22 - 13. Ethics in psychiatry

13. Ethics in psychiatry

© SPMM Course 13. Ethics in psychiatry Ethics provides guidance on decisions that we make in clinical practice. The first written book on medical ethics was authored by Ishaq bin Ali Rahawi. This book called Adab al-Tabib (Conduct of a Physician), is thought to be first published in 9th century Hammurabi code is the first attempt in history to codify medical competence and legal liability for negligence. It is mostly concerned with surgical negligence and imposes eye-for-eye sentences for assaults on noblemen though slaves can be ‘replaced if accidentally damaged’! Hammurabi cannot be regarded as a code of ethics. Charaka, an ancient Indian physician, proposed what seems to be the earliest of medical ethics relevant to modern medicine. This clearly outlined four ethical principles of a doctor:  Friendship  Sympathy towards the sick (Caring attitude)  Interest in cases according to one's capabilities and  No attachment to the patient after his recovery. Charaka also emphasised the personal values central to the nobility of the profession, thus: 'Those who trade their medical skills for personal livelihood can be considered as collecting a pile of dust, leaving aside the heap of real gold'. Furthermore, 'He who regards kindness to humanity as his supreme religion and treats his patients accordingly, succeeds best in achieving his aims of life and obtains the greatest pleasures'. Charaka also advised his fellow practitioners to “always strive to acquire knowledge” (i.e. Continuous Professional Development in modern terms) and highlighted the importance of confidentiality. Present day ethical principles:

1. Higher order principles: Deontology and teleology are two alternative higher-order ethical principles concerning current medical practice. The term Deontology derives from the Greek ‘Deon’ for ‘duty’ indicating the centrality of rules in governing medical practice. Accordingly, rights and duties determine action and so it is also called as absolutism. According to Ross, some duties are right because of their very nature (such as the duty to tell the truth); these are called prima facie duties. Others are right in particular circumstances, called duty proper. Whilst this approach (duty-based approach) provides security and clarity, there may be conflicts in managing particular problems and meeting the individual patient’s wishes and needs. Examples of rules include GMC Good medical Practice and the RCPsych code of ethics.

© SPMM Course The term Teleology derives its name from the Greek ‘Teleon’, meaning ‘purpose’ and the central concept is that rather than rights, people have interests, whether these are concerns, desires or needs. Accordingly, the broad judgment of benefits and harm determine medical practice. It assumes that the right action is the one that has the best foreseeable consequences. It is also called as consequentialism or utilitarianism. Utilitarianism takes two forms:  Act utilitarianism deals with a specific act only (situational ethics).  Rule utilitarianism deals with general practices (for which rules can be established). Evaluation of utilitarianism: The strengths of utilitarianism lies in its practicality and clarity. It approximates the principle of ‘beneficence’ (see below) and fits well with approaches to public policy. Two factors extraneous to psychiatry influence utilitarianism's position in psychiatric ethics. First, legislated responsibilities of psychiatrists, particularly in relation to issues of public safety (e.g., when applying Mental Health Act). Such legal imperatives are invariably utilitarian in nature and have usually emerged in the context of social and political responses to issues such as public safety especially in relation to forensic patients. The other factor promoting utilitarian thinking in psychiatric ethics has been the profound changes to healthcare systems in the face of globalization and financial pressures (managed care settings). 2. Prima facie principles: American philosophers Tom Beauchamp and James Childress and British doctor & philosopher Raanon Gillon pioneered the following prima facie principles:  autonomy—respecting patients' wishes and freedom of choice  beneficence—acting in patients' best interests  Non-maleficence—avoiding harm – primum non nocere.  Justice—treating problems equally, with equitable distribution of resources to the needy. These four principles are the main guiding aspects of current practice, and most other related ethical discussions relevant to clinical practice can be brought under these topics. 3. Models of doctor – patient interaction:  The paternalistic model. It is assumed that the doctor knows best. It is an autocratic model where treatments are prescriptive. May be desirable in emergency situations. But often this approach results in a clash of values.