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1. ETHICs in Psychiatry Dr. Rency Raj Rajan

2. ’ Ethikos ’ : Rules of conduct that govern natural disposition in human beings Aim – To deal with the relations b/w people in different groups and often entails balancing rights. Ethics are more important in Psychiatry Line of demarcation b/w normal and abnormal is often hazy, appropriateness of diagnosis and treatment can be questioned. Psychiatric treatment may be utilized for controlling behavior for vested interests – as the treatment aims at modifying behavior. Close relationship b/w patients and the therapist could lead to intense transference which may be maliciously utilized. Due to impaired contact with reality of the Psychiatric patients, their decisions may not ultimately benefit them.

3. Issues power and intimacy in psychodynamic– psychotherapy relationships privacy and boundaries in treatment conducted undue influence, unconscious bias, and conflicts of interest in human studies patient confidentiality in publishing patient case reports

4. HISTORY Hippocratic Oath of the 4th century BC Percival’s Medical Ethics from the late 1800s World Medical Association’s Declaration Of Geneva,1948 International Code of Medical Ethics,1949 World Psychiatric Association – Declaration Of Hawaii,1976 – Regarded as fundamental to ethical practice of Psychiatry Revised by World Psychiatric Association in Declaration Of Madrid Code of Ethics for Psychiatrists in India,1989

5. 5 World Psychiatric Association - The Declaration Of Hawaii Adopted unanimously by the General Assembly of the World Psychiatric Association at its meeting in Hawaii in 1977 The Psychiatrist shall serve the best interest of the patient and be also concerned for common good and just allocation of health resources. Patient must be offered the best therapy available and be treated with the solicitude and respect due to the dignity of all human beings and to their autonomy over their own lives and health. A therapeutic relationship between patient and Psychiatrist is founded on mutual agreement. It requires trust, confidentiality, openness, cooperation and mutual responsibility.

6. 6 World Psychiatric Association - The Declaration Of Hawaii The Psychiatrist should inform the patient of the nature of the condition, of the proposed diagnostic and therapeutic procedures, including possible alternatives, and of the prognosis. Give the patient power to choose. 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, cannot see what is in his or her best interest or, for the same reason, is a severe threat to others. As soon as the above conditions for compulsory treatment no longer apply the patient must be released, unless he or she voluntarily consents to further treatment. The Psychiatrist must never use the possibilities of the profession for maltreatment of individuals or groups, and should be concerned never to let in appropriate personal desires, feelings or prejudices interfere with the treatment.

7. 7 World Psychiatric Association - The Declaration Of Hawaii Must maintain confidentiality unless the person himself releases Psychiatrist from professional secrecy. Informed consent must be taken and anonymity must be maintained while doing any research. Every patient or research subject is free to withdraw for any reason at any time from any voluntary treatment and from any teaching or research program in which he or she participates.

8. 8 CODE OF ETHICS FOR PSYCHIATRISTS IN INDIA Draft recommendation prepared by Prof. J.S.Neki Prof. D.N.Nandi Prof. A.K. Agarwal Dr. J.K. Trivedi Dr. V.N. Vahia Approved by Indian Psychiatric Society in 1989

9. ETHICAL SCHOOLS OF THOUGHT Model Major Figure(s) Key Features Strengths Limitations Deontology, or the Ethics of Duty Immanuel Kant There is an absolute good and right. To be ethical, persons must fulfill these absolute duties unconditionally. Some moral judgments apply in almost all circumstances to everyone (e.g., respect for persons). Conflicting obligations. Too much emphasis on obligation, not enough on consequences or relationships. Very abstract. Utilitarianism, or the Ethics of Consequences John Stewart Mill & Jeremy Bentham Weigh the consequences of actions and rules. Those that bring about the greatest good for the most people are most ethical. Useful in formulating public policy because it requires impartial assessment of all interests. Has beneficence as a goal. Difficult to translate into practice. Practices that harm individuals and groups may be ethically justifiable in this model. May demand that the minority sacrifice too much for the majority.

10. ETHICAL SCHOOLS OF THOUGHT Model Major Figure(s) Key Features Strengths Limitations Justice-based ethics John Rawls Decisions should be made with respect and fairness in relation to each individual. Demonstrates respect for the individual person. Has equality as a goal. Neglects principles beyond fairness in clinical decision making. Virtue-based ethics John Gregory & Thomas Percival Ethical decisions are rooted in qualities or character, such as honesty and faithfulness. Actions are right only if they are what a virtuous person would do in the same situation. Internal values and habits rather than external rules and imperatives. Highlights importance of qualities of the individual, of personal character. Virtue may be too unclear or pluralistic to serve as a basis for judgment. Persons may act wrongly out of virtue (e.g., withhold the truth from a dying patient to avoid emotional upset).

11. BASIC ETHICAL PRINCIPLES Principles of Biomedical Ethics, Beauchamp and Childress defined the most critical among the principles to be autonomy, beneficence, nonmaleficence , and justice.   The Belmont Report on human research ethics: respect for persons   Ethics scholarship: emphasized the principle of respect for the law

12. BIOMEDICAL ETHICS PRINCIPLES: 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. Veracity “Honesty,” involving the positive duty to tell the truth and the negative duty to avoid deception.

13. 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

14. APPROACHING ETHICAL DILEMMAS Recognizing Ethical Issues and Tensions requires sensitivity, knowledge of ethical principles and how they may come into conflict Gathering Additional Information and Expertise Data or expert guidance could come from the patient’s prior medical records or clinical practice and ethics guidelines. speaking with an experienced supervisor requesting an ethics or a legal consultation Why? Patient’s judgement may be clouded due to previous drug use and present day withdrawal/ delirium, pain, early dementia. Treat this underlying cause – Patient’s decisional capacity improves. Cultural, religious preferences, past experiences, family stress may all cloud the decisions.

15. APPROACHING ETHICAL DILEMMAS Identifying Risky Situations and Arranging for Appropriate Safeguards patient is impulsive and the caregiving team must ensure the safety of the patient Working within One’s Scope of Practice and Engaging in Continuous Learning Remaining aware of advances in one’s field Reflecting on One’s Values and Perspectives team-based care and teaching settings

16. DECISION MAKING STRATEGIES Jonsen , Siegler , and Winslade created a four-part model clinical indications: diagnose inform and educate treatment options provide treatment competently patient preferences: Autonomy quality of life: Refers to the sense of personal satisfaction individuals express and/or experience with regard to their physical, mental, and social situations. socioeconomic or external factors: Interest of society Role of family members Cost & Limitations

17. EXAMPLES OF ETHICAL PRACTICE STANDARDS IN PSYCHIATRY Therapeutic Relationship and Professional Boundaries: No Business dealings No intimate relationships No expensive gifts Confidentiality Refers to the physician’s duty not to release information learned in the course of treatment.

18. EXAMPLES OF ETHICAL PRACTICE STANDARDS IN PSYCHIATRY Informed Consent Capable and knowledgeable individuals may choose freely a course of action regarding their health. 3 components: Information Sharing Decisional Capacity ( Grisso & Applebaum ) Ability to express Ability to understand relevant and factual info Ability to reason Appreciate meaning of decision and evaluate choices Voluntarism

19. EXAMPLES OF ETHICAL PRACTICE STANDARDS IN PSYCHIATRY Psychiatric Opinions: Its unethical to render a definitive psychiatric opinion about someone with limited info or from a biased source of info Always personally evaluate before rendering an opinion

20. :References: Chapt : 60.2: ETHICS IN PSYCHOATRY, Comprehensive Textbook of Psychiatry, edited by Sadock . B. J, Sadock V. A, Pedro Ruiz, Volume III, 10 th edition, South Asian Edition, Wolters Kluwer , Lippincott Williams & Wilkins, 2017, pg: 4441-4448