Transcript (PPS, 1.15MB) - Psychiatrist in Sydney

Ethics in psychiatry
Himalee 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?
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
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……
Gruesome effects of
physical treatments
Prefrontal lobotomy
Insulin coma therapy
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
Jill
Dr. Brown GP
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Withdrawn into self since childbirth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 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
Surveying competing ethical
theories:
 All theories  A formulation of presumed moral judgements
 Guidelines as to how these might apply to given circumstances
 Reviewed theories –
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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 particularsprovide a starting point for moral judgement
Quartet of Principles:
 1. Non-maleficence
4. justice
2. beneficence
3. Autonomy
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
Sexual
/romantic
social
Professional
relationship
business
caretaking
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
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1 Psychiatrists shall respect the essential humanity and dignity of every patient.
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2 Psychiatrists shall not exploit patients.
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3 Psychiatrists shall provide the best attainable psychiatric care for their patients.
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4 Psychiatrists shall strive to maintain confidentiality of patients and their families.
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5 Psychiatrists shall seek valid consent from their patients before undertaking any procedure or
treatment.
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6 Psychiatrists shall not misuse their professional knowledge and skills.
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7 Psychiatrists involved in clinical research shall comply with ethical principles embodied in national and
international guidelines.
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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.
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9 Psychiatrists have a duty to attend to the health and well-being of their colleagues, including trainees
and students.
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10 Psychiatrists shall uphold the integrity of the medical profession.
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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