ETHICS IN PSYCHIATRY Dr. Tuti Wahmurti AS, dr , SpKJ

ETHICS IN PSYCHIATRYDr. TutiWahmurti AS, dr, SpKJ REFERENCES Lubit RH, Ladds B, Eth S. Ethics in Psychiatry. In : Sadock B J & Sadock V editors, Kaplan & Sadocks Comprehe nsive Text book of Psychiatry 9thed, Lippincot Williams & Wilkins. Philadelphia, 2005 : 3988 – 97 2. Sadock BJ, Sadock VA. Synopsis of Psychiatry Behavioral Sciences / Clinical Psychiatry 10th ed. Lippincot Williams & Wilkins, Philadelphia, 2007: 1365 – 1373.

INTRODUCTION (1) • In reallity, all people have ethical models in their minds, although they may be unware of them. • All people have a set of principles that guide their actions. • Ethics as dicipline deals with what is good and what is bad, what is right and what is wrong, and moral duties, obligations, and responsibility.

INTRODUCTION (2) • Moral principles refer to ideals of human conduct, such as virtue, that apply to all mankind. • “Do not unto others as you would not have them do unto you.” • Conformity to shared standards, rights, and duties. • Persons are morally obliged to abide by established norms but only to the degree that they serve human principles and the control of conduct. • Jean Piaget described morality as developing gradually, in conjunction with the stages of cognitive development.

INTRODUCTION (3) • Ethical guidelines. • A knowledge of ethical principles • Ethical conflict : Tension between what one wants to do and what is ethically right to do. • Ethics deal with the relations between people in different groups and often entail balancing rights. } Help physician avoid ethical conflicts.

PROFESSIONAL ETHICS • Professional ethics : • Codes of ethics : Reflect a consensus about the general standards of appropriate professional conduct. • Refer to the principle of conduct that govern the behavior of physicians • The appropriate way to act when in a professional role. • Derive from a combination of morality, social norms, and the parameter of the relationship people have agreed to have.

PROFESSIONAL ETHICS • The standards of professional conduct, that derive from the special influence, that doctors have a result of the trust that people place in them, and the norms of behavior that have developed, and lead people to expect certain conduct. • Principles of Medical Ethics with Annotations Especially Aplicable to Psychiatry ( APA ) : ideal standards of practice and professional virtues of practitioners.

BASIC MEDICAL ETHIC PRINCIPLES Four ethical principles that physician ought to weigh in their work : • Respect for Autonomy. • Beneficence • Nonmaleficence • Justice

1. Respect for Autonomy • It may mean honoring an individual’s right not to hear every detail and even choosing someone else (e.g. family or doctor) to decide the best course of treatment. • A person act intentionally after being sufficient information and time to understand the benefits, risks, and costs of all reasonable options. • Patients need time to think and to talk with friends and family about their decision. • If the patient is not in state of mind to make decisions for himself / herself alternative decision-making (guardianship, conservators, health care proxy)

2. Beneficence • The proffesion’s belief that they have an obligation to society • Physicians must need their patients interests, even to the neglect of own. • Guidelines have been proposed for permitting beneficence to overrule patient autonomy. • When the patient faces substantial harm or risk of harm, the paternalistic act is chosen that ensures the optimal combination of : maximal harm reduction, low added risk, and minimal necessary infringement on patient autonomy.

3. Non maleficence • Physicians must be careful in their decisions and actions, and must ensure that they have had adequate training for what they do. • Physians need to be open to seeking second opinions and consultations • Physicians need to avoid creating risks for patients by an action or inaction. • First do no harm (primum non nocere).

4. Justice The concept of justice concerns the issues of reward and punishment and the equitable distribution of social benefits issues : • Whether resources should be distributed equally to those in greatest need. • Whether they should go to where they can have the greatest impact on the well-being of each individual served. • To where they will ultimately have the greatest impact on society.

THE PRINCIPLES of MEDICAL ETHICS ESPECIALLY APPLICABLE to PSYCHIATRY • Shall be dedicated. • Shall be honestly. • Shall respect the law. • Shall respect the right of patients, colleagues, other health professionals • Shall continue to study. • Shall, in the provision of appropriate patient care, except in emergencees be free to choose whom to serve the doctor – patient relationship. • Shall recognize a responsibility to participate in activities contributing to an improved community.

1. Shall be dedicated A physician shall be dedicated to providing competent medical service with compassion and respect for human dignity A physician should not be a party to any type of policy that excludes, segregates, or demeans the dignity of any patient because of ethnic origin, race, sex, creed, age, socioeconomic status, or sexual orientation.

2. Shall be honestly A physician shall deal honestly with patient and colleagues : • The requirement that the physician / psychiatrist conducts himself / herself with propriety in his / her profession and in all actions of his / her life is especially important for the physician / psychiatrist because the patient tends to model his / her behavior on that of his / her physician / psychiatrist by identification

3. Shall respect the law • A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient. e.g drug abuser • It would seem self – evident that a physician who is a law-breaker might be ethically unsuited to practice his / her profession.

4. Shall respect the rights of patients, colleagues 4.1. Psychiatrist’s records, including even the identification of person as a patient, must be protected with extreme care. Confidentiality is essential to psychiatric treatment. A physician shall respect the rights of patients, of colleagues, and other health professionals, and shall safeguard patient’s confidences within the constraints of the law. • Especially : • Marital problems • Schizophrenic patient • Patient with HIV / AIDS

4.2. A physician may release confidential information only with the authorization of the patient or under proper legal compulsion. Informed consent For a patient’s consent to be informed, 3 essential elements must be satisfied : competency, information, and voluntary.

Informed consent • Five areas of information are generally provided : Diagnosis – description of the condition or problem. Treatment – nature and purpose of proposed treatment. Consequences – risk and benefits of the proposed treatment. Alternative – viable alternatives to the proposed treatment, including risks and benefits Prognosis – projected outcome with and without treatment.

Confidentiality • Confidentiality refers to the therapist’s responsibility to not release information learned in the course of treatment to third parties. • Confidentiality refers to the right of patient to have communications spoken or written in confidence to a physician / psychiatrist kept undisclosed to outside parties without authorization.

5. Shall continue to study A physician shall continue to study, apply, and advance scientific knowledge, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated. • A life time learning • Rendering good care

6. The doctor – patient relationship The doctor – patient relationship is a vital factor in effective treatment of the patient that preservation of optimal conditions for development of a sound working relationship between the doctors and their patient should take precedence over all other considerations. There was a time when doctors decided that was best for a patient and informed the patient what the course of treatment would be

7. Responsibility to participate to an improved community A physician shall recognize a responsibility to participate in activities contributing to an improved community • Psychiatrist should foster the cooperation of those legitimately concerned with the medical, psychological, social, and legal aspects of mental health and illness. • Psychiatrist are encouraged to serve society by advising and consulting with the executive, legislative, and judiciary branches of the government. • Physician should clarify whether they speak as an individual or as a representative of an organization

CONCLUSION Ethics Professional Ethics ( Medical Ethics ) Code of Medical Ethics Basic Ethical Principles The principle of Ethics Especially Applicable to Psychiatry

ETHICS IN PSYCHIATRY Dr. Tuti Wahmurti AS, dr , SpKJ