians have an ethical obligation to advocate for any care that
will materially benefit their patients, regardless of any allocation guidelines or gatekeeper
directives.

14. • iii. Responsibility to Treat- The treating physician has sole responsibility to determine what is
medically necessary. Psychiatrists must be careful not to discharge suicidal or violent patients
prematurely merely because continued coverage of benefits is not approved by a managed
care company.
• iv. Responsibility to Cooperate with Utilization Review- The psychiatrist should cooperate
with utilization reviewers' requests for information on proper authorization from the patient.

15. 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.

16. Psychiatric diagnosis
• There are certain schools of thought that doubt the very existence of Psychiatry. Humanists
raised objections, pointing out that dissenters in the various political systems are labeled as
mentally sick.
• All these instances raise questions on boundaries of mental illness.
• ICD-10 by WHO,DSM-5 by APA, to a large extent puts an end to controversy.
• 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

17. Informed consent
• Seeking consultation= Consent for treatment.(medical paternalism).
• NOW, a greater emphasis - the patient's human rights i.e, pt. should be informed about
1, the nature of illness
2, treatments available
3, take part in the decision-making process.
• Consumer protection movement compels the medical profession to provide a detailed
information for their own safeguard.

18. • 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.
• Liberty to ask any further clarification or information.

19. Voluntary vs Involuntary 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.
• Pt. demand discharge after a few days of hospitalization & they need to be persuaded to
continue treatment.
• To be evaluated on the principle of beneficence.

20. • 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 (13 million) suffer from serious psychiatric illnesses, who
needs to 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.

21. 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.”

22. • 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 & be permitted to appeal to it, personally or
through a representative without interference by hospital staff or by anyone else.

23. 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.
• 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.

24. Protective Privilege Vs Public Peril
• 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, & 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.

25. • 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. A psychiatrist can petition the judge for an in-
camera(private) review to define what precise information must be disclosed.
• The confidentiality clause will require more careful monitoring as the new Mental Health Act
has come into operation.

26. 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

27. 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 & no. of trained personnel might affect treatment.
• Pharmaceutical companies-undue importance on newer anti depressant -much costlier than
TCAs

28. Psychiatric research.
• Helsinki Declaration guidelines regarding the use of human subjects in research.
• Any research which is not likely to directly benefit the patient should not be undertaken.
• No human subject should undergo research without adequate safeguards. The researcher has
to be a protector of the interest of the patient.
• 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.
• While publishing research material, one should take care that the research publication does not
violate the confidentiality.

29. • 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.

30. APPROACHING ETHICAL DILEMMAS
• Recognizing Ethical Issues and Tensions.
• Gathering Additional Information and Expertise
• Identifying Risky Situations and Arranging for Appropriate Safeguards
• Working within One’s Scope of Practice and Engaging in Continuous Learning
• Reflecting on One’s Values and Perspectives

31. DECISION-MAKING STRATEGIES
• Jonsen, Siegler, and Winslade created a 4-part model that many health care settings have
adopted:
• (1) clinical indications
• (2) patient preferences,
• (3) quality of life, and
• (4) socioeconomic or external factors.

32. Impaired physicians
• A physician may become impaired due to psychiatric or medical disorders or the use of mind-
altering and habit-forming substances (e.g., alcohol and drugs)- interfere with cognitive and
motor skills required to provide competent medical care.
• An incapacitated physician should be reported to an appropriate authority, and follow specific
hospital, state, and legal procedures.

33. Professional misconduct
• Practicing fraudulently and with gross negligence or incompetence.
• Practicing while the ability to practice is impaired.
• Being habitually drunk or being dependent on, or a habitual user of, narcotics or a habitual
user of other drugs having similar effects.
• Immoral conduct in the practice of the profession.
• Permitting, aiding, or abetting an unlicensed person to perform activities requiring a license.
• Refusing a client or patient service because of creed, color, or national origin.
• Practicing beyond the scope of practice permitted by law.
• Being convicted of a crime or being the subject of disciplinary action in another jurisdiction.

34. Physicians in Training
• It is unethical to delegate authority for patient care to anyone who is not appropriately qualified
and experienced, such as a medical student or a resident, without adequate supervision from
an attending physician.
• Within a healthy, ethical teaching environment, residents and medical students may be involved
with, and responsible for, the day-to-day care of many ill patients, but they are supervised,
supported, and directed by highly trained and experienced physicians.

35. IPS code of ethics for psychiatrists(1989)
• 1. A psychiatrist has a clear social responsibility.
• 2. A psychiatrist must maintain high standards of professional competence and ensure
continuing self-education.
• 3. Benevolence and patient interest precede self interest.
• 4. A psychiatrist must maintain high moral standards.
• 5. Patient welfare is of paramount concern to a psychiatrist. It includes not treating cases which
are not in his domain, terminating treatment when cannot help the patient, and treating with the
best of the ability.
• 6. Confidentiality of the patient records must be meticulously maintained.

36. Take home message
• 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
• Unfortunately ethical issues are not given any attention in UG &PG medical education. Ethical
issues should be discussed, so that young doctors are sensitized to kind of problems they are
likely to face.
• It is mandatory that the teachers of these young medicos should themselves put up exemplary
models as the ethical practices are largely learned by the process of imitation.

37. REFERENCES
• Sadock BJ, Sadock VA, Ruiz P. 60.2. In: Kaplan and Sadock's comprehensive textbook of
psychiatry. Philadelphia: Wolters Kluwer.; 2017.
• Sadock BJ, Sadock VA, Ruiz P. 36.2. In: Kaplan and Sadock's synopsis of psychiatry:
Behavioural Sciences/Clinical Psychiatry. 11th ed. Philadelphia: Wolter Kluwer; 2015. p. 2920–
32.
• Vyas JN, Niraj Ahuja P.77.In: Textbook of postgraduate psychiatry,vol-2 : Ethics in psychiatry.
2nd edition. New Delhi : Jaypee brothers medical publishers;2008.p.1019-24