ETHICS LECTURE – Dr D. Lyons

Ethics derived from the Greek word ETHIKOS, meaning disposition

It’s the study of conduct – whether an action is right or wrong (the goodness and badness of motives and ends of an action.

In the past given little emphasis on the medical curriculum: summarized before as the 5 A’sAbortionAdulteryAlcoholismAssociation (with non-medically qualified physicians or quacks)Advertising

Of all these ‘evils’ the Medical Council was dedicated to stamping out, most objectionable was advertising

NOW all is changed – medical ethics is transformed from an obscure aspect of professional practice into a high profile media activity.

Shock horror tabloid journalism has brought medical dilemmas to a world wide audience.

Debating point: Is this good or bad??

What is the nature of the profession’s relationship with the media?

Ethical issues are not just philosophical exercise – dilemmas touch most of us at the most intimate, painful and vulnerable part of our lives.e.g. – one in seven suffer infertility, some will have seen a relative die in pain or emotional distress, a few know they suffer from a major genetic disorder, others are carriers for genes like Cystic Fibrosis.Ethical issues touch us at the core of our being.Deeply personal tragedy may be involved.

Fundamental Ethical Principles

Autonomy (respecting the decision-making capacities of autonomous persons).

Non malfeasance (avoiding the causation of harm. Justice (fairness in distribution of benefits and risk).Above principles don’t form a moral framework of theory, but do provide

framework to allow reflection on moral problems._________________

Principles only relevant if they seem to apply to given circumstances – can’t consider every nuance of every moral dilemma.

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Poor decision making often reflects a lack of information – thus gathering information often helps solve seemingly intractable problems, or at least clarifies which ethical principle should be most reflected upon.

For Good Ethical Practice

Consider all factors and individual actuation

Weigh up relative importance of each principle

Psychiatry – A Special Case

Insanity not mentioned in Hippocratic Oath Treatment of mentally ill was centred on restraint of freedom;

variety of harsh treatments – beating, purgation, bleeding, cold baths.

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French Revolution - Pinel: 1790’sChains removed from his patients.

Rise of the Asylum (York Retreat) Asylums became overcrowded – pessimism about mental

illness.

Twentieth Century: Rise of psychiatric profession.

Increased efforts to apply ‘scientific’ treatments, but extreme use of psychosurgery

Abuse of psychiatry in Nazi Germany and Soviet Union, advent of psychotropic drugs and, ironically, rise of anti-psychiatry movement.

Closure of institutions begins in 1960’s in response to treatment innovations.

Glasnost – readmission of Soviet psychiatry to professional bodies after rehabilitation.

1999, Chinese Government cracks down on Falun Gong practitioners, branding political dissenters as mentally ill.

Nature of Psychiatry

Psychiatrists treat people who lack insight, who are brought to medical attention against their will, who are complained about.

Can we apply medical model to mental illness?

? Ignores individual expression of mental distress

How do we define normality in terms of beliefs, attitudes and behaviour?

Psychiatry, if exploited, could be used to reinforce social norms Psychiatry is one of the most heavily regulated medical

specialties Committal to hospital against patients’ will is governed by

Mental Health Act In some countries efforts are being made to allow enforced

treatment in the community of those with ‘dangerously severe Personality Disorder’

Balance of power in doctor-patient relationship still overwhelmingly lies with Doctor against the Patient

Information disclosed to psychiatrist may be intimate and painful – leads to transference elements and doctor dependency.

Patient advocacy groups and service user representatives have role in hospital policies.

Psychiatric Ethics

Boundary violations – sexual and non-sexual (time, gifts, location, money, self-disclosure, non-sexual physical contact).

Inherent limitations of making a psychiatric diagnosis (too subjective, but ICD and DSM aim to reduce error – be prepared to review diagnosis).Diagnosis can reassure – humanely transform social deviance into medical illness, but can also lead to exclusion and dehumanisation.

Ethical aspects of psychotherapies – financial exploitation, recovered memories.

Risks and benefits of drug treatments ECT/Psychosurgery Nursing interventions – physical restraints and administration of medication,

seclusion and isolation. Special situations of children and older adults (capacity and consent).

Forensic psychiatry. Ethics and psychiatric research Ethics of suicide – Is it ever rational (Debating point).

Ethical Responsibilities in Psychiatry

Confidentiality“3 people can keep a secret if two of them are dead” – Benjamin Franklin.

Patient records How much information should you share with G.P.? Who do you take collateral history from? Dealing with requests for information from third parties. Dangerous patients – pedophilia, suicide, homicide, HIV. Genetics, e.g. Huntington’s. Special situations – group therapy, family and couple therapy. Can a court make you disclose all confidential information?

Can the doctor – patient relationship survive in a broader atmosphere of information sharing, e.g. multidisciplinary teams, need to disclose medical details to health insurers etc.

Practical Dilemmas - 1

65 year old widower learns that Colon Ca that he had two years previously has metastasized and that he has weeks or months to live. He insists he is told the full prognosis. All his life he has been an advocate of voluntary euthanasia and now wants to die with dignity, rather than in excruciating pain. He doesn’t want to be a burden to his daughter, who has a young family. He talks candidly of wanting to die and plans to collect enough tablets to enable to die in what he terms a decent fashion.

Is this a rational suicide?

Should we as doctors respect his wish to die with dignity?

Must we force him to live to endure continuing pain and despair?

Practical Dilemmas - 2

A 40-year old housewife and mother of 3 children presents with apathy, withdrawal and self-neglect for weeks. She wakens early and has lost weight and has developed an unshakable belief that she is worthles and deserves to die. She suffered a similar episode 3 years ago and was treated with antidepressant medication and responded well.

Is her wish to die irrational? If she refuses admission to hospital, is it justified to

deprive her of her liberty?

Practical Dilemmas – 3

A 35-year old married woman and mother of three small children has been feeling despair since the death in a domestic fire of her youngest child, 8 months earlier. During this period, her feeling of loss has increased to the point where she feels she must join her ‘kiddy in heaven’. She has always been a devout catholic and she believes that she must join the deceased child, while the others can be cared for by her husband. She is convinced that she was to blame for the tragedy and felt she shouldn’t have left the child unattended. She tried to hang herself on the day of consultation, but her husband managed to intercede, although he is close to breaking point himself. He has little doubt that she will kill herself unless help can be provided. He, as a devout catholic himself, can also appreciate his wife’s wish to join the child in heaven.

Is there any ‘sound reasoning’ to her wish to die? Is her wish to die impulsive, lacking deliberation, or

distorted by mental illness? Can her grief over her loss be relieved with treatment,

and does the chance of success of an intervention dictate what the psychiatrist should do?

Debating Point : Should we always intervene to prevent such an irreversible act such as suicide?