Ethics in psychiatry

1. Ethics in psychiatry Himalee Abeya Consultant Psychiatrist

2. 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

3. Are ethics ‘different’ in Psychiatry? Inter-relationship of aspects of Psychiatric Treatment Therapeutic Alliance Goals of interaction Distinct features of Patient Radden,J. (2002) Notes towards a professional ethics for psychiatry. ANZJP,36.52

4. 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.

5. Historical concerns… • Misuse of asylum – custodial ‘warehouse’ William Hogarth • The Rake's Progress: the Rake in Bedlam • 1735

6. Historical concerns…… Gruesome effects of physical treatments Insulin coma therapy Prefrontal lobotomy

7. 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

8. Jill, Tim and the baby Dr. Jones ψ Jill Tim Dr. Brown GP Baby Withdrawn into self since childbirth Family found she had had extramarital affair - ?paternity MSE - “they have been out to get me” – paranoid Not suicidal or homicidal,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

9. Jill, Tim and the baby Immediate 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

10. 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)

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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).

18. 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”

19. 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

20. Boundary transgression

21. 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?

22. 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

23. 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

24. Thank you