ETHICS

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ETHICS
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Ethical principles

• Autonomy
• Beneficence
• Non-maleficence
• Justice
• Respect

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Ethical principlesAutonomy

• Right of patient to self determination.
• Informed consent
• intentional choice. Consent vs assent.
• Freedom from undue outside influence. Persuasion
  vs manipulation
• Rational understanding of issues - including
  competency
• Right of mentally ill to be treated despite
  inability to consent
• Utilitarian principles vs deontological
• Testamentary capacity
• Confidentiality, least restrictive care, not
  discriminate, balance of rights, who should
  decide

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Ethical principlesBeneficence

• duty of doctor to act in best interests of their
  patients
• duty of care
• paternalism (including power differential and
  passivity and compliance of patients), violence
  to self and others, involuntary detention,
• Best possible medical care - including not
  refusing reasonable referral, continuity of care,
  peer review, QA, share knowledge.

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Ethical principlesNon-maleficence

• Do no harm
• Boundaries
• impaired doctor,
• conflicts of interest,
• misuse of skills
• accountability

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Ethical principlesJustice

• In this context a fair distribution and
  application of psychiatric services.
• right to health care for all - should money buy
  better care,
• advocacy
• uphold standards
• resources and service issues is it appropriate
  use of resources, statutory obligations, shifts
  in health care to less autonomy, Uphold the
  integrity of the medical profession. Strive to
  improve the quality of psych services, promote
  the just allocation of services and contribute to
  the education of society regarding mental health.
  May need to act as advocates to ensure their
  patients have the best possible psychiatric
  services.

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Ethical principlesRespect

• Respect of patients wishes/ choices, dignity of
  patient.

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Declaration of Helsinki

• World Psychiatric Association 1991
• cant do placebo trials for serious conditions
  where there is already an effective drug
• Cant condone, or participate in, the use of
  torture or other forms of cruel, inhuman or
  degrading treatment even when ordered to do so by
  State Authorities.

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Research ethics
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Relationship with drug company

• Be transparent in what monies are taken
• Make sure the process isnt questionable
• Dont let it influence your clinical judgement
• Be even-handed accept from many companies
• Dont alter the program of a meeting to suit
  company
• Err on side of rejecting gifts, declare conflicts
  of interest to patients/employer
• Dont accept drug samples marketing exercise
• Avoid writing advertorials

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The UN

• Universal declaration of human rights 1948
• Declaration on the rights of the child 1959

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Kids in detention centres
Contravenes Australias responsibility under UN
convention on the Rights of the Child
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Kids in detention centres
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HIV

• Psychiatrists can disclose HIV status to
• Identified person who is at risk because of
  patients uncontrollable behaviour
• Regulatory authorities where AIDS diagnosis is
  reportable
• Other inpatients where patients behaviour places
  them at risk can not be controlled

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Issues in releasing records
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Medico-legal reports
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Independent medical exams

• Consent
• Privacy
• Expertise
• Information source disclosure
• Professional knowledge
• Professional boundaries

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Financial interest in tx/hosp.

• Do not let it affect clinical judgment
• Transparent to patient
• Transparent to HIC, private funder
• Record in clinical notes

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RANZCP code of ethics
1 Psychiatrists shall respect the essential
humanity and dignity of every patient. 2
Psychiatrists shall not misuse the inherent power
differential in their relationships with
patients, either sexually or in any other way. 3
Psychiatrists shall provide the best possible
psychiatric care for their patients. 4
Psychiatrists shall strive to maintain patient
confidentiality. 5 Psychiatrists shall seek
informed consent from their patients before
undertaking any procedure or treatment. 6
Psychiatrists shall not misuse their professional
knowledge and skills. 7 Psychiatrists shall
continue to develop and share their professional
knowledge and skills with medical colleagues and
trainees in psychiatry. 8 Psychiatrists shall
share the responsibility of upholding the
integrity of the medical profession. 9
Psychiatrists have a duty of care to the health
and well-being of their colleagues, including
trainees in psychiatry. 10 Psychiatrists
involved in clinical research shall adhere to
ethical principles embodied in national and
international guidelines. 11 Psychiatrists shall
strive to improve the quality of, and access to,
mental health services, promote the just
allocation of health resources and contribute to
community awareness of mental health and mental
illness.
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Confidentiality expanded
4.1 In view of the particularly sensitive nature
of patient information, psychiatrists have a
special responsibility to maintain
confidentiality. 4.2 With changes in
information technology and organisational
structures, psychiatrists have a particular
responsibility to hold clinical information in
confidence and take reasonable steps to safeguard
that information. 4.34 Other than as may be
required by law, information about patients
obtained from other sources is subject to the
same principle of confidentiality. 4.5
Confidentiality cannot be absolute. A careful
balance must be maintained between preserving
confidentiality and the need to breach it in
order to promote the best interests and safety of
the patient and the safety and welfare of other
persons. 4.6 Psychiatrists may disclose
confidential information if their patient intends
to harm an identified person or persons.
Psychiatrists may have an overriding duty to
inform the intended victim(s) and/or the relevant
authorities. 4.7 Clinical information may need
to be shared with colleagues in order to provide
optimal care. The patient should be informed of
the limits of confidentiality as part of the
process of obtaining consent. Where the patient
is unable to understand the concept of
confidentiality and its limits, consent may be
required from relatives or guardian legally able
to represent the patient. 4.8 While upholding
the principle of confidentiality, psychiatrists
must act within the constraints of the law.
However, psychiatrists should question the need
for disclosure or argue for only limited
disclosure in legal proceedings. 4.9 If required
to disclose clinical information, psychiatrists
shall seek to divulge only what is relevant,
strive to separate fact from opinion and avoid
unnecessary speculation. 4.10 When psychiatrists
breach confidentiality they must be able to
justify their actions. 4.11 Safeguarding
confidences applies regardless of whether the
psychiatrist-patient relationship has ceased or
the patient has died, except in specific
circumstances such as a relatives need to
ascertain an hereditary risk.
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Informed consent expanded
5.1 Psychiatrists shall inform the patient of the
purpose, nature, benefits, side-effects and risks
and costs of a proposed procedure or treatment
this information shall be conveyed in a way that
may best be understood by the patient. 5.2
Psychiatrists shall also inform the patient of
alternative indicated treatments and their
respective purpose, nature, benefits,
side-effects and risks. The patient shall be
provided with adequate opportunity to choose
between alternatives. 5.3 Psychiatrists shall
ensure that each patients consent for treatment
is obtained without coercion. 5.4 A patients
capacity to provide consent may fluctuate. A
psychiatrist shall assess the patients current
capacity acknowledging that some decisions
require higher levels of capacity. 5.5
Psychiatrists shall provide new information, in a
timely manner, which might reasonably affect the
patients original or ongoing informed consent.
5.6 Impaired capacity does not imply that the
patient should be given less information. 5.7
In the case of an incompetent patient,
psychiatrists shall seek consent wherever
possible from a relative or guardian legally able
to give consent or other statutory agent. 5.8
In the case of patients who are minors,
psychiatrists shall seek consent from a relative
or guardian but where the patients are of
sufficient maturity and understanding, shall seek
their consent as well. 5.9 Psychiatrists shall
inform patients that they may withdraw their
consent at any stage without compromising other
aspects of their care. 5.10 A patients consent
for a procedure or treatment may need to be
waived in certain circumstances, for example
- the patients life or physical and/or mental
health are at risk - the patients condition
poses a threat to the life or welfare of others
- patients are not competent to judge what is
in their interests regarding treatment (in which
case substituted consent may be necessary from a
relative or guardian legally able to consent).
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Service delivery
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National Mental Health Strategy

• Promote the mental health of the Australian
  community
• To, where possible, prevent the development of
  mental disorder
• Reduce the impact of mental disorders on
  individuals, families and the community and
• Assure the rights of people with mental illness.

• Meeting CommStates 1993-98
• Confirmed as National Mental Health Plan 2003-2008

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National Mental Health Strategy

• For successful community
• care of people with MI
• specialised mental health services that recognise
  their rights and respect their dignity
• general medical services, housing, accommodation
  support, social support, community and
  domiciliary care
• income security, employment and training services

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National Suicide Prevention Strategy 1992 onwards

• Focus on all community with specific reference to
  HIGH RISK groups
• young men
• rural residents
• the elderly
• people with substance use
• Prisoners
• rural communities
• people with mental illnesses,
• Aboriginal and Torres Strait Islander peoples

• NS advisory council
• Living is for Everyone framework for high risk
  groups
• Access to means
• National projects population-based, focus on
  community building
• Local projects service oriented community-based
  initiatives

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Mental health literacy
Jorm et al ANZJP 2005 Impact of
Beyondblue Recognition of vignette as depressed
? 2003 vs 1995 and changes in view about
counselling and medications BUT difference
between states which funded Beyondblue and those
that didnt was slight (30 vs 25 change (from
36 to 67 in exposed states and 42 to 66 in
unexposed states)
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Prevention
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The college on MH services the 16 principles
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The psychiatrist in disasters
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The psychiatrist in disasters

• WHO roles for MHPs
• Teaching
• Leadership
• Mobilising support at different levels
• Preventive psychiatry
• 1st six months monitoring for MH problems
• Follow up of those psychologically affected

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Multidisciplinary team
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Recommendations for better MDT function
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College on teamwork

• Leadership is the process of influencing others
  to engage in the work behaviours necessary to
  reach organisational goals.
• Management is the process of achieving
  organisational goals by the four major functions
• planning,
• leading and
• organising,
• Controlling
• Psychiatrists arent necessarily MDT leaders
• Clinical responsibility/duty of care is separate
  from leadership
• MDTs are an important part of collaborative
  approach to MH care that involves
  consumers/carers/GPs etc.

PLOC
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College on telepsychiatry
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College on telepsychiatry
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Disability
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College submission re psychiatrist shortages
Australasian Psychiatry Mar 2005

• Better profile of psychiatry in med training
• Better exposure of trainees to
• High prevalence disorders
• Psychological therapies
• Better integration of services
• Opposes two tier Public low prev/Private high
  prev
• Formal links between city hospitals rural
  centres
• GP supervision item numbers/better links