Ethics in psychiatry

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Ethics in psychiatry

• Himalee Abeya
• Consultant Psychiatrist

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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

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

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Historical concerns

• Misuse of asylum custodial warehouse

William Hogarth The Rake's Progress the Rake
in Bedlam 1735
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Historical concerns
Gruesome effects of physical treatments
Insulin coma therapy
Prefrontal lobotomy
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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
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Jill, Tim and the baby
Dr. Jones ?
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Withdrawn into self since childbirth Family found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
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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 Jills right to self
  determination Vs promoting her welfare

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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)

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Kantianism

• Deontological theory Immanuel Kant
  Grounded in duty
• Right moral action is justified by a persons
  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

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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

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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

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Virtue theory

• Identified with Aristotle - Avoids rules and
  principles altogether a persons 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

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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

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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
• Baiers 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
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Confidentiality

• Confidentiality is the obligation not to reveal a
  patients 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).

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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 wifes 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

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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

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Boundary transgression
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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?

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Involuntary treatment

• Involuntary psychiatric treatment most commonly
  comprises psychiatric hospitalization or
  court-ordered outpatient treatment. Mandated
  treatment generally uses the states enforcement
  apparatus to place individuals into medical care
• Under MHA 2007, NSW

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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
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Thank you