Lesson 11 - Ethical Issues In Mental Illnesses PDF

PSY 056T: ABNORMAL PSYCHOLOGY S a ra h M a la ki  LESSON 12: ETHICAL ISSUES IN MENTAL ILLNESSES Introduction Ethics is as old as the art of healing itself. Ethics has been derived from the Greek term ethikos, meaning “rules of conduct that govern natural disposition in human being...

PSY 056T: ABNORMAL PSYCHOLOGY S a ra h M a la ki  LESSON 12: ETHICAL ISSUES IN MENTAL ILLNESSES Introduction Ethics is as old as the art of healing itself. Ethics has been derived from the Greek term ethikos, meaning “rules of conduct that govern natural disposition in human beings”. In simpler terms ETHICS means principles of right conduct. Encyclopedia Britannica – “ethics as a systematic study of the ultimate problems of human conduct ”. Ultimate problems are concerned with the concepts of right and wrong, morality and similar other issues. Today, organ transplantation, euthanasia, and artificial prolongation of life are issues on which clear ethical guidelines are required. Goals of Ethics Deliver competent, compassionate, and respectful care. Deal honestly with patients and colleagues. Act within the boundaries of law. Respect the rights and autonomy of patients. Be responsible to the community and society. Sources of Ethics Law: ethics and law are closely related but not synonymous. Religion: many ethical decisions have their roots in religion. Professional associations and their guidelines. Objectives of Professional Ethics To provide guidelines of conduct among the professionals themselves. Referral from one therapist to another, giving comments on the opinion of another professional, and charging consultation fee from co professionals and their families. To formulate guidelines in dealing with the patients, their relatives and third parties.  Class Discussion Discuss ethical issues in mental health care Objectives of Professional Ethics… The various areas included are the following: 1. Diagnosis. 2. Informed consent. 3. Voluntary and involuntary treatment and hospitalization 4. Confidentiality. 5. Respect for the patient and his human rights. 6. Third party responsibility. 7. Psychiatric research. 1. Diagnosis Certain schools of thought have doubted the existence of the discipline of Psychiatry. Thomas Szasz believes that it does not make sense to classify psychological problems as diseases or illnesses, and that speaking of "mental illness" involves a logical or conceptual error. Humanists raised objections, pointing out that dissenters in the various political systems are labeled as mentally sick. All these raise the basic question regarding the boundaries of mental illness. 1. Diagnosis… WHO published the ICD-10 making the diagnoses precise and more acceptable. APA - 5th revision of its diagnostic system published the DSM–V. Both diagnostic systems are compatible with each other puts to end the controversy of psychiatric diagnosis. However, one should not equate a psychiatric diagnosis with legal insanity, or it should not be used as a defense for reduced responsibility. 2. Informed Consent Till recently, after seeking consultation, psychiatrists generally decided treatment which they felt to be best in the interest of patient. Human rights of the patient should be reasonably protected, and the patient should be informed about the nature of illness and treatments available, so that he/she can partake in the decision- making process. Consumer protection movement compels the medical profession to provide a detailed information for their own safeguard. It has the following constituents: A. Information to be provided by the treating physician. B. Competence of the patient to comprehend the information provided. C. Freedom to choose. 2. Informed Consent… A. Information to be provided by the treating physician: Nature of the disorder. Prognosis of the disorder without treatment and with each of the alternative treatment methods. Treatment options available. Reasons for specific treatment being offered and drawbacks of the same. A specific statement that the consent could be withdrawn whenever the patient wishes so. Information of treatment options, like drugs, may not be fully understood by the patient to make decisions based on certain prevailing biases and prejudices against each of these treatment methods. 2. Informed Consent… B. Competence of the patient to comprehend the information provided. Competence in this context refers to the patient's ability to understand the nature and severity of his presenting problems, and his/her need of suggested therapeutic help and its limitations. Whether a mentally ill person is likely to possess such as ability has been debated for a long time by several researchers. Psychiatric patients may not have insight and hence, are not able to give consent for their treatment. 2. Informed Consent… B. Competence of the patient to comprehend the information provided… Even if they give consent, it may be for wrong reasons, e.g., a manic patient may challenge the doctor to give all the drugs that he has. Such consent has no meaning. Before giving consent, patient should fully comprehend the information provided and should be able to decide on the course of treatment in an understanding manner Assessing competence – ▪ Whether he/she is able to objectively understand that he/she is ill and requires treatment? ▪ Can he/she understand the nature of each treatment option & their consequences? 2. Informed Consent… B. Competence of the patient to comprehend the information provided…. Patient can be treated in an emergency even without the consent. The treatment of a stuporose or acutely excited patient should not be deferred on account of non-availability of the consent. Minors (below the age of 18 years) are not considered to be legally competent to give consent. Specified relatives can give consent for admission in mental hospitals and for treatment of patients on an outdoor basis. One should take such consent in writing and as soon as the patient is competent, his/her consent should be obtained. 2. Informed Consent… C. Freedom to choose: Informed consent a priori i.e., the person has freedom to choose from certain available options. In a country like ours with meagre psychiatric facilities and poor economic conditions, real options are however not truly available. The patients either do not have easy access to or if somehow, they reach a facility, they have to accept whatsoever is available. It is the duty of every mental health professional to educate and inform the affected person about the treatment modalities available to him and his right to choose them. It is better to have a standard written information sheet, with an addition of a clause that the patient is at liberty to ask any further clarification or information. 3. Involuntary Vs. Voluntary Treatment As psychiatric patients do not consider themselves to be ill, they must be hospitalized or treated against their will. Patients are usually admitted as 'voluntary' or 'informal' patients, by obtaining their signatures on consent form without obtaining their real consent. It is undeniable that most of the so-called voluntary patients are coerced to some extent for accepting hospitalization. Coercion may be from employer, family, or medical personnel. Patients demand discharge after a few days of hospitalization, and they need to be persuaded to continue treatment. 3. Involuntary Vs. Voluntary Treatment… Temporary hospitalization to regain sanity is a much preferable alternative to staying chronically sick. Any psychiatric patient can be taken to a court of law where the evidence of his being mentally sick can be produced, and order for admission can be obtained. Sometimes, relatives seek hospitalization of the individual on account of malicious intentions, and the treating physician should be wary of this. 4. Confidentiality Anything learned during the professional relationship should not be revealed to others without the consent of the patient. Records of the patient should be strictly safeguarded, so that no unauthorized person can have access. Unauthorized person include any person other than the treating team and the family member on whose consent patient has been admitted. However, after having achieved recovery, if the patient advises the therapeutic team that even the admitting family member/relative should not have access to the patient's record, his wishes should be respected. The employers, insurance companies and other interested parties should be provided information after obtaining consent from the patient. 4. Confidentiality… Confidentiality – Problems Associated When the information provided by the patient can be dangerous to others or himself, the dilemma of protective privilege vs public peril ARISES. E.g.: if a patient informs his therapist that he is planning to kill Mr. X, should the psychiatrist inform Mr. X or the police, so that protective measures could be taken? Similarly, if a bus or train driver suffering psychosis poses threat to the public safety, should the psychiatrist inform the police or remain silent? 4. Confidentiality… Confidentiality – Solutions Consider the nature and the severity of the risk involved, and then decide on an appropriate measure which may cause least breach of confidentiality. Discuss with the close family members and a colleague to decide on an appropriate action. Confidentiality – Summoning the Psychiatrist to Testify One should obtain the consent from the patient, and if that is not forthcoming, then one must depose after lodging protest with the judge. 5. Respect for the Patient and His Human Rights Each patient must be respected as an individual and the aim of the treatment should be towards an early restoration of the functioning of the individual. Nothing should be done which could be perceived as violation of human rights of the individual. Unnecessary restraints, keeping a person in solitary cell, and afflicting physical punishment would be considered as highly unethical practices. 5. Respective for the Patient and His Human Rights… Each patient should have facilities for basic human rights like privacy, uncensored opportunities to communicate with others, and basic requirement of food, hygiene etc. Every treatment method should be in conformity with the basic human rights and aversive treatment methods which may inflict pain or torture must be avoided. 6. Third Party Responsibility In the modern era, medical treatment has no longer remained within the confines of doctor-patient relationship. Many external agencies influence both the content as well as the form of treatment, i.e., insurance companies; pharmaceutical companies, the government, etc. 7. Psychiatric Research Research is essential for the advancement of knowledge. However, when research is involved with human beings, certain safeguards are a must. For example: informed consent; do no harm; confidentiality; absence of coercion; beneficent towards experiment participants; etc. References 1. https://www.slideshare.net/sramragh/ethical-issues-in-psychiatry. 2. Ethical Issues in Psychiatry. Presenter: Dr. Sriram. R., Final year MD Postgraduate in Psychiatry Chairperson – Dr. Cattamichi Vinila, Senior Resident in Psychiatry. 3. Reference Textbook of Postgraduate Psychiatry, Second Edition. Editors – JN Vyas and Niraj Ahuja. 4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Washington, DC: 2013. [Google Scholar] Thank you www.daystar.ac.ke