ETHICS IN MENTAL

HEALTH
OUTLINE
• Definition of terms
• Introduction
• Codes of practice
• Ethical approaches
• Ethical principles
• Ethical problems
Definition of terms
• Mental health according to WHO (World health organization) can be
defined as a state of mental well-being that enables people to cope
with the stresses of life, realize their abilities, learn well and work
well, and contribute to their economy.
• Ethics can be defined study of the philosophy of human conduct with
emphasis on the determination of right and wrong .
 INTRODUCTION
• Ethical guidelines and a knowledge of ethical principles help
psychiatrists avoid ethical conflicts (which can be defined as tension
between what one wants to do and what is ethically right to do) and
think through ethical dilemmas (conflicts between ethical perspectives
or values).
• The conclusion that it is ethically right to act in one way rather than
another should be;
1. Based on agreed ethical approaches and principles
2. Logically sound
3. Consistent across decisions
 CODES OF PRACTICE
• Hippocratic oath.
• Geneva declaration.
• The American Medical Association's (AMA's) Principles of Medical Ethics
and the American Psychiatric Association's (APA's) Principles of Medical
Ethics.
• World psychiatric association code of ethics.
• Medical and dental council of Nigeria code of ethics
 HIPPOCRATIC OATH
I swear to fulfill, to the best of my ability and judgment, this covenant:
• I will respect the hard-won scientific gains of those physicians in whose steps I
walk, and gladly share such knowledge as is mine with those who are to follow.
• I will apply, for the benefit of the sick, all measures [that] are required, avoiding
those twin traps of overtreatment and therapeutic nihilism.
• I will remember that there is art to medicine as well as science, and that
warmth, sympathy, and understanding may outweigh the surgeon's knife or the
chemist's drug.
• I will not be ashamed to say "I know not," nor will I fail to call in my colleagues
when the skills of another are needed for a patient's recovery.
 HIPPOCRATIC OATH
• I will respect the privacy of my patients, for their problems are not disclosed
to me that the world may know. Most especially must I tread with care in
matters of life and death. If it is given me to save a life, all thanks. But it may
also be within my power to take a life; this awesome responsibility must be
faced with great humbleness and awareness of my own frailty. Above all, I
must not play at God.
• I will remember that I do not treat a fever chart, a cancerous growth, but a
sick human being, whose illness may affect the person's family and economic
stability. My responsibility includes these related problems, if I am to care
adequately for the sick.
 HIPPOCRATIC OATH

• I will prevent disease whenever I can, for prevention is preferable to cure.

• I will remember that I remain a member of society, with special obligations to
all my fellow human beings, those sound of mind and body as well as the
infirm.
• If I do not violate this oath, may I enjoy life and art, respected while I live and
remembered with affection thereafter. May I always act so as to preserve the
finest traditions of my calling and may I long experience the joy of healing those
who seek my help.
 ETHICAL APPROACHES
• Duty based approach:
Sets out clinicians obligations in a series of rules. For example, doctors must not have sexual
relationships with their patients. Advantage is that there is no controversy. Disadvantage is
that this approach is inflexible and difficult to apply to complex cases.

• Utilitarian approach:
Balances judgement about benefit and harm. Instead of applying specific rules, each case is
assessed individually. Advantage is it’s flexibility. Disadvantage is in controversy on best
decision to be undertaken by care givers.

Both approaches overlap in practice.

ETHICAL PRINCIPLES

• Respect for autonomy

• Beneficence

• Non-maleficence

• Justice
RESPECT FOR AUTONOMY

Autonomy requires that a person act intentionally after being given

sufficient information and time to understand the benefits, risks, and
costs of all reasonable options. It may mean honoring an individual's
right not to hear every detail and even choosing someone else (e.g.,
family or doctor) to decide the best course of treatment.
BENEFICENCE

• Refers to doing good

• Promoting what is best for the patient.

NON-MALEFICENCE

To adhere to the principle of nonmaleficence (primum non nocere or

first, do no harm), psychiatrists must be careful in their decisions and
actions and must ensure that they have had adequate training for what
they do. They also need to be open to seeking second opinions and
consultations. They need to avoid creating risks for patients by an
action or inaction.
JUSTICE

The concept of justice concerns the issues of reward and punishment

and the equitable distribution of social benefits. Relevant issues include
whether resources should be distributed equally to those in greatest
need, whether they should go to where they can have the greatest
impact on the well-being of each individual served, or to where they
will ultimately have the greatest impact on society.
 ETHICAL PROBLEMS
• The doctor-patient relationship
• Sexual boundary violations
• Non-sexual boundary violations
• Confidentiality
• Consent
• Compulsory treatment
• Mistreatment of patient
• Research
• Illegal activities
DOCTOR-PATIENT RELATIONSHIP

A relationship of trust between doctor and patient is the basis of ethical

medical practice. This relationship should be in the patient’s interests
and based on the principles outlined above of respect for autonomy,
beneficence, non-maleficence, and justice.
 SEXUAL BOUNDARY VIOLATIONS

• For a psychiatrist to engage a patient in a sexual relationship is clearly unethical.

• Various criminal law statutes (rape charges) have been used against psychiatrists
who violate this ethical principle.
• The issue of whether sexual relations between an ex-patient and a therapist
violate an ethical principle, however, remains controversial.
• Proponents of the view "Once a patient, always a patient" insist that any
involvement with an ex-patient even one that leads to marriage-should be
prohibited. This may be because transference reactions are known to persist for
years even after therapy and can influence decision making.
• Sexual relationships between a psychiatrist and patient’s relatives are also
prohibited in many jurisdictions. In child psychiatry, the family is usually the
Non-sexual boundary violations

• Impose their own values and beliefs on their patients: for example,
when counselling about termination of pregnancy.
• Put the interests of third parties before those of patients: for
example, the interests of family or employers.
• Financial gain: for example, by prolonging treatment in private
practice beyond that truly necessary.
• Business: business relationships with current patients are considered
unethical in most places. Business relationships with former patients,
while not clearly unethical, also raises ethical issues
 CONFIDENTIALITY
• Confidentiality refers to the therapist's responsibility not to release
information learned in the course of treatment to third parties.
• Before disclosure of patient’s information even in research and clinical
settings, consent should be gotten.
• Situations where there may be problems regarding confidentiality include
1. Seeking information from others
2. Disclosing information to others
3. Assessment on behalf of a third party
4. Care in the community
5. Group therapy
6. Couples therapy
CONFIDENTIALITY

• Exceptions to the rule of confidentiality include

1. Exceptions in the patient’s interest

2. Exceptions in the public interest
3. Exceptions for legal representative
CONSENT
• Informed consent is the process in which a health care provider
educates a patient about the risks, benefits and alternatives of a given
procedure or intervention.

• For a patient to be said to have given consent, he/she must

1. Have a CLEAR AND FULL UNDERSTANDING of the nature of the
illness, the possible treatments, and likely side effects
2. Agree FREELY to receive treatment
3. Be COMPETENT (have legal capacity) to take the decision
 CONSENT
• Situations where explicit consent may not be required include:
1. Implied consent: for example, when a patient holds out his
arm to have his blood pressure measured.
2. Necessity : a circumstance in which grave harm or death is
likely to occur without intervention, and there is doubt about
the patient’s competence
3. Emergency : to prevent immediate serious harm to the patient
or to others, or to prevent a crime.
CONSENT
Legal aspect of consent:
The legal concept of capacity to consent relates to a patient’s ability to
comprehend and retain information about the treatment, to believe this
information, and to use it to make an informed choice.
Patients may lack the capacity to give informed consent by reason of the
following:
1. Young age (≤ 11 years in Nigeria)
2. Learning disability
3. Mental disorder
CONSENT
• Consent in advance
1. Living wills
2. Advance directives
3. Power of attorney
• Consent by proxy
 COMPULSORY TREATMENT
• Most jurisdictions have legislation to ensure that people with severe mental illness
can be treated involuntarily.
• There are however checks to prevent abuses. Generally conditions for involuntary.
Treatment include:
1. There is suspected mental illness
2. Detention is necessary for the health or safety of others
3. The patient refuses voluntary admission
4. Appropriate treatment is available
• Two medical opinions are required with at least one from a qualified psychiatrist. For
longer detention periods and possibly complicated treatment, a judicial
pronouncement is usually needed.
 MSTREATMENT OF PATIENT
• This is a wrong resulting from a physician s negligence.
• Simply put, negligence means doing something that a physician with a duty to
care for the patient should not have done or failing to do something that should
have been done as defined by current medical practice
• To prove medical negligence, it must be established that:
1. The doctor owed the patient a duty of care
2. The doctor was is deviation from standard of care
3. The patient suffered damages
4. There is direct link between damages and deviation
 RESEARCH
• Informed consent is crucial to the ethical conduct of research
• Consent for research has some peculiarities:
1. Patients should be specifically aware that research is not for their benefit
2. Patient must be free from coercion or inducement
3. Patient should be aware that they have a right to withdraw consent at any
time without any penalty
4. In addition to the investigator, another individual should be encouraged to
monitor the patient’s condition and report any concerns
5. In placebo controlled trials patients must be aware of the probability of
receiving placebo and the possible effects of this.
ILLEGAL ACCIVITIES
• Health insurance fraud
• Falsifying medical reports
• Moonlighting
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