Ethics in psychiatryHimalee Abeya

Consultant Psychiatrist

Ethics

‘ethikos’ – Greek for ‘disposition’

“Has a philosophical home in the discourse of moral philosophy, the study of conduct with respect to whether the act is right or wrong, and to the goodness and badness of the motives and ends of the act

Are ethics ‘different’ in Psychiatry?

Therapeutic Alliance

Distinct features of Patient

Goals of interaction

Inter-relationship of aspects of Psychiatric Treatment

Radden,J. (2002) Notes towards a professional ethics for psychiatry. ANZJP,36.52

Ethical conduct by psychiatrists

Ethical conduct by psychiatrists goes beyond mere knowledge of ethics principles.

It also requires certain moral skills and habits.

These assure that ethically sound judgment and the actions that follow fall within accepted ethical bounds.

Historical concerns… Misuse of asylum – custodial ‘warehouse’

William Hogarth • The Rake's Progress: the Rake in Bedlam • 1735

Historical concerns……

Prefrontal lobotomyInsulin coma therapy

Gruesome effects of physical treatments

Historical concerns……

Misuse of Psychiatry for political purposes

“Government using the fig leaf of psychiatry to cover-up the imprisonment of people with minds of their own” – A dissenter, 1956

Jill, Tim and the baby

Dr. Jones ψ

Dr. Brown GP

Jill Tim

Baby

Withdrawn into self since childbirth

Family found she had had extramarital affair - ?paternity

MSE - “they have been out to get me” – paranoid

Not suicidal or homicidal, not delirious

Jill, Tim and the babyImmediate Outcome:

Jill refused to got to hospital -‘want to be with baby’

Tim supported her decision

Ethical issues:

Did he owe allegiance to Jill & helpless baby or to Tim

Dilemma: protect life & wellbeing of patient VS crucial interests of others

Dilemma: respect Jill’s right to self determination Vs promoting her welfare

Surveying competing ethical theories:

All theories - A formulation of presumed moral judgements Guidelines as to how these might apply to given circumstances

Reviewed theories – Deontology (Kant) Utilitarianism (Mill) Principlism (Beauchamp & Childress) Virtue theory (Aristotle) Ethics of care (Baier)

Kantianism

Deontological theory – Immanuel Kant Grounded in duty

Right moral action is justified by a person’s intrinsic values

Basis for establishing moral rules is rational argument - yields universally applicable categorical imperatives

Once set – this is binding

With Jill:

Respect for autonomy - ?Categorical imperative

Utilitarianism

J.S. Mill – principle of utility

Basic tenet – An act is morally right if when compared to alternative acts it yields the greatest balance of good and the least balance of bad

With Jill:

Difficult to calculate benefits or risks of either compulsory or non-compulsory treatment

Principle based ethics

Beauchamp & Childress – Principlism

Attempts to reconcile divergence b/n above

Philosophical pragmatism: widely held principles – too general to address particulars- provide a starting point for moral judgement

Quartet of Principles: 1. Non-maleficence 2. beneficence 3. Autonomy

4. justice

Limitations in approach – prima facie duty introduced by W. D. Ross

With Jill – conflicting prima facie obligations

Virtue theory Identified with Aristotle - Avoids rules and

principles altogether – a person’s character is at centre of moral deliberation

Develop traits that promote virtuous behaviour – advances common good

Criticism – Virtue? & can it be taught?

With Jill:

Is virtue in the Dr.s sufficient? Not enough to deal with moral complexity of case

Ethics of care A contemporary variant of virtue theory – with

feminism & psychological constructs (esp. emotion) draw on

Affords primacy to character traits ( ones that are intrinsic to extending care) and interpersonal relationships over rules.

The conventional family serves as a model for moral behaviour

A criticism – it is a method and not a conceptual theory; therefore subjective, even inconsistent

A potential remedy

Ethical deliberation has to encompass the pursuit of features that constitute moral actions as well as traits of character that are morally praiseworthy

Baier’s care ethic (centred on trust) complemented by a more structured framework of principlism – best combination

An ethical framework for psychiatry; SIDNEY BLOCH and STEPHEN A. GREEN, The British Journal of Psychiatry 2006 188: 7-12

Confidentiality

Confidentiality is the obligation not to reveal a patient’s personal information without his or her explicit permission

Part of the foundation of the physician-patient relationship.

It is important to distinguish between the ethical duty to keep confidences (an obligation created by and owed to the patient) from the legal duty that governs the handling of private medical information (an obligation created by the state).

Do we tell Mr. Y?

Mr. Y.is 51: Wife, Ms. X. is 30. Have same GP

Mr. Y. - major depression, exacerbated by numerous social stressors. These include a recent diagnosis of AIDS, his wife’s diagnosis of HIV, their inability to conceive a child

Ms. X. was born a man, but underwent a sex change in Brazil when he was 18; later worked in the sex trade, and contracted HIV

Ms. X. is unwilling to allow her psychiatrist and GP to tell Mr. Y. about her history as she feels it would “destroy him”

The frame and its boundaries

Professional boundaries: “the edge or limit of appropriate behaviour by the psychiatrist in the clinical setting”

Boundary violation – transgressions that are potentially harmful to or exploitative of the patient

Boundary crossing – Non sexual boundary transgression in which ultimate effect is positive

Boundary transgression

In lieu of payment…..

A psychiatrist treats a patient for phobias

As she cannot afford to pay him, he arranges for her to become his house cleaner in lieu

Is this an acceptable arrangement?

Involuntary treatment

Involuntary psychiatric treatment most commonly comprises psychiatric hospitalization or court-ordered outpatient treatment. Mandated treatment generally uses the state’s enforcement apparatus to place individuals into medical care

Under MHA 2007, NSW

RANZCP – Code of Ethics 1 Psychiatrists shall respect the essential humanity and dignity of every patient.

2 Psychiatrists shall not exploit patients.

3 Psychiatrists shall provide the best attainable psychiatric care for their patients.

4 Psychiatrists shall strive to maintain confidentiality of patients and their families.

5 Psychiatrists shall seek valid consent from their patients before undertaking any procedure or treatment.

6 Psychiatrists shall not misuse their professional knowledge and skills.

7 Psychiatrists involved in clinical research shall comply with ethical principles embodied in national and international guidelines.

8 Psychiatrists shall continue to develop, maintain, and share their professional knowledge and skills with medical colleagues, trainees and students, as well as with other relevant health professionals and patients and their families.

9 Psychiatrists have a duty to attend to the health and well-being of their colleagues, including trainees and students.

10 Psychiatrists shall uphold the integrity of the medical profession.

11 Psychiatrists shall work to improve mental health services and promote community awareness of mental illness and its treatment and prevention, and reduce the effects of stigma and discrimination.

May 2012, RANZCP

Thank you