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ETHICS LECTURE – Dr D. Lyons
Ethics derived from the Greek
word ETHIKOS, meaning
disposition
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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’s
Abortion
Adultery
Alcoholism
Association (with non-medically qualified physicians or
quacks)
Advertising
Of all these ‘evils’ the Medical Council was dedicated to
stamping out, most objectionable was advertising
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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?
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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).
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Non malfeasance (avoiding the causation of harm.
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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.
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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
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Consider all factors and individual
actuation
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Weigh up relative importance of each
principle
Psychiatry – A Special Case
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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’s
Chains removed from his patients.
Rise of the Asylum (York Retreat)
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Asylums became overcrowded – pessimism about mental
illness.
Twentieth Century: Rise of
psychiatric profession.
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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
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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
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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.
Psychiatric Ethics
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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
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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
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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.
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Is this a rational suicide?
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Should we as doctors respect his wish to
die with dignity?
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Must we force him to live to endure
continuing pain and despair?
Practical Dilemmas - 2
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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.
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Is her wish to die irrational?
If she refuses admission to hospital, is it justified to
deprive her of her liberty?
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Practical Dilemmas – 3
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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.
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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?