Child and adolescent psychiatry

Ethical dilemmas unique to child and adolescent psychiatry are consequences of the child psychiatrist’s duty to serve as advocate for child patients while simultaneously having professional responsibilities to the parents and guardians of the children, as well as to child-related institutions inclusive of schools, juvenile justice systems, and childcare agencies. In addition, awareness of developmental differences is paramount, as continuous maturation occurs from ages zero through eighteen years and beyond. With this in mind, the chapter first reviews ethical principles and reasoning and the influence of context on such ever-present matters as assent/consent/dissent, agency, assessment, treatments, and confidentiality, and then hones in on current and future dilemmas posed by the needs of transitional age youth and the impacts of social media, marijuana decriminalization, alternative sexual and gender expressions, minority vulnerabilities, and casualties of global conflicts. A separate section focuses on ethical considerations relevant to research performed with child subjects.

Psychiatric diagnosis

Prior discussions of ethics in psychiatric diagnosis have focused on the development of classifications of psychopathology and the social features and implications of the use of psychiatric diagnostic categories. This chapter focuses instead on the ethics and values involved in the conduct of psychiatric diagnostic assessment ethics in the practice of diagnosing in mental health. The authors build an account of ethics of diagnostic practice using virtue epistemology theory, undergirded by Pellegrino’s account of medical morality as helping, healing, caring, and curing. The authors develop a set of diagnostic virtues (receptivity, empathy, inquisitiveness, self-knowledge, rigour, resolve, fallibilism, fecundity, practical wisdom, and faithfulness) and apply them to an illustrative case scenario.

Psychiatric ethics and the professions

The chapter provides a critical analysis of past understandings of the characteristics of professions. Many of these characteristics have lost meaning in the twenty-first century. High status has been diminished partly by professionals’ betrayal of the values they expound, but partly also by social factors such as rapid communication of information and changed understanding of the nature of knowledge, both of which have led to general scepticism about expertise. Professionals’ previous relative autonomy is challenged by government intervention and by the fact that more professionals are employed in large organizations where managers are the power centres. The chapter argues for a ‘new professionalism’ and takes two principles from the Code of Ethics of the Royal Australian and New Zealand College of Psychiatry to demonstrate how carefully deliberated codes of ethics can enunciate the particular values which the professions contribute in a well-functioning society.

Neuroethics

Neuroethics, located at the interface of conceptual and empirical dimensions, carries major implications for psychiatry, such as the neuroscientific basis of ethical concepts as moral agency. Drawing on data in neuroscience, this chapter highlights issues central to psychiatric ethics. First, it addresses a reductionistic model of the brain, often conceived as purely neuronal, and then it discusses empirical data suggesting that the brain’s activity is strongly aligned to its respective social (e.g., relation to others) and ecological (e.g., relation to the environment and nature) contexts; this implies a relational rather than reductionist model. Second, it suggests that self (e.g., the experience or sense of a self) and personhood (e.g., the person as existent independent of experience) must also be understood in such a social and ecological and, therefore, relational and spatio-temporal sense. Ethical concepts like agency, therefore, cannot be limited solely to the person and brain, but must rather be understood in a relational and neuro-ecological/social way. Third, it discusses deep brain stimulation as a treatment that promotes enhancement. In sum, this chapter presents findings in neuroscience that carry major implications for our view of brain, mental features, psychiatric disorders, and ethical issues like agency, responsibility, and enhancement.

Boundary violations

Professional boundaries can be described as the ‘edge’ or limit of appropriate behaviour by the practitioner in the clinical setting. The therapeutic frame comprised of this set of boundaries allows the clinician and the patient to interact in a safe and productive way. These boundaries can be violated by sexual contact between the practitioner and the patient or by nonsexual overinvolvement. The mental health clinicians who transgress boundaries may do so for different reasons, and there are varied characterological and symptomatic clinical pictures that lead to boundary violations. Detailed evaluation of each individual case is necessary to determine if the clinician can be rehabilitated or not. Rehabilitation generally involves psychotherapy, monitoring, practice limitations, continuing education, and supervision. The digital era has brought about new forms of boundary violations involving cyberspace and the relative ease with which information about patients can be accessed.

Psychiatry of the elderly

This chapter describes the ethical issues that arise in the setting of mental illness, and particularly dementia, in old age. It affirms the importance of understanding each older person as an individual, embedded in a unique history and in relationships which sustain their identity even in the face of cognitive decline. Autonomy and paternalism are discussed, and the alternative concept of ‘parentalism’ introduced. Decision-making capacity and competence are extensively analysed from both philosophical and practical viewpoints, with particular reference to the Mental Capacity Act 2005, and to mechanisms for decision-making for noncompetent patients. Topics briefly treated include predictive diagnosis and mild cognitive impairment, end-of-life care, truth telling, sexuality, and the UN Convention on the Rights of Persons with Disabilities. The text is aimed at old age psychiatrists and other practitioners in the field, as well as at those with an interest in ethical issues in old age.

Trauma and psychiatry

Over the last decade, psychological trauma has re-emerged as a critical factor in psychiatric discourse. The ubiquity of traumatic stress, extending from the hidden ‘epidemic’ of violence within families to the vexed challenges posed by the chaotic geopolitical challenges since 9/11, has forced psychiatry to engage again with the area. This chapter examines the ethical challenges arising from the reformulation of posttraumatic stress disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, trauma-informed care in health systems, recent progress in the understanding of the psychobiology of traumatic stress, and how psychiatrists must position themselves in an increasingly illiberal society that often fails to protect the most vulnerable people.

Psychiatry and the pharmaceutical industry

Conflicts of interest pervade the relationship between the psychiatric profession and pharmaceutical industry, threatening ethical standards of psychiatric care. They influence the quality and cost of treatment, the objectivity of research and educational activities, and the integrity of individual psychiatrists, as well as the profession in general. Various groups, apart from drug companies, bear responsibility for the prevalence of conflicts of interest, including individual practitioners and researchers, medical academe, professional organizations both within and external to psychiatry, and branches of the government. Reforming practices and policies that encourage such conflicts can only be contained by efforts aimed at educating the profession and public as to the relevant issues, as well as enlisting governmental action, in order to hold industry and the profession more accountable for potentially unethical collaborative activities.

Allocation of mental health resources

Resource allocation in mental health occurs at four levels. First, within the total allocation a society makes to health care, how much should go to mental health? In most societies, mental health services have been discriminated against. The quest for parity with medical and surgical services reflects the effort to undo this discrimination. In the Oregon priority-setting process, mental health conditions ranked high among community choices. Second, within the mental health sector, which conditions should receive priority? Some priority should be given to those with the most severe impairments, but no principles tell us just how much priority the sickest should receive. Third, within a particular area, such as schizophrenia, how much resource should be devoted to prevention, treatment of acute episodes, or rehabilitation of those with chronic conditions? Finally, in the care of individual patients, how much treatment is ‘enough’? Where and how is the line drawn between interventions regarded as ‘medically necessary’ versus interventions that are desirable but ‘optional’? In the absence of shared principles for making these allocational decisions, societies must establish fair decision-making processes, in which the rationales for policies and decisions are shared with the public, the rationales address meeting population needs in the context of available resources, and a robust appeals process allows patients, families, and clinicians to challenge decisions and policies. Because societies will develop their own distinctive approaches to resource allocation, progress requires looking at the allocation process in an international context.

Suicide

Beyond the clinical difficulties in treating suicidal patients, suicide is a unique ethical challenge to psychiatrists. For unlike therapy in which patients and doctors share the desirability of the treatment’s goal, suicidal patients and doctors diverge in the way they consider the value of life as such. This makes the traditional standards of informed consent, beneficence, and the ‘do not harm’ principle hard to apply. After shortly outlining the history of the philosophical attitude towards suicide, including its ‘medicalization’ in modern times, the article tackles the problem of intervention in preventing suicidal behaviour, by examining four clinical cases that are distinguished by the intention of the patient, the effectiveness of treatment, and the rationality of the motive. The following section then addresses the heated debate on physician-assisted death, which is more controversial than suicide prevention. Two real-life cases, Bouvia and Chabot, are discussed in detail. Finally, the article focuses on the unique ethical features of research of suicide behaviour and treatment.