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In this essay we will discuss about:- 1. Definition of Ethics 2. Historical Development of Ethics 3. Ethical Issues in Psychiatry.
Essay # 1. Definition of Ethics:
‘Random House’ dictionary defines ethics as a system of moral principles, the rules of conduct recognized in respect to a particular class of human actions or a particular group culture etc.
Chamber’s dictionary mentions ethics as that branch of philosophy which is concerned with human character and conduct.
Encyclopaedia Britannica defines ethics as “a systematic study of ultimate problems of human conduct.” Ethics deals with tightness and wrongness of certain actions and to the goodness and badness of the motives and ends of such actions. It relies on “judgement” and addresses itself to what ought to be.
Essay # 2. Historical Development of Ethics:
Much before Hippocrates laid down the rules of conduct contained in the oath, Ayurvedic texts gave a much more comprehensive and well documented description of the codes of behaviour for the teacher, for students of medical sciences, attendants, and various other activities connected with health care.
Guru used to administer the following oath to his students:
“A bachelor that you shall be, you shall abstain from all sex activities, anger, greed, attachment, pride, grandiosity, jealousy, roughness, back biting, immorality, idleness and defamation; you shall keep your head shaved and nails cut every fifth day; shall remain properly dressed, every day to speak the truth and be respectful and obedient to the Guru.” He warned his disciple that of the later acted otherwise, it would amount to immorality and he will loose all the powers gained through imparted knowledge.
The “Guru” in turn used to take the following oath himself. “If you (disciple) keep to all the requirements worthy of a disciple student and if I do not systematically and fully impart the proper knowledge due to you, I shall be condemned to be a sinner for all times and will be bereft of all my knowledge.” There was great importance attached to moral values and conduct.
This was the bond of Guru-Chela relationship. Upon completion of their course, the practioners were called upon “to treat brahmins, gurus, poor, friends, saints and destitute without distinction like ones own brethren.” Long before the birth of Christ, medical codes were derived from prayers and oaths in a number of writings.
Some of them are:
a. Code of Hammurabi (2000 B.C.)
b. Sun-ssu Kiao, the father of Chinese medicine.
c. Medical Ethics or a code of Institutes and percepts adapted to the professional conduct of physicians and surgeons
d. International Code of Medical Ethics (in the Geneva Declaration of the World Medical Association in 1948).
e. Declaration of Sydney (1968).
f. Declaration of Oslo (1970).
g. Declaration of Medical Ethics (by American Medical Association, 1973) entitled Annotations especially applicable to Psychiatry.
Objectives of Ethics:
The main objectives of professional ethics are:
a. To provide guidelines of conduct among the professionals themselves. It includes type of referral, commenting on opinion of another professionals, charging fee from co-professionals and their families.
b. To formulate guidelines in dealing with the client e.g., maintaining dignity of the client; confidentiality, secrecy and privacy of information; providing competent and efficient advice; charging money; referral etc.
Essay # 3. Ethical Issues in Psychiatry:
The main ethical issues in psychiatry involve the following areas:
(I) Patient-Physician Relationship:
There are many therapeutic processes involved in Patient Physician relationship.
They are defined as:
a. Rapport:
Conscious feeling of harmonious accord, sympathy, and mutual responsiveness between two or more persons.
b. Empathy:
The intellectual and emotional awareness and understanding of another person’s state of mind. It involves the projection of oneself into another person’s frame of reference.
c. Transference:
It is a process whereby the patient unconsciously projects his emotions, thoughts and wishes related to significant people in his past life onto people in his current life. It can be positive or negative.
d. Countertransference:
It is a process whereby psychiatrist unconsciously projects his emotions, thoughts and wishes from his past life onto the patient’s personality or onto the material is presenting, thus expressing unresolved conflicts and/or his own personal needs.
e. Resistance:
It is a theoretical construct which reflects any attitude or behaviours which run counter to the therapeutic objectives to the treatment. It is of many types — conscious, ego, id or superego resistance, manifested by many behaviours.
f. Therapeutic Alliance:
It is a process whereby the patients mature, rational, observing ego, is used in combination with the psychiatrists analytic abilities to advance their understanding of the patient.
Essentially, the relationship is one of mutual trust and confidence. The patient may regard the therapist as a father figure, lover, or an object of hate or revenge. Doctor-patient relationship can be friendly, corporate, authoritarian, egalitarian, caretaker, parental, helper etc.
(i) Confidentiality, Privacy and Privileged Communication:
Confidentiality involves the sharing of secrets and secrecy stands for tendency to conceal. The issue of confidentiality in psychiatry has raised numerous ethical concerns. According to Medical Ethics, “A physician shall safeguard patients confidence within the constraints of law”. The only exception to this rule is when the patient is dangerous to others.
The American Psychiatric Association has further clarified that where disclosure of a confidence is proper for instance, if compelled by a lawful court order or authorized by the patient, such disclosure should be limited to only that information which is relevant to a given situation, preferably with patient’s consent (i.e., privileged communication).
Records of the patients should be strictly safeguarded but computerization of the records in hospitals may lead to some ethical problems as data can be deciphered by others. Confidentiality, secrecy and privacy should also be maintained in therapeutic procedures e.g., psychotherapy, psychoanalysis, hypnosis, abreaction, etc. When the therapist communicates a case history or publishes a photograph, the patient’s informed consent should be taken.
(ii) Informed Consent:
It is the most complicated and important issue. In West, a lot has been written about this but in our country, it is quite different. The real problems come up when the patients are uneducated, unsophisticated and have little knowledge of science. They have confidence, trust and faith in their doctors and medicines.
Such patients may be shocked to learn that the doctor is not sure about the medicine or the procedure he is going to try. This creates a feeling of distrust and insecurity, leading to lingering suspicion. This may be appropriate in the western set up, but may create iatrogenic suspicion. Thus a heavy moral and social responsibility lies on the doctor when he takes the informed consent.
The conclusions of the President’s Commission (U.S.A.) have several implications regarding informed consent:
i. Although the informed consent doctrine has substantive foundation in law, it is essentially an ethical imperative.
ii. Ethically valid consent is a process of shared decision-making based upon mutual respect and participation and not a ritual to be equated with reciting the contents of a form that details the risks of particular treatments.
iii. Though informed consent is portrayed as a highly rational process, implying thereby that it may be suitable for and applicable to well educated, self-aware individuals, the desire for information, choice and respectful communication about decisions in universal (emphasis added).
iv. Incompetence as a disqualifying factor should be considered in only a minority of cases.
v. Information should not be withheld merely because it is unpleasant.
vi. Judicious attempts to involve family members in decision making for patients to understand information and in decision making. However, due regard must be given to privacy of patients and for the possibility of coercion.
vii. To protect the interests of those who lack decision-making capacity and to ensure their well-being and self-determination, decisions by other (relatives, friends or at least 2 treating physicians) should attempt to replicate the once patient would make if he/ she were capable of doing so.
Setting up of ethics committees, developing clear guidelines for making decisions and reserving courts only for matters of substantive importance and provision of legal guidelines for advance directives can help improve the situation.
Informed Consent in Psychiatry:
Three of the elements of the legal model of the decision making process are voluntariness, competency and understanding. All these three play an important role in psychiatric disorders. It is often argued that to disclose information to patients in the manner required by law would compromise the effectiveness of psychiatric treatment. However, the presence of mental disorder does not ipso facto eliminate the need for disclosing information or obtaining consent.
The question whether the concept of informed consent applies with the same rigour in psychiatry as in rest of medicine is an important one. It is likely that the psychiatrist may invoke therapeutic – privilege to withhold information more easily on the ground that disclosure will seriously upset the patient.
It is important to note that withholding of information is appropriate only when it would so upset the patient that rational decision making will be precluded. To-date, relatively few cases have raised the issue of informed consent in the context of psychiatric treatment. All the cases have dealt with an organic rather than psychological therapy.
For understanding informed consent three variables namely provision of information, understanding and competence should be considered.
A. Provision of Information:
Patients should be provided with information about the research before their decision considered valid. They must be informed of the risks, discomforts, side effects, the anticipated benefits, available alternatives and likely consequences of failure to take part in research. This information should be provided in simple language.
B. Understanding:
Judicially it is not deemed necessary that the patient actually understand what he is told. The act of informing someone does not assure that one will understand the information that has been provided. It is therefore uncertain what obligation the researcher has to attempt to ascertain the level of understanding.
C. Competence:
Patients are presumed to have the capacity to comprehend the information with which they are provided. If a patient is not competent, any decision taken is not valid. Exactly what this means is not clear.
Several tests of competence may have to be applied.
There are basically 5 categories:
1. Evidencing a choice.
2. “Reasonable” outcome of choice.
3. Choice based on ‘rational’ reasons.
4. Ability to understand and
5. Actual understanding.
The insanity defense has become a popular and ethically controversial issue following the verdict of not guilty by the reason of insanity for John Hickley in his trial to assassinate President Regan. The M’ Naghtens rule states, to establish a defense on the ground of insanity, it must be clearly proved that, at the time of the committing of the act, the party accused was labouring under such a defect of reason, from disease of the mind, as not to know the nature and quality of the act he was doing or if did know it that he did not know what he was doing was wrong.
Informed consent is also important in:
i. Admission or Discharge of Patient:
Telling the patient and informants about indications for admission, treatment modalities to be used, cost of therapies and admission and finally, likely complications and precautions after discharge.
ii. Investigations:
Investigations to be used i.e., options, indications, advantages, cost, complications of an investigation.
iii. Treatment Methods:
Available options, advantages, cost, complications of an investigation.
iv. Treatment Methods:
Available options, advantages, disadvantages and costs of each treatment modality. Use of dependence producing drugs.
v. Research i.e.,:
Research Revealing history, photographs, signs or diagnosis of patient or other family members using traumatic procedures, data collection, transfer and presentation of data.
vi. Drug Trials:
Using placebo or experimental drug with unknown side effects.
vii. Medicolegal Problems:
Role of informed consent is also important in issues of marriage, divorce, property dispute or criminal responsibility; revealing information to court, working place or relatives. When patient is not in a condition to give informed consent, informed consent from close relatives, friends, office colleagues or treating physicians (at least two, deciding in the interest of patient) is especially important. In remitting disorders e.g., mood disorders, an informed consent may be obtained for future episodes.
(II) Consent to Medical Examination:
Consent means voluntary agreement, compliance or permission. To be legally valid, it must be given after understanding what it is given for, and of risks involved.
Kinds of consent:
Consent may be:
(1) Express, i.e., specifically stated by the patient, or
(2) Implied. Express consent may be (a) Verbal, or (b) written.
“Therapeutic privilege” is an exception to the rule of “full disclosure”. In these cases the doctor may exercise discretion as to the facts which he discloses.
Reasons for Obtaining Consent:
(1) To examine, treat or operate upon a patient without consent is assault in law, even if it does not cause any harm or even if it is beneficial and done in good faith. The patient may recover damages.
(2) If a medical practitioner fails to give the requisite information to a patient before asking for his consent to a particular operation or treatment, he may be charged for negligence.
Rules of Consent:
1. Consent is necessary in every medical examination.
2. Written consent is not necessary in every case. However, it should be taken for proving the same in the court if necessity arises.
3. Any procedure beyond routine physical examination, such as, operation, blood transfusion.
4. The consent should be free, voluntary, clear, intelligent, informed, direct and personal. There should be no undue influence, fraud, misrepresentation of facts, compulsion and threat of physical injury death or other consequences.
5. The doctor should inform the patient that he has right to refuse to submit to examination and that the result may go against him. Oral consent should be obtained in the presence of a disinterested third party e.g., nurse.
6. The doctor should explain the object of the examination to the patient, and he should be informed that the findings will be embodied in a medical report.
7. In criminal cases, the victim cannot be examined without his/her consent. The court also cannot compel a person to get medically examined against his will.
8. (A) When a person is arrested on a charge of committing an offence and there are reasonable grounds for believing that an examination of his person will afford evidence as to the commission of an offence, a registered medical practitioner can examine such person, even by using reasonable force if the examination is requested by a police officer not below the rank of sub- inspector.
(B) In the case of a female, the examination should be made only by or under the supervision of a female registered medical practicioner (S.53, Cr.P.C.).
9. In cases of drunkenness, the person should not be examined, and blood, urine or breath should not be collected without his consent.
10. A prisoner can be treated forcibly without consent in the interest of society.
11. Consent given for committing a crime or an illegal act, such as criminal abortion, is invalid.
12. A person above 18 years of age can give valid consent to suffer any harm which may result from an act not intended or not known to cause death or grievous hurt.
13. A person above 18 years of age can give valid consent to suffer any harm which may result from an act, not intended or not known to cause death done in good faith and for its benefit.
14. A child under 12 years of age and an insane person cannot give valid consent to suffer any harm which may occur from an act done- in good faith and for its benefit.
15. A consent given by a person under fear of injury, or under a misconception of a fact is not valid. The consent given by an insane or intoxicated person, who is unable to understand the nature and consequences of that to what he gives his consent, is invalid (Sec. 90, I.P.C.).
16. Any harm caused to a person in good faith, even without that person’s consent is not an offence, if the circumstance are such that it is impossible for that person to signify consent, and has no guardian or other person in lawful charge of him from whom it is possible to obtain consent.
17. The doctor should inform reasonably to the patient about the nature, consequences and risks of the examination or operation before taking the consent.
18. For contraceptive sterilisation, consent of both the husband and wife should be obtained.
19. The consent of one spouse is not necessary for an operation or treatment of the other.
20. Consent of the inmates of the hostel, etc., is necessary if they are above 12 years.
21. It is unlawful to detain an adult patient in hospital against his will.
22. The nature of illness of patient should not be disclosed to any third party without the consent of the patient.
23. When an operation is made compulsory by law, e.g., vaccination, the law furnishes the consent.
24. Consent is not defence in cases of professional negligence.
25. Pathological autopsy should not be conducted without the consent of the guardian or legal heirs of the diseased.
26. If any person that donated his eyes to be used for therapeutic purpose after his death, the eyes can be removed only with the consent of the guardian or legal heirs.
27. A living adult person can give consent for donating one of his kidneys to be grafted into another person.
28. For organ transplantation, the organs of the deal person, such as heart, kidneys, liver, etc., should not be removed without the consent of the person having lawful possession of the body.
29. There is no special form for obtaining written consent.
(III) Right to Treat and to be Treated:
When a patient suffering from a serious cardiac illness needing intensive and urgent care refuses to go to a hospital or refuses any kind of treatment, no one can force him to do otherwise. In contrast when a seriously disturbed mentally ill does so, he is usually certified or forced to undergo treatment much against his will.
Right to treat and to be treated for raises ethical issues involving complex legal implications. Use of particular therapy when it is not called for also raises ethical issues. Health can be right or a privilege according to system prevalent in our country. The right to refuse treatment is complicated ethical issue both legally and psychiatrically. Compulsory hospitalization also involves ethical issues.
(IV) Selfish Motives:
Another crucial question on the ethical front requires some self-searching. How many of us are really interested in treating a patient selflessly i.e., without regard to enhancement of our own interests, self-prestige, monetary advantage, research, publications etc.
(V) Fraud and Abuse in Psychiatric Practice:
The definitional problems of what is fraudulent or abusive make it difficult to delineate and precisely determine what is inappropriate and illegal in the practice of psychiatry.
Towary and Sharfsten (1978) have enlisted a number of fraudulent and abusive practices:
i. Upgrading i.e., billing for services more extensive than those actually provided.
ii. Ganging i.e., billing for multiple services to the members of the same family on the same day.
iii. Touting i.e., employing obstructive ways such as appointing agents, soliciting professional support etc., for enhancing private practice.
iv. ‘Self-advertisement’ and ‘self-aggrandisement’ using audiovisual aids and mass media communication methods.
v. Unavailability of treating physician because of his absence (usually abroad) for participation in big conference.
vi. Calling pressmen to publish reports of the research work done.
vii. Doing unethical drug trials and giving false reports for receiving money from the pharmaceuticals.
viii. Missing lectures, teaching unprepared topics or passing or upgrading in examinations ‘on approach’.
ix. Not keeping one uptodate with recent developments in the field of treatment and care of patients.
x. To practice quackery under the garb of modern medicine.
xi. To write unscientific drug combinations to get favour from Pharmaceuticals.
xii. Selling of samples.
xiii. Making addicts or sustaining them.
xiv. Billing for services not rendered.
xv. Ping-Ponging i.e., multiple referrals between psychiatrists or other professional brothers when there is no real necessity for these services.
xvi. Charging for physicians services actually provided by non-physicians professionals not eligible for reimbursement.
xvii. Offering or receiving kickbacks.
xviii. Billing more than one part for the same services.
xix. Distributing sample drugs indiscriminately to anyone who can pay.
xx. Making excessive profits from a legitimate treatment, and.
xxi. Steering: Directing patients to a particular pharmacy.
Some other Unethical Practices are:
i. Devoting much less than required time and effort in attending to outpatients and inpatients in hospitals.
ii. While away in hospital, gossiping or roaming about and not doing full duty during working hours.
iii. Prolonging the illness, creating relapses or exacerbation or wrongly treating the patients (intentionally).
iv. Sexual promiscuity, abuse or exploitation of patients.
v. Giving ineffective treatment or using treatments for indications not normally called for.
vi. Exploiting or blackmailing patients for privacy or secrecy.
vii. Giving wrong evidence in court (after receiving favour from a party).
viii. False medical certification.
ix. Duping the patients by administering of such procedures like injections of distilled water, I.V. glucose and tonics etc. when not warranted.
x. Criticizing the prescription of specialists of one’s own speciality to please the patients.
xi. Receiving gifts or economical status non-uniform fee from patients.
xii. Not referring the patient to other physicians when one knows that patient is not psychiatrically ill.
xiii. Not respecting the basic rights and human nature of the patients.
Other Professional Misconducts:
Infamous Conduct (Serious Professional Misconduct):
It is defined as something which might reasonably be regarded as disgraceful or dis-honourable by professional men of good repute and competence. It involves an abuse of professional position.
Medical Ethics (Published by Medical Council of India (MCI) and by several State Medical Councils):
Anyone found guilty of any of the following offences mentioned in the warning notice issued by the Medical Council of India will be liable to have his name erased from the Medical Register:
i. Adultery.
ii. Conviction, improper conduct or association with a patient or members of the patient’s family by a Court of Law for offences involving moral turpitude.
iii. Issuing a false, misleading or improper certificate in connection with sick benefit, insurance passport, attendance in court, public services etc.
iv. Withholding from health authorities information of notifiable diseases.
v. Performing or enabling an unqualified person to perform any illegal procedure for which there is no indication.
vi. Contravening the provisions of the drugs.
vii. Selling Act Scheduled poisons to the public under cover of his qualifications, except to the patients.
viii. Dichotomy or fee splitting i.e., receiving or giving commission or other benefits to a professional colleagues or manufacturer or traders in drugs or a chemist.
ix. Using of touts or agents for procuring patients.
x. Disclosing the secrets of a patient that have been learnt in the exercise of his profession, except in a court of law.
xi. Covering i.e., assisting someone who has no medical qualification to attend, treat or perform a procedure on some person in respect of matters requiring professional discretion or skill.
xii. Association with manufacturing firms (i.e., personal ownership, receiving rebates or commission).
xiii. Advertising (unusual publication in lay press reports of cases treated publicising scale of fees, unusually large sign boards or manufacturing firms) but he can write to lay press matter of public health, he can announce his availability schedule or can advertise the institution but not his name).
xiv. Professional association with bodies or societies of unqualified persons formed for the purpose of training unqualified practitioners.
xv. Running an open shop for sale of medicines or equipment.
xvi. Refusal to given professional service on religious ground.
xvii. Drunk or disorderly so as to interfere with proper skilled practice of medicine.