ETHICAL ASPECTS IN RESEARCH AND CLINICAL PSYCHIATRY

Ethical aspects in research and clinical psychiatry

Abstract

In fields like medicine, where trust and respect for human dignity are crucial, it is imperative nowadays that every decision should be backed up but what we call ethical sustainability.

Psychiatry is perhaps the least biological of all medical branches but at the same time the most sensitive to any developments in fundamental sciences. Being both applied neuroscience and philosophical debate, most ethical dilemmas acquire a particular dimension, one that makes then more difficult to define and handle.

Psychiatric practice has raised throughout time more controversy than any medical field, because nowhere is the distinction between facts and human values more ambiguous and difficult to articulate. As with other medical branches, ethical aspects in psychiatry involve several activities, such as clinical practice, scientific research and teaching.

The purpose is always the same: to offer premises for a behavior that respects individual beliefs, social custom and human dignity. The unprecedented developments in modern medicine and complex sociological conditions in which it is practiced raise new ethical issues concerning what is just, what is right and fair in doctors and patients behavior. It is necessary, in the current context , to reassess ethical principles and most of all to adapt them to new situations.

Key words: ethics, ethical principles, psychiatry.

Introduction

From its very beginning as a social practice, medicine had to deal with ethical dilemmas, and moral custom, religious belies and legal standard have been the guiding tools in solving these issues.

Bioethics, as a term, was established in 1971 by the American oncologist Van Rensselaer Potter in the book called Bioethics- a bridge to the future to define a new discipline which should combine biological knowledge, the science of the living systems with that of human values. Potter also speaks about the dangers threatening the very existence of life, due to the separation between science and humanism (he stated the necessity of a merge between moral values and science leading to defining different, specialized bioethics.

At a students conference on ethical issues, in 1998, prof. Henry Wuff synthesized different ethical principles, as follows:

Autonomy- respecting the right to self-determination and protecting those with limited autonomy

Non maleficence- a principle established from the very beginning of medical practice states that a doctor should not do anything to harm a patient.

Benevolence- a doctor should do anything in his power to promote health and well-being of his patients.

The unprecedented developments in modern medicine and complex sociological conditions in which it is practiced raise new ethical issues concerning what is just, what is right and fair in doctors and patients behavior, individuals and even society as a whole. It is necessary, in the current context to reassess ethical principles and, most of all, to adapt them to new situations.

In fields like medicine, where trust and respect for human dignity are crucial, it is imperative nowadays that every decision should be backed up but what we call ethical sustainability.

Ethical dimensions in psychiatric research

As with other medical branches, ethical aspects in psychiatry involve several activities, such as clinical practice, scientific research and teaching. The purpose is always the same: to offer premises for a behavior that respects individual beliefs, social custom and human dignity.

Psychiatric practice has raised throughout time more controversy than any medical field, because nowhere is the distinction between facts and human values more ambiguous and difficult to articulate. Psychological normality, deviance, mental illness, different therapies are partly defined by the structure of socially accepted moral values, more than any other illness. Psychiatrists have taken, throughout time, the role of both spiritual counselor, confident and detached scientist, concerned only with the well-being of the patient. Psychiatry is perhaps the least biological of all medical branches but at the same time the most sensitive to any developments in fundamental sciences. Being both applied neuroscience and philosophical debate, most ethical dilemmas acquire a particular dimension, one that makes then more difficult to define and handle.

Psychiatrists and other mental health care professionals have to deal with people in highly vulnerable situations and have to establish with them relationships that are at the same time close and also detached. In this respect, a therapist or a psychiatrist should have all the relevant information about a patient in order to be efficient but should maintain the necessary distance in order not to assume other roles apart from that of a therapist and retain a scientific point of view. Any intervention, considered from a bioethical point of view, should fulfill at least three conditions. First of all, it should be adequate to the problem at hand, secondly, it should respect the principle of benevolence, in a sense that it should do good to both the intended recipients and the one performing it; and , last but not least, it should be just, so that its outcome can be generalized to the whole society. If these coordinates are respected, then everybody should realize that a good professional acknowledges both the duty to inform subjects or patients, an their right to be informed, in order to attain both scientific and clinical purposes.

In the past, society has perceived the mentally ill as a threat to others, and so these people were treated differently. Today a patient with mental illness has the same rights as any other patient, including the right to privacy in their relationship with the doctor.

The general ethical principles that define the doctor-patient relationship are found in World Medical Associations Declaration published during the 47^th General Assembly in Bali, Indonesia, in 1995. During this assembly WMA defined a code of general ethical principles:

Accomplishing a relationship between doctor and patient based on correct and complete informing of the patient, including information about risks derived from the treatment

Treatment without patients consent and non-voluntary admission in hospital will be considered as exceptions and will be applied only in acute states of illness, when a patients condition represents a danger to himself or to society

Psychiatric therapy should be individualized for each patient and according to his condition and diagnosis

Confidentiality and keeping medical privacy will be guaranteed, and relevant data may be disclosed only in case of danger and only to by the proper authorities

The psychiatrist will be loyal to the patient, and in case of conflict (as defender of social values appointed by society), to inform the patient about the nature of his conflict

The psychiatrist will not use his position to physically, mentally or sexually abuse his patient

The psychiatrist will not allow a person or a group of persons to influence treatment or his medical decisions

The mentally ill patient benefits from a special medical and legal measures whose sole purpose is to protect both patient from the consequences of his actions and society from traumas generated by an individual partly or totally lacking decision capacity.

Unlike any other medical fields, where a patient can not be treated without an informed consent, there are in psychiatry two ways of hospital admission: one with consent (voluntary) and one without consent (non-voluntary).

Although we might say in a first instance that most trouble occurs concerning non-voluntary admissions, there are, however, a lot of differences of opinion concerning informed consent. According to Beauchamp and Childress, this subject has probably been more focused upon that any other issue in bioethics. The great interest generated by informed consent derives from its primary function to allow and protect autonomy and individual decisions, a turning point in bioethics and the gold standard of medical decision-making. We must not forget, however, that informed consent depends heavily on certain interpersonal and intrapsychic conditions, such as: mutual trust, empathy, and the ability to communicate clearly. The emotional charge usually associated with illness and hospitalization can easily interfere with these conditions.

The purpose of informed consent is to allow the patient to consider, weigh and put in balance the advantages and disadvantages of the intended treatment, so that a rational choice between accepting and refusing treatment can be made. Optimal use of this principle prevents or diminishes possibility that error, negligence, force, or lie occur, and also encourages an auto critical attitude on the part of the doctor.

To exclude possible abuse that may occur in non voluntary admissions, a clarification of its premises was necessary. These premises are now regulated by law no. 487/2002, where art. 29 clearly defines situations when non voluntary admission is appropriate.

a. Patients behavior represents an imminent danger to himself or people around him

b. Patient has no ability to understand his illness or the necessity of treatment

c. Patient has been previously placed under legal interdiction and a tutor was appointed

d. Patient is under age; in this particular case the psychiatrist must ask for, and obtain, informed consent from the patients personal or legal representative

In cases a. and b., in which informed consent can not be obtained from a legal or personal representative of the patient, the psychiatrist acts on self responsibility, begins any diagnosis and treatment procedures he may find necessary, on a strictly limited period of time, necessary to accomplish the main purpose of the treatment. These cases shall be notified and subjected to analysis from the procedure revising committee, as stipulated in art. 52 of the above-mentioned law.

The decision for non voluntary admission shall be confirmed in maximum 72 hours (based on the notification written by the doctor who admitted the patient) by a procedure revising committee consisting of 3 members, as follows: 2 psychiatrists, different, if possible, from the doctor who admitted the patient, and a doctor form another medical specialty or a representative of civil society.

The committee examines the patient periodically in maximum 15 days, or when the doctor currently caring for the patient requests it

The committee is required to specify the decision they took in the patients medical record and to inform the patients personal or legal representative

It must be specified that a non voluntary admitted patient has to be treated and cared for in similar conditions as the rest of the patients in that hospital (unit).

Restrictions regarding individual freedoms of the non voluntary patient are dictated by his health state and the effectiveness of the treatment. Some of a patients rights may not be restricted:

a.    The right to personal correspondence and private use of phone

b.   Communication, according to his wish, with any competent authority that has anything to do with his situation, family members, lawyers

c.    Access to newspapers or magazines

d.   The right to vote, provided his civil rights are not restricted

A non voluntary admitted patient has the right to be informed about the internal rules of the hospital. Non voluntary hospitalization is not a base for restricting legal capacity of a person.

Psychiatric research, even if designed to enhance and refine knowledge that can be generalized, must respect human dignity and individual rights. On the other hand psychiatric research faces the same standards as medical and biological research, with the note that it may include areas from what we may call social sciences. This is the case of, for example, studies on effectiveness of psychotherapies or on implementing alternate models of mental health, where subjects and participants perception can not be dismissed as irrelevant, and becomes part of the studied interventions.

Among other considerations, debate on using placebo in psychiatric research is much more complicated than in pure organic medicine. The best known documents regarding ethics in human research are: The Helsinki Declaration, Medical Sciences Organizations Internal Council Guides, European Guides. Key points in all these documents are informed consent of subjects and participants in the research, independent re-evaluation of ethical aspects of the study, benefits to the community after completion of clinical trials, distinction between research that benefits the participants and research whose only purpose is extending knowledge. There is also the issue of conflict of interests, financial or of other nature, issues related to confidentiality and the right to privacy.

There are other contexts in which an ethical behavior is imperative, one of these being teaching. Students should know how to help protect  confidentiality and patients privacy, how to avoid social stigmatization and personal involvement in the lives of the people they treat.

Teaching by practice and by power of example- two key strategies in teaching psychiatry- demand a conscious effort on the part of the teacher.

Issues surrounding ethics in psychiatry remain an open subject, the dynamic evolution of this discipline and psychopathological innovations and subsequent treatments demanding permanent re-evaluation of ethical principles, permanently adapting them to modern times.