Psychiatric Ethics Research Articles

Bloch Sidney and Green Stephen A., (eds), Psychiatric Ethics. 4th ed., New York: Oxford, 2009. 538 pp. $57.50

Bloch Sidney and Green Stephen A., (eds), Psychiatric Ethics. 4th ed., New York: Oxford, 2009. 538 pp. $57.50

P02-45 - Factitious disorder: a relational ethics perspective in consultation liaison-psychiatry

Factitious disorder confront the consultation liaison psychiatrist with (self)destructive behaviour and some lies from the patient trying to involve the physician in this behaviour. There is always a difficult balance between patient autonomy, open communication and the promotion of patient health, doctor integrity and maintenance of the constructive doctor/team-patient relationship.Consultation liaison psychiatrists are more and more requested to accomplish a role of “clinical ethicists” and they are really well prepared to that propose because they usually cope by means of the biopsychosocial model with clinical, legal, social, economic, religious and institutional problems.Common ethical principles (beneficence, autonomy, justice, vulnerability, dignity, responsibility) are referential tools on clinical decision making. However, in psychiatric ethics we feel the need to construct a more clinical model: relational ethics. Its main references come from a dialogical, hermeneutical and pragmatic ethics based on an intersubjectivity perspective of human development which can deal with the practical rationality in clinical psychiatry faced with complex but concrete situations. It recognizes interpersonal and intrapsychic conditions of authenticity, a process of mutual reciprocity in order to allow psychic growth.We describe the way this theoretical and deliberative proposition can be easily applied to a particular case of a young man with factitious disorder admitted to the dermatological department of a Universitary Hospital.

“Through a glass, darkly”: the clinical and ethical implications of Munchausen syndrome

Patients who present repeatedly for care with medically unexplained symptoms raise challenges for the health system. One proposed strategy for dealing with such patients is the introduction of electronic medical records (EMRs) to identify these patients and thus limit the demands on resources their management involves. This measure may ultimately be appropriate but fails to consider equally critical core issues in psychiatric ethics. Identifying patients as "somatisers" invites a problematic relaxation of clinical vigilance, increasing the likelihood that an actual life-threatening medical problem will not be identified. Management of such patients requires regular, structured therapeutic contact with a skilled mental health clinician, that is independent of the patient's distress level. Psychiatric problems and medical problems are frequently seen as two distinct, unrelated categories. This is a false dichotomy, as mental health and physical health are interdependent. Given patient privacy considerations, EMRs would be unlikely to reveal the kind of sensitive mental health information needed for the identification and management of somatising patients in busy health systems. Cost-effective interventions for somatising patients' problematic behaviour, such as structured clinical intervention, antidepressant medication and cognitive behaviour therapy, are available at a fraction of the cost of EMR systems. Citing cost savings as a justification for violating the privacy of mental health patients compounds the manifest injustice these patients already face in the health system.

Promoting the Teaching of Psychiatric Ethics

Promoting the Teaching of Psychiatric Ethics

Notes on a few issues in the philosophy of psychiatry.

The first part called the Preamble tackles: (a) the issues of silence and speech, and life and disease; (b) whether we need to know some or all of the truth, and how are exact science and philosophical reason related; (c) the phenomenon of Why, How, and What; (d) how are mind and brain related; (e) what is robust eclecticism, empirical/scientific enquiry, replicability/refutability, and the role of diagnosis and medical model in psychiatry; (f) bioethics and the four principles of beneficence, non-malfeasance, autonomy, and justice; (g) the four concepts of disease, illness, sickness, and disorder; how confusion is confounded by these concepts but clarity is imperative if we want to make sense out of them; and how psychiatry is an interim medical discipline.The second part called The Issues deals with: (a) the concepts of nature and nurture; the biological and the psychosocial; and psychiatric disease and brain pathophysiology; (b) biology, Freud and the reinvention of psychiatry; (c) critics of psychiatry, mind-body problem and paradigm shifts in psychiatry; (d) the biological, the psychoanalytic, the psychosocial and the cognitive; (e) the issues of clarity, reductionism, and integration; (f) what are the fool-proof criteria, which are false leads, and what is the need for questioning assumptions in psychiatry.The third part is called Psychiatric Disorder, Psychiatric Ethics, and Psychiatry Connected Disciplines. It includes topics like (a) psychiatric disorder, mental health, and mental phenomena; (b) issues in psychiatric ethics; (c) social psychiatry, liaison psychiatry, psychosomatic medicine, forensic psychiatry, and neuropsychiatry.The fourth part is called Antipsychiatry, Blunting Creativity, etc. It includes topics like (a) antipsychiatry revisited; (b) basic arguments of antipsychiatry, Szasz, etc.; (c) psychiatric classification and value judgment; (d) conformity, labeling, and blunting creativity.The fifth part is called The Role of Philosophy, Religion, and Spirituality in Psychiatry. It includes topics like (a) relevance of philosophy to psychiatry; (b) psychiatry, religion, spirituality, and culture; (c) ancient Indian concepts and contemporary psychiatry; (d) Indian holism and Western reductionism; (e) science, humanism, and the nomothetic-idiographic orientation.The last part, called Final Goal, talks of the need for a grand unified theory.The whole discussion is put in the form of refutable points.

Psychiatric Ethics Consultation in the Light of DSM-V

Psychiatric Ethics Consultation in the Light of DSM-V

Neuroethics and psychiatry

The field of neuroethics is experiencing a great deal of activity at present, as researchers come to realize the potentially dramatic implications of new work in neuroscience and its applications. This review aims to describe some of the work of direct relevance to psychiatric ethics. The review focuses on ethical issues surrounding the use of propranolol to treat or prevent posttraumatic stress disorder, issues concerning the capacity of the mentally ill to give informed consent to medical treatment and the potential social implications of cognitive enhancers and other interventions into the mind. It is argued that psychiatric ethics would benefit from a consideration of cognate questions arising in neuroethics; in particular, neuroethics has the potential to remind psychiatrists that individual treatment decisions can have broad social implications.

A review of ethics in psychiatric research

To summarize important recent contributions to the literature on the subject of ethics in psychiatric research. Current literature reflects an expansion in the range of psychiatric research on ethics topics. Articles continue to appear on core ethics subjects such as informed consent, but many recent contributions focus on diverse issues such as third-party privacy, the ethics of Internet-based research, revisiting the wisdom of imposing medical ethics requirements on observational research, and psychiatric research ethics as applied to special populations such as children or older persons. Psychiatric research is critical for the elucidation, prevention, and treatment of mental diseases. Increased attention and novel approaches taken to obtain informed consent, correcting therapeutic misconception, and guarding privacy will advance the research enterprise and continue to ensure that the subjective experiences of participants in psychiatric research remain positive.

Introduction: The Diversification of Psychiatric Ethics

Introduction: The Diversification of Psychiatric Ethics

Many Faces of the Dual-Role Dilemma in Psychiatric Ethics

To identify the various potential manifestations of the dual-role dilemma in the psychiatric ethics literature. The terms 'dual role', 'dual agency', 'overlapping roles', and 'double agency' were searched on the electronic databases PubMed, Medline, Embase and PsychInfo. Classic papers in the field of psychiatric ethics and their references were manually searched. Papers were selected for relevance to the topic of the dual-role dilemma in relation to psychiatry. The dual-role dilemma is most explicitly addressed in the literature on forensic psychiatry and military psychiatry. Review of the ethics literature in other fields of psychiatry indicates many instances of the dilemma of psychiatrists facing conflicting obligations akin to the dual-role problem identified in the literature on forensic psychiatry. Many of these dilemmas are characterized by the presence of a powerful third party to whom the psychiatrist has some perceived obligations. In psychiatric ethics, the dual-role dilemma refers to the tension between psychiatrists' obligations of beneficence towards their patients, and conflicting obligations to the community, third parties, other health-care workers, or the pursuit of knowledge in the field. These conflicting obligations transcend a conflict of interest in that the expectations of the psychiatrist, other than the patient's best interests, are so compelling. This tension illustrates how the discourse in psychiatric ethics is embedded in the social and cultural context of the situations encountered. It appears that as society changes in its approach to the value of liberal autonomy and the 'collective good', psychiatrists may also need to change.

Psychiatric Ethics — A Complicated Challenge

<p>How did we get here? Socrates posed one of the most fundamental questions of human existence in pondering, “How should I live the good life?” The issue is brought into focus when contemplating what kind of professional life we seek as psychiatrists. In the dialogue <cite>Euthyphro</cite>, Socrates discusses the nature of what is good. <cite>Euthyphro</cite> contends that the pious or good is that which is endorsed by the gods. Socrates is at odds with such a “divine command” approach to morality, using an ingenious argument of logic, which positions the good prior to the existence of the gods — if the good is good because the gods tells us it is good, then good is independent of the gods, and we don’t need them. Such doubt casts a pall over the questions of how is man to live and, by extension, what is it to be a good physician.</p> <H4>ABOUT THE GUEST EDITORS</H4> <p>Michael Robertson, MB, BS, FRANZCP, is the Director of Psychiatry at the Royal Prince Alfred Hospital in Sydney, Australia. He is a clinical lecturer in the Discipline of Psychological Medicine at the University of Sydney and is a visiting lecturer at the Centre for Values, Ethics and the Law in Medicine at the University of Sydney. Dr. Robertson has published in the field of psychiatric ethics, philosophy, and psychiatry and psychiatry in popular culture. He has published research in the treatment of traumatic stress syndromes and is co-author of the book, <cite>Interpersonal Psychotherapy — A Clinician’s Guide</cite>.</p> <p>Dr. Robertson is on the Editorial Board of <cite>Australasian Psychiatry</cite>, and is a member of the international board of advisors for the International Federation of Psychotherapy.</p> <p>Garry Walter, MB, BS, FRANZCP, is Professor of Child and Adolescent Psychiatry at the University of Sydney and Area Clinical Director of Child and Adolescent Mental Health Services, Northern Sydney Central Coast Health in New South Wales, Australia. He is Editor of <cite>Australasian Psychiatry</cite> and serves on several other editorial boards.</p> <p>Prof. Walter has published more than 200 articles and book chapters and has won a number of prestigious research awards. His major research interests are in mood disorders in young people, physical treatments in psychiatry, psychiatric stigma, ethics, and publishing processes.</p>

Ethics and Design Flaws of Humanity

<p>This last month before the New Year, the topic of <cite>Psychiatric Annals</cite>, guest edited by Michael Robertson, MB, BS, FRANZCP, and Garry Walter, MB BS PhD FRANZCP, our colleagues from the University of Sydney in Australia, is Psychiatric Ethics — A Complicated Challenge. A beautiful introduction to the series appears in their Guest Editorial.</p>

Overview of Psychiatric Ethics VI: Newer Approaches to the Field

The aim of this paper is to consider two recent approaches to moral philosophy - postmodernism and discourse ethics - and evaluate their potential contribution to psychiatric ethics. Postmodern ethics arose from the perceived moral failures of the grand theories of ethics, as evident in the horrors of the twentieth century. As a result, such approaches to ethics emphasize the individual's moral situation in a particular context, such as the doctor-patient relationship. Postmodern approaches have some relevance to current and future psychiatric practice. Discourse ethics sees ethical norms generated by a process of a discourse procedure, in which all members of a discourse are able to express their views. Discourse ethics allows the generation of moral 'norms', which are universal in as far as all those affected by them can accept their consequences. Applied to professional ethics, psychiatrists are members of a large group engaged in a discourse with diverse parts of society, yet exist within small moral communities in which micro-discourses are compatible with different individual ethical positions.

Overview of Psychiatric Ethics I: Professional Ethics and Psychiatry

Objectives:The aim of this paper is to describe the current status of psychiatric ethics as a form of professional ethics and apply this approach to a common clinical situation. Conclusion: Psychiatry is a profession and, like all professions, comprises a set of specific skills and knowledge that are applied for the ‘common good’ of society. Such a proposition places the psychiatrist in a position of tension between contractarian and Hippocratic ideals of ethical conduct, in that there is an assumption of moral equivalence between the law and ethics. The supposition that legally defensible behaviours are the same as ethically defensible behaviours is integral to the definition of professional ethics. This frequently places psychiatrists at odds with the ‘do no harm’ principle.(Reprinted with permission from Australasian Psychiatry 2007; 15(3):201–206; full text of article available online at www.informaworld.com/10.1080/10398560701308274)

Overview of Psychiatric Ethics V: Utilitarianism and the Ethics of Duty

The aim of this paper is to describe the ethical theories of utilitarianism and the ethics of duty (Kant's ethics) and to evaluate their value as theoretical bases of psychiatric ethics. Utilitarianism is a well-established moral philosophy and has significant instrumental value in dealing with common ethical problems faced by psychiatrists. Despite its capacity to generate solutions to ethical problems, utilitarianism requires a process of what Rawls described as 'reflective equilibrium' to avoid morally repugnant choices, based on utility. The criticisms of utilitarianism, such as the problems of quantifying utility and the responsibility for consequences, are very relevant for psychiatry. Singer's model of utilitarian thinking is particularly problematic for our profession. Kant's ethics provides the pretext for duty bound codes of ethics for psychiatrists, but suffers from problems of flawed claims to the universalizability prescribed by Kant's 'categorical imperative'. Kant's valorization of reason as the core of the autonomy of persons is a valuable insight in understanding psychiatrists' ethical obligations to their patients.

Does it make sense to speak of neuroethics?

The field of bioethics has been split into subspecialties over the past few decades. In some cases, it was divided in terms of social domains, such as clinical ethics, research ethics and public‐health ethics. In other cases, it was separated in terms of methodological approaches, including principle‐based bioethics, virtue ethics and narrative ethics. Yet more divisions were made in terms of medical specialties, such as paediatric ethics, surgical ethics and psychiatric ethics. A more recent trend is to identify subfields in terms of new lines of scientific or technological investigation, such as genethics, nanoethics and neuroethics. > …the basic ethical concerns about threats to identity are not different in the context of neuroscience or genetics… Given the rich history of bioethics, we would not suggest that there is only one correct way forward or that speaking of new subfields is completely wrong. Indeed, Adina Roskies recently made a strong case specifically for neuroethics: “although neuroethics may appear to consist of a collection of diverse and unrelated concerns, the various issues emerging from the confluence of neuroscience and ethics are so densely interconnected that it is defensible, and may even be profitable, to consider them as a unified whole” (Roskies, 2006). Because no one has the infinite energy necessary to consider all aspects of bioethics, limiting oneself to a quasi‐discrete scientific arena can help to focus attention. Moreover, because studying ethics requires a firm grip on the science—and it will take ethicists time to catch up with the latest research in fields as complex as genetics, nanoscience and neuroscience—we can appreciate the case for speaking of bioethical subfields. Nevertheless, although we grant that speaking in such terms can be reasonable, we also want to call attention to some of the dangers associated with carving up bioethics into ever more specialized subfields that …

The Psychiatric Significance of the Personal Self

Drawing upon literature reviews in psychiatry, the social sciences, and philosophy, this article defines the concept of the “personal self” and briefly describes its importance to the following areas of psychiatry: (1) mental illness, (2) psychiatric ethics, (3) diagnosis, (4) the clinician, (5) clinical research, (6) psychiatric pluralism, and (7) the goals of psychiatric treatment. The personal self is a Western common-sense concept which is characterized by five aspects: agency, identity, trajectory, history, and perspective. Because of the intimate and often ambiguous relationship between the personal self and mental illness, the personal self has considerable psychiatric significance in moral, professional, research, and existential realms.

Overview of Psychiatric Ethics II: Virtue Ethics and the Ethics of Care

The aim of this paper is to consider the components of two moral theories--the ethics of virtue and the ethics of care--and their relationship to psychiatry. Although both theories reflect fundamentally desirable human qualities, neither provides a comprehensive account of psychiatric ethics. We are therefore drawn to a similar conclusion as those of Hare (1993) and Bloch and Green (2006), in that these theories offer a complementary approach to other ethical theories in psychiatry.

Overview of Psychiatric Ethics I: Professional Ethics and Psychiatry

The aim of this paper is to describe the current status of psychiatric ethics as a form of professional ethics and apply this approach to a common clinical situation. Psychiatry is a profession and, like all professions, comprises a set of specific skills and knowledge that are applied for the 'common good' of society. Such a proposition places the psychiatrist in a position of tension between contractarian and Hippocratic ideals of ethical conduct, in that there is an assumption of moral equivalence between the law and ethics. The supposition that legally defensible behaviours are the same as ethically defensible behaviours is integral to the definition of professional ethics. This frequently places psychiatrists at odds with the 'do no harm' principle.

Ethics of art therapy and use of patient-produced art

The great revolution of bioethics has been the incorporation of the principle of autonomy to the ethical model and parts from the assumption of recognizing human beings as autonomous beings. A paternalistic, authoritarian ethics has been substituted by ethics of autonomy.Some specific requirements are needed so that an informed consent can be achieved: competence and ability of the patient to understand and willingness to decide.The WPA has made different Declarations specifying Psychiatric Ethics. Art Therapy has developed a specific set of ethical standards. The role of art making in therapy poses unique ethical dilemmas and concerns for therapists such as:Confidentiability: Art expressions must be recognized as confidential communications. Permission to display, exhibit, publish or share art expressions must be obtained from either the patient or in the case of a child, the parent or guard.Ownership: The patient owns the art created in art therapy.The artwork of the patient, especially the plastic artwork is used sometimes with artistic and commercial aims, which raises ethical and even legal problems.There is a large background institutional or private exhibitions of the so-called psychopathological art.The work created by the patient belongs to him and only the patient/author of the artwork can, in principle, decides over its use.If the patient agrees to display of his art expression in any form the therapist must be careful to consider if this is in his best interest based on the context.