Indian context

1. ETHICS IN PSYCHIATRY

2. Scenarios- How to go about???
1. 60 year old elderly female from a poor back ground,
married, with a single girl child presenting in delerium.
Attendee(patient’s daughter) could not comprehend the
nature of illness or the treatment options available even
after explaining many times. After two days of treatment
she would not consent for any treatment despite
deterioration in the patient’s condition.
2. A 28 yr female, a case of BPAD confesses about her
series of extra marital relations during a past manic
episode and is currently being threatened by one of
those males demanding for a continuous relationship
with the patient. The husband is apparently unaware of
any of these.

3.  Word ethics has been derived from the Greek term
ethikos, meaning “rules of conduct that govern
natural disposition in human beings”.
 simpler terms  means principles of right conduct
 Encyclopedia Britannica – “ethics as a systematic
study of the ultimate problems of human conduct ”.
 Ultimate problems  the concepts of right and wrong,
morality etc.,
E-T-H-I-C-S

4. Historical:
 The Charaka Samhita- 600 BC
 The Hippocratic Oath, devised about 400 BC
 the sixth century Hebrew Book of Asaph Harofe
 the tenth century Persian physician, Haly Abbas.
 The direct forerunner of modern codes, “the Code of
Institutes and Precepts”, (1803 AD) by the English
physician, Thomas Perceval.

5. Psychiatric ethics is of a recent origin
 In 1973 the American Psychiatric Association-
First code of ethics in Psychiatry
 In 1977, the World Psychiatric Association --
code of ethics which is known as the
"Declaration of Hawaii".
 Indian Psychiatric Society adopted its ethical
code in 1989.

6.  Rapid advancement of medical knowledge.
 Today ,organ transplantation, euthanasia, & artificial
prolongation of life are issues on which clear ethical
guidelines are required.
 without adequate standards, self-regulation can
degenerate into self-protection; and self-protection
ultimately damages the profession.

7. Ethics is much more relevant to psychiatry because….
 Line of demarcation between normal & abnormal is hazy
and psychiatric diagnosis & treatment can be easily
questioned.
 The treatment aims at modifying behavior, perceived as an
implied threat may be utilized for controlling behavior for
certain vested interests.
 Intense transference between the patient & therapist which
may be maliciously utilized.
 Psychiatric patients may not be fully in contact with reality,
they might consent to decisions which are not ultimately to
their benefit.
 Ex:A manic patient may give a blank cheque to the therapist

8. Concepts:
 In psychiatry, by contrast to medicine, there are a
number of important prima facie connections
between our diagnostic concepts and ethics
 justification for involuntary psychiatric treatment
 the insanity defence- ’mad but not bad’
 Medical/Moral dimension:
 psychopathic personality (a medical concept) and
delinquency (a moral concept).
 hysteria/malingering
 alcoholism/drunkenness.
• abuses of psychiatry: USSR-Delusions of reformism

9. Objectives of professional ethics
 To provide guidelines of conduct among the
professionals themselves.
 To formulate guidelines in dealing with the patients, their
relatives and third parties in areas of
1. Psychiatric diagnosis.
2. Informed consent.
3. Voluntary and involuntary treatment & hospitalization.
4. Confidentiality.
5. Respect for the patient and his human rights.
6. Third party responsibility.
7. Psychiatric research.

10.  Humanists raised objections, pointing out that
dissenters in the various political systems are labeled
as mentally sick.
 The boundaries of mental illness. ???
 WHO published the ICD-10 making the diagnoses
precise & more acceptable.
 APA -- 5th revision of its diagnostic system, DSM – IV.
 Both diagnostic systems are compatible with each
other puts to end the controversy of psychiatric
diagnosis.
1.PSYCHIATRIC DIAGNOSIS

11. However,
 One should not equate a psychiatric diagnosis with
legal insanity or it should not be used as a defense
for reduced responsibility.
 Because large number of psychiatric diagnoses do
not fulfill the legal conditions required for insanity.
 Only for clinical purposes, as it provides a
reasonable guideline regarding etiology,
management & prognosis.

12. 2.INFORMED CONSENT
 Medical paternalism: seeking consultation = consent for
treatment
 NOW, a greater emphasis  the patient's human rights
 the nature of illness
 treatments available
 take part in the decision-making process.
 Consumer protection movement compels the medical
profession to provide a detailed information for their
own safeguard.

13. Constituents of an Informed Consent:
A. Information to be provided by the treating
physician.
B. Competence of the patient to comprehend the
information provided.
C. Freedom to choose.
A specific statement that the consent could be withdrawn
whenever the patient wishes so.
Liberty to ask any further clarification or information.

14. several practical problems.
 Informing a patient of schizophrenia / BPAD
 Information of treatment options, like drugs &
ECTs, may not be fully understood by the patient &
make decisions on the basis of certain prevailing
biases and prejudices against each of these
treatment methods.

15. Competence of Patient:
 Competence in this context refers to the patient's
ability to understand the nature & severity of his
presenting problems, and need of suggested
therapeutic help and its limitations.
How to asses competence ?
 By asking a few questions on the information made
available to him.
 Whether patient is able to objectively understand that he
is ill & requires treatment?
 Can he understand the nature of each treatment option
& their consequences?

16. However,
 Pt can be treated in an emergency even without the
consent.
 Stuporose or acutely excited patient

 Minors (below the age of 18 years)  Relatives consent
 Mental Health Act (1987) allows specified relatives to
give consent for admission in mental hospitals & for
treatment of pts on an outdoor basis.
 One should take such consent in writing & as soon as the
patient is competent, his consent should be obtained.

17. 3.INVOLUNTARY vs VOLUNTARY
TREATMENT
 As psychiatric patients do not consider themselves to
be ill, they have to be hospitalized or treated against
their will.
 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.
 Demand discharge after a few days of
hospitalization & they need to be persuaded to
continue treatment.
 To be evaluated on the principle of beneficence.

18.  Temporary hospitalization to regain sanity is a much
preferable alternative to staying chronically sick

 Evidence for mentally ill in court of law  Order for
admission can be secured.
 Problem : 1% of the Indian population (12 million) should
be screened by the judiciary
 A large number of such patients are treated as outpatients
& the only available consent is that of the concerned
relatives.
Peele, Chodoff & Taub state that "it is a perversion
and travesty to deprive these needy and suffering
people of treatment in order to preserve a liberty
which is in actuality so destructive as to constitute
another form of imprisonment.”

19. The Hawaii declaration of the WPA
“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 can not
see what is in his best interest or, for the same reason, is
a severe threat to others. In these cases, compulsory
treatment may or should be given, provided that it is
done in the patient's best interest and over a reasonable
period of time, a retroactive informed consent can be
presumed and, whenever possible, consent has been
obtained from someone close to the patient.”

20. As soon as the above conditions for compulsory
treatment or detention no longer apply the
patient must be released, unless he or she
voluntary consents to further treatment.
Whenever there is compulsory treatment, there
must be an independent and neutral body of
appeal for regular inquiry into these cases.
Every patient must be informed of its existence
and be permitted to appeal to it, personally or
through a representative without interference by
hospital staff or by anyone else.
Continued…

21. 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 & 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.
 The employers, insurance companies & other
interested parties should be provided information after
obtaining consent from the patient.

22. Protective Privilege Vs Public Peril:
 EX: if a patient is planning to kill Mr. X, should the
psychiatrist inform Mr. X or the police, so that
protective measures could be taken?
 Similarly, a bus or train driver suffering psychosis poses
threat to the public safety. Again, should the psychiatrist
inform or remain silent?
 Consider the nature & 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 & a colleague
to decide on an appropriate action.

23.  When courts summon the psychiatrist to testify.
One should obtain the consent from the patient, and if
that is not forthcoming, then one has to depose after
lodging protest with the judge.
 The confidentiality clause will require more careful
monitoring as the new Mental Health Act has come
into operation.
 The records of the patient may be inspected by the
"inspectors" at any time. Some of these "inspectors"
may not be professionally trained. Therefore, one
must only record all the observations which seem to
be relevant to diagnosis and treatment.

24. 5.RESPECT FOR THE PATIENT
AND HIS HUMAN RIGHTS
 Each patient has to 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. Ex:
 Restrains
 Keeping in Solitary cell
 ECT as punishment
 Pain or torture as aversive methods

25. 6.THIRD PARTY RESPONSIBILITY
 Many external agencies influence both the content as well
as the form of treatment.
 In Western countries, insurance companies often provide
funds for the treatment, likely to influence policy of
hospitalization and its duration and sometimes provide
treatment option guidelines.
 In India Govt. funded availability of drugs & trained
personnel might affect treatment.
 Pharmaceutical companies undue importance on newer
anti depressant  much costlier than TCAs

26. 7.PSYCHIATRIC RESEARCH
Helsinki Declaration guidelines regarding the use of human
subjects in research.
 1.Any research which is not likely to directly benefit the patient
should not be undertaken.
 2.No human subject should undergo research without adequate
safeguards. The researcher has to be a protector of the interest
of the patient.
 3. Any patient, who is not able to give informed consent, should
not normally be included for purposes or research, unless such a
permission has been sought from the concerned family member
or relative.
 4. While publishing research material, one should take care that
the research publication does not violate the confidentiality.
 Declaration of Madrid 1996-WPA

27.  In India there are few legislations for the
professional service & the public gives carte
blanche (unlimited authority) to the therapist.
 A mechanism of inner controls has to be evolved to
maintain a high standard of practice & to develop
public confidence.
Some more points:
 Fees should be appropriate to the local conditions &
should not be increased without appropriate reason.
 Gifts of any kind during the therapy are not permitted.
 Any kind of sexual advance towards the patient is
strictly prohibited

28. Ethics --- the relationship among psychiatrists
themselves.
 Entertain a patient only after a due referral from
the treating psychiatrist.
 Psychiatrists often do not react to the
malpractices of their colleagues misguided
notion disservice to the profession.
 On the contrary, such black sheep in reality bring
the profession to disrepute and their exposure in
public would cleanse the profession.

29. Training the young:
 Unfortunately, ethical issues are not given any
attention in the undergraduate & postgraduate
medical education.
 Ethical issues should be discussed formally, so that
young doctors are sensitized to the kind of problems
they are likely to face.
 Ethical practices are largely learned by the process of
imitation and, as such, it is mandatory that teachers
should themselves put up exemplary models for the
young medicos.

30. IPS code of ethics for psychiatrists(1989)
1. Responsibility
2. Competence
3. Benevolence
4. Moral standards
5. Patient welfare
6. Confidentiality
Principles in West:
1. Autonomy
2. Beneficence
3. Non-maleficence
4. Justice

31. Carry home message….
….summary

32. Ethical codes have to be implemented with
sincerity.
Ethical committees may be formed at central
and zonal levels.
Should consider complaints either from public or
from fellow professionals and then, carefully
investigate them.

33. One should be clear with…..
1. Psychiatric diagnosis.
2. Informed consent.
3. Voluntary and involuntary treatment & hospitalizatio
4. Confidentiality.
5. Respect for the patient and his human rights.
6. Third party responsibility.
7. Psychiatric research.

34. References
 1. Vyas JN, Niraj Ahuja. Textbook of postgraduate psychiatry,
vol-2 : Ethics in psychiatry. 2nd edition. New Delhi : Jaypee
brothers medical publishers;2008.
 2. Michael G. Gelder, Juan J. López-Ibor, Nancy Andreasen
.New Oxford Textbook of Psychiatry,Vol-1: Psychiatric ethics:
codes, concepts, and clinical practice skills .London: Oxford
University Press;2000.
 3.Kishor.M, Vinay.H.R,Kiran
Kumar.K,Lakshmi.V.Pandit.Glimpses of Psychiatry for doctors
and medical students :Ethics & Medicine. 1st edition. Mysore:
Tata Printing Press and Publications;2013.