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Ethics & ethical issues in Psychiatry

History of medical ethics

Hippocratic Oath- Classic VersionI swear by Apollo, the Physician and Aesculepius and Hygeia and Panacea and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant:

To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art - if they desire to learn it - without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else.

I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.

I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.

I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.

Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.

What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.

If I fulfil this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.

What are medical ethics?Medical ethicsis a system of moral principles that apply values and judgments to the practice ofmedicine.

What are the objectives of learning?Discuss essential components of traditional & modern principles of medical ethicsAbide by the principles in common clinical situations/dilemmasCommunication of the rights & responsibilities of patientsChoose correct doctor-patient relationship & actions according to situational demands in clinicAdopt the standard of professionalism.

Branches of Ethics

Normative Ethics: Concerned with the established norms of conduct, that provide theoretical framework & principles to deal with a practical problem.

Descriptive Ethics: Concerned with the study & compilation of data on the moral behavior & beliefs expected by society regarding behavior of doctors, dilemmas & medical issues.

Principles of Ethics

AutonomyNon-maleficenceBeneficenceJustice/EquityThere are four basic principles of medical ethics. The principles address the issue of fairness, honesty, and respect for fellow human beings.

Autonomy:People have the right to control what happens to their bodies. This principle simply means that an informed, competent adult patient can refuse or accept treatments, drugs, and surgeries according to their wishes.

These decisions must be respected by everyone, even if those decisions arent in the best interest of the patient.

Nonmaleficence:First, do no harm In every situation, healthcare providers should avoid causing harm to their patients.

Beneficence a practitioner should act in the best interest of the patient & minimize harm.

Justice/Equity

concerns the distribution of scarce health resources, and the decision of who gets what treatment (fairness and equality).

Ethical Issues: Informed ConsentInformed Consent: refers to the idea that a person must be fully informed about and understand the potential benefits and risks of their choice of treatment.Properties of informed consentTaken in advance, Free-will (no coercion/threat), Must be given the options, Should be completely informed about the treatment/procedures/success rates/side-effects. If the patient is incapacitated, laws around the world designate different processes for obtaining informed consent, typically by having a person appointed by the patient or theirnext of kinmake decisions for them. Exception: Medical emergencies when patient is unconscious & alone. Or children under the age of 16.

Ethical Issues: Confidentialityis commonly applied to conversations between doctors and patients protected by Law. It is an important issue inprimary care ethics, where physicians care for many patients from the same family and community, and where third parties often request information from the considerable medical database typically gathered in primary health care.

Breaching of confidentiality exceptions:When patient authorizes to do so (e.g. employment)Information shared between a health care team (e.g. HIV precautions)Disclosure in favor of patient (e.g. harassment) Disclosure in favor of public interest (e.g. STI, unfit to drive)Research purpose but in form of dataLegislative requirements (Law on Public Health & Control of diseases)

Ethical Dilemmas

Accepting gifts from patientsSexual boundaries violationCharges & Fee: Colleagues, teachers, medical studentsE-consultationsRelationship with mediaRelationship with Pharmaceuticals

Patients rights & responsibilitiesTo be treated with respect & care. Informed consent of treatment, procedure, risks, side-effects, costs, alternate treatments & details of support care. (Can withdraw consent & refuse research treatment at any time)Obtain second opinionHave complete information about their issues & can request for personal files. They can obtain legal advice regarding any matter arising from treatment. Contact their loved ones or inform nursing staff to restrict someones visits/calls. Leave the hospital at any time (except when at high risk of injury).Responsible for keeping appointments, compliance to treatment, inform doctor of second opinion, conduct themselves in a manner not disruptive to the well-being or rights of other patients or staff.

Doctor-Patient RelationshipA unique relationship between doctor-patient based on trust the patient poises in his doctor & the unconditional positive regard that a doctor holds for his patient in return. The relationship can take 3 forms:Vertical Model: Doctor in complete control without role of the patient (unconscious/immobilized/incapaciatated) Teacher-Student: Doctor plays role similar to authority (teacher/ parent) who dominates, guides & controls.Horizontal Model: There is mutual participation where they behave as partners in healing & care.

Issues in doctor-patient relationshipThe relationship should be based on empathy & not friendship, love or affection. These can lead to possible complications:Doctor assuming role of savior wanting to rescue patient.Doctors inability to shut-off patients problems in personal life.A need to control everything & prevent death. Doctor becomes judgmental & passes value judgments.Doctor visualizes his own troubles in his patients & avoids discussion or gets overly involved when unnecessary. Medical student seeking/giving material/financial help.

Issues Psychological reactionsThe 3 important issues in doctor-patient relationship are:

TransferenceCounter-transferenceResistance

Psychological issuesTransferenceis the redirection of feelings and desires and especially of those unconsciously retained from childhood toward a new object. There can be positive or negative transference & needs to be addressed instead of finding it threatening. It is only inappropriate when patterns of transference lead to maladaptive thoughts, feelings or behaviors. as important in a person's childhood.

This allows the client to experience feelings that would otherwise be inaccessibleANALYSIS OF TRANSFERENCE allows the client to achieve insight into the influence of the past

Psychological issuesCounter-transference is defined as redirection of apsychotherapist's feelings toward a clientor, more generally, as a therapist's emotional entanglement with a client.

Psychological issuesResistanceis the phenomenon often encountered in clinical practice in which patients either directly or indirectly oppose changing their behavior or refuse to discuss, remember, or think about presumably clinically relevant experiences.

Analysis of ResistanceHelps the client to see that cancelling appointments, fleeing from therapy prematurely, etc., are ways of defending against anxietyThese acts interfere with the ability to accept changes which could lead to a more satisfying life

Professionalism in healthcareA healthy doctor-patient relationship is dependent upon the standard of professionalism & excellence of the doctor.KnowledgeSkills- written/verbal communicationPatient management skillsSkills in Research Attitudes: Towards patientsTowards Self-developmentTowards Society

ProfessionalismProfessional attire/mannerRespect for time & punctualityGrasp knowledge about patients under careConscientiousnessIntegrity in reporting patients findingAvailability to the patientsRelationships with colleagues, hospital staff & patients.