Confidentiality The concept of confidentiality is central to any doctor±patient relationship, but especially in psychiatry where the essence of the relationship is com- plete disclosure by patients of their innermost motives and intimate areas of life. Yet the clinical setting on many occasions renders the concept very porous to the extent that it is virtually non-existent. Nurses, residents, social workers, psychologists, ward clerks, Medicaid reviewers and accreditation bodies read the patient's chart. So one may say that the great majority of people who see the patient's information do not have any personal interest in or knowledge of the patient and look at their charts in an administrative capacity [22±24]. Furthermore, the computerization of health care information has both positive and negative consequences. The sharing of information between health care professionals has become easier as transmission of data has been simplified. On the other hand, the security measures in place to protect personal information may be lacking. Unauthorized access or disclosure, therefore, becomes a greater concern for patients and may have a chilling effect on the disclosure of information by patients to their health care providers [25±29]. Psychotherapy Psychotherapy, in the broad sense, is an accepted component of many medical interventions and is an implicit or explicit part of the majority of physician±patient contacts. The specialty of psychotherapy is a complex of activity-related strategies to influence perception and behavior in order to eliminate or reduce mentally induced or associated disorders. It also helps patients to cope with physical illness or psychosocial burdens as well as to prevent illness. As such, the term ``psychotherapy'' describes in general a field of medical care and specifically a treatment method (a specialty field). Since it is not ethically acceptable to apply procedures of treatment for which there are no specific indications and no evidence of effectiveness and safety, and since medical treatments of any nature should be administered under the provi- sions of general good practice rules regarding their indications, effective- ness, safety, and quality control, this general rule should apply also to psychotherapy. In a more specific and restricted sense, psychotherapy comprises tech- niques involving verbal and non-verbal communication and interaction to achieve specified treatment goals in the care of mental disorders. It belongs to a complex of medical, cultural, spiritual and personal issues; therefore, 112 PSYCHIATRY IN SOCIETY the highest ethical behavior of the therapist is to be expected [30]. Because, by definition, psychotherapy engages intimate thoughts, emotions and fan- tasies, it may evolve into an intense physician±patient relationship. This may result in a situation in which power is unequally shared between therapist and patient, so that the latter may become extremely vulnerable. Psychotherapists should not use such vulnerability to personal advantage or transgress the boundaries established by the professional relationship. This refers not merely to sexual misconduct and abuse of patients by their therapists, but even more to the psychological processes that propel the therapist into the manifold forms of ``emotional exploitation'' and narcissis- tic abuse [31]. Thus, the general rules that apply to any medical treatment also apply to specific forms of psychotherapy in regard to its indications and outcomes, positive or negative. The risks of psychotherapy are varied and not to be underestimated: psychopathological deterioration, destruction of family relationships, financial burdens, juridical stress, etc. Psychotherapy should therefore be assessed in the same way as any other treatment in psychiatry with regard to criteria of indication, effectiveness, safety and quality control. Senf argues that the therapeutic task of psychotherapy is the effective treatment and prevention of disorders. This task is fulfilled only when the patient has received a diagnosis and the therapy specifically necessary for that diagnosis, and when there is an adequate relationship between the duration of therapy and outcome [32]. Price is doubtful about some of the propositions of this argument, even if it were clearly an ethical matter. He questions whether patients should be denied psychotherapy if the diagnosis is in doubt and refers to cases where diagnosis does not become clear until psychotherapy is well advanced and the patient is secure enough to confide fully in the therapist [33]. Regarding the combination with other therapies, Sultanov suggests that psychotherapy-pharmacotherapy should be proposed and explained to the patient each time it is medically indicated, and that psychotherapy alone should not be conducted when pharmacotherapy is also necessary for the treatment [34]. Counseling or Psychotherapy? Scientific psychotherapy as an established method of treatment of illness differs essentially from professional psychological counseling and other forms of ordinary counseling; individual psychological treatment tech- niques may have their own status within the field of counseling without, however, having a justified claim to be considered psychotherapy. It is therefore necessary to determine definite criteria in the sense of general THE NEW ETHICAL CONTEXT OF PSYCHIATRY 113 principles and obligatory standards with regard to both content and tech- nique as to what is to be considered scientifically supported psychotherapy for the treatment of illness, and what is not. Only in this manner can one stem the growing tendency to refer to any professional psychological coun- seling as psychotherapy. Senf identifies psychotherapy as a field of medical care, a method for the treatment of psychiatric disorders, while counseling is devoted mainly to problems of living, such as marital, sexual and family problems. He defines psychotherapy as a professional therapeutic action within the context and according to the rules of the public health system. It is a theoretically deduced and empirically secured setting to bring about goal-oriented changes in the perception and behavior of patients on the basis of well- founded and empirically secured theories on the management of mental disorders, and requires qualified diagnostic methods and differential diag- nosis, taking all available methods and procedures into consideration. It should therefore be a method that maintains ethical guidelines and carries out quality control [32]. Who Carries Out Psychotherapy? In view of the above definition, psychotherapy as a treatment method can only be carried out by professional therapists with recognized training, i.e., only medical doctors and psychologists with a university degree and both long-term theoretical and clinical training in a recognized center for psychotherapy [32]. Price argues that this statement is meaningless and potentially harmful in the absence of a clear definition of psychotherapy. He suggests classifying psychotherapy into the following three broad cat- egories: 1. Basic psychotherapy, which should be applied by all medical practitioners as it includes all the techniques for developing a good doctor±patient relationship and ensures that the patient remains in treatment with sufficient confidence in the doctor to take any recommended medica- tion. 2. General psychotherapy, which, he suggests, should be used by all psy- chiatrists and involves helping patients to cope with whatever chaos their lives are in and dealing with whatever factors seem to have precipitated the presenting illness. He recommends that this form of psychotherapy should not take much more than two or three sessions and that it should not be handed over to a nurse or other assistant unless it is clear that a more prolonged therapy is required. 114 PSYCHIATRY IN SOCIETY 3. Specialist psychotherapy, which aims at making fundamental and long- term changes in the patient's way of thinking, feeling and behaving. This form should be carried out by psychiatrists who have had special training over and above the general psychiatric training and who devote the majority of their time to the practice of psychotherapy [33]. An important question asked in that regard by Karasu is how much the definition of therapeutic goals in both psychodynamic and other psy- chotherapies depends upon the therapist's concept of man [35]. Is it adjust- ment, optimal adaptation to the social environment as if the meaning of human life were integration with and adjustment to others? Or is it the maximal development of the patient's potential, as if the criteria of a healthy existence were only within the individual human being? [36] With regard to their own values, therapists need to keep their ``ethical countertransference'' under constant observation [37]. In any case, psychotherapists should be particularly sensitive to boundary violations, whether these are of a sexual nature, or for narcissistic, financial, academic or professional gains. Senf also suggests that in order to satisfy the therapeutic task, psychotherapists must be instructed in more than one psychotherapeutic procedure. Training in only one psychotherapeutic procedure increases the risk that patients will not receive the therapy they need. If psychotherapy is seen as a scientific discipline which can be both taught and learned, it must in principle be possible to carry out parallel training, or, after extensive training with the emphasis on one procedure, to proceed to another. However, he argues that the danger of unsystematic eclecticism void of theories on illness and treatment must be considered [32]. As in any other form of therapy, informed consent must be obtained for the application of psychotherapy, particularly such that the benefits and risks are fully understood by the patient. Informing the patient should be part of the initial stage of the therapeutic process. It is also the duty of the psychiatrist to protect patient privacy and confidentiality as part of preserv- ing the healing potential of the doctor±patient relationship. At the initiation of psychotherapy, the patient should be advised that the contents and any materials produced will be kept in confidence, except where the patient gives specific permission (after being well informed of the reasons) or in exceptional circumstances of unavoidable serious risk to a third party from the patient, as in serious child abuse, or serious risk to another or the patient (e.g., cases of potential violence). Patients are also entitled to know of any possibilities of disclosure to third parties: e.g., to paying third parties/ insurance companies, to other (supervising) colleagues, or in scientific pub- lications of individual cases. THE NEW ETHICAL CONTEXT OF PSYCHIATRY 115 Involuntary Hospitalization Psychiatry accepts the clinical responsibility of determining which individ- uals, on the basis of mental disease and the law, shall be deprived of autonomy rights by involuntary commitment to receive protection and perhaps treatment through clinical services. This burden of judgment and responsibility weighs heavily on the physician±patient relationship and on the professional identity of the physician. Psychiatrists perceive their dis- cipline as being at risk when their assertion of this authority is criticized by society and by the patient whose autonomy rights are compromised. The Steering Committee on Bioethics (CDBI) of the European Community stated that deprival of liberty as a result of involuntary placement or admin- istration of an involuntary treatment should always be accompanied by procedures to protect the rights of the person concerned [38]. Criteria for such involuntary placement involve the existence of a mental disorder which represents a serious danger to the person concerned, including to his/her health, and/or a serious danger to other persons (provided that the placement or the treatment or both are likely to be beneficial to the person concerned in all cases). The CDBI stated that the patient must be examined by a psychiatrist or other medical doctor and the decision for involuntary placement should be confirmed by a relevant independent authority, which should base its deci- sion on valid and reliable standards of medical expertise. The committee, however, distinguished between involuntary placement and involuntary treatment, where the latter does not necessarily follow from the former. It stated that a distinction should be made between the legal ground for involuntary placement and the legal ground for involuntary treatment; i.e., involuntary admission as such does not mean that patients can in any event be treated against their will, nor that involuntary treatment should inevitably require involuntary placement. The UN resolution on the rights of mental patients, issued in 1991, states that involuntary admission or a voluntary patient's being retained as involun- tary shall occur only if a qualified psychiatrist authorized by law for that purpose determines that that person has a mental illness and considers that there is a serious likelihood of immediate or imminent harm to that person or other persons, or that failure to admit and treat may lead to serious deterior- ation of that patient's condition. A second opinion should be obtained where possible and if the second opinion is not in agreement, involuntary admission or retention should not take place. It also states that a mental health facility may receive involuntary patients only if the facility has been designated to do so by a competent authority. Once involuntary admission has taken place, a review body, consisting of one or more independent psychiatrists, should periodically review the case to consider whether the criteria for involuntary 116 PSYCHIATRY IN SOCIETY admission are satisfied. The resolution also states that an involuntary patient can apply to a review body for release or voluntary status. In reality, the distinction between voluntary and involuntary admission is not as clear as stated in the law. Patients are often induced or pressured into accepting voluntary admission. If voluntary admission were to be main- tained as truly voluntary, involuntary admissions would be likely to in- crease. The family role is strong in ``enforcing'' voluntary admissions in traditional societies, which have no need for involuntary admissions. In traditional societies respect for and obedience to family decisions exceed the autonomy of the individual in importance. Gardener et al. reported that an influential rationale for involuntary hospitalization is that prospective patients who refuse hospitalization at the time it is offered are likely to change their belief about the necessity of hospitalization after receiving hospital treatment [39]. Many patients who initially judged that they did not need hospitalization revised their belief after hospital discharge, and admitted that they had needed hospital treatment. However, perceptions of coercion were stable from admission to follow-up, and patients' attitudes toward hospitalization did not become more positive. Coerced patients did not appear to be grateful for the experience of hospitalization, even if they later concluded that they had needed it. Euthanasia The ethical question of physician-assisted suicide continues to be an issue of controversy, such suicide being strongly opposed by some organizations, e.g., the WPA, the American Medical Association (AMA) and the American Psychiatric Association (APA), and equally strongly supported by others. Many concerns have been raised about the inexact standards for determin- ing which patients are truly terminally ill and at the end of life. In addition, questions have been raised about whether physician-assisted suicide re- quests are truly those of the patient or those of caretakers who may under- standably wish to be relieved of their care burdens. The Bioethics Declaration of Gijyn recommends that the ethical debate on end-of-life issues should be continued in order to analyze in depth the different ethical and cultural conceptions in this context and in order to assess the way to their harmonization [16]. Although laws may allow physician-assisted suicide in the future, the place of psychiatrists would most likely be in assessing competence and the presence or absence of a psychiatric illness influencing the patient's deci- sions. The Madrid Declaration stresses that the physician's duty is, first and foremost, the promotion of health, the reduction of suffering, and the protection of life. The psychiatrist, among whose patients may be some who THE NEW ETHICAL CONTEXT OF PSYCHIATRY 117 are severely incapacitated and incompetent to reach a decision, should be particularly careful of actions that could lead to the death of those who cannot protect themselves because of their disability. The psychiatrist should be aware that the views of a patient might be distorted by mental illness such as depression. In such situations, the psychiatrist's role is to treat the illness. Ethical Questions Arising from Managed Care Systems The UN Resolution 46/119 for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care calls upon all national govern- ments to adopt appropriate legislative, juridical, administrative, educative and other provisions to ensure the right of every human being to the best mental health care available, stated as the ``right to receive such health and social care as is appropriate to his or her health needs'' (principle VIII) [2]. The implication of that principle is that this human right will be violated in all places where the best possible care is not available, as through lack of financial or organizational/administrative resources. Therefore, the author- ities are obliged to try to overcome this lack in order to provide the best possible therapy according to the most developed psychiatric knowledge, experience, and technique. These problems of resource allocation, which are currently growing rap- idly worldwide, as well as new challenges through progress in research, led the WPA to make the guidelines more specific. Probably the greatest chal- lenge as we move into the 21st century will continue to be the changing economic influences in psychiatric treatment as well as the business focus in patient care. The business focus has often created a dilemma for the psy- chiatrist as both clinician and administrator, or clinician and stockholder. If psychiatric ethics move to more of a business ethic, the traditional covenant of trust between doctor and patient may be irrevocably shattered. It would mean moving from that covenant to a corporate ethic of doing the least for your customers without dissatisfying them [40, 41]. Current market forces are demanding high-quality health care with im- proved access and at the lowest possible cost. In addition, there is a new emphasis on accountability both to the payers of insurance and to the public. With regard to the issue of providing quality care at the lowest possible cost, there are considerable pitfalls in the marketplace. The current competitive nature of psychiatric care is driving down the amount of funds that payers are providing for psychiatric and substance abuse treatment. This is especially true in mature managed care markets using capitation as a form of payment. Unfortunately, capitation rates continue to fall while comprehensive psychiatric services are being promised. This leaves many 118 PSYCHIATRY IN SOCIETY to wonder whether there is honest disclosure of what will be provided and the real limitations once capitation rates have fallen significantly. Some ethicists see no more peril in managed systems of care than in fee-for-service systems [42]. The influence of managed care and third-party payers in mental health services has changed not only the doctor±patient relationship, but also the disclosure of information. The obligations of managed care organizations toward shareholders regarding maximization of profits and minimization of costs may conflict with the principles of good clinical practice. Psychiatrists working in man- aged care organizations should uphold the needs of the patients and the rights of the patient to the best treatment possible above considerations of cost or organizational demands. In agreement with UN Resolution 46/119, psychiatrists should not imple- ment policies directed against parity of benefits and other entitlements and should desist from work under conditions of discrimination against the mentally ill (e.g., parity and entitlements) or against any other group of patients. In the field of psychiatry, practitioners should uphold the well-being of their patients above considerations of expenditure to save costs. However, while professional independence to apply best practice guidelines and upholding the welfare of the patient should be the primary considerations for a psychiatrist working in or out of managed care organizations, it is also true that working for them entails a commitment to the profit-making of those organizations. It is also the duty of the psychiatrist to protect patient privacy and confidentiality as part of preserving the healing potential of the doctor±patient relationship. Unless managed care is a component of a general health policy based on equity and access to services, it will be an obstacle to patients' proper management opportunities. Because of the diversity, not only of mental patients, but also of the mental illnesses they have, mental patients within the present privately based insurance system may suffer from discrimin- ation due to lack of parity with other medical conditions. Psychiatrists should be aware of mental health care policies and systems that discriminate against mental patients, should oppose those policies against parity of benefits and other entitlements, and should refuse to work under conditions of discrimination against any group of patients in any way. They should oppose discriminatory practices against mental pa- tients that limit their benefits and entitlements, curb the scope of treatment or restrict their access to proper medications. In that context it would be unethical for psychiatrists to collaborate with any form of mental health care service that varies from the existing consensus guidelines for ethical and quality standards in the treatment of mental disorders. THE NEW ETHICAL CONTEXT OF PSYCHIATRY 119 Torture and the Death Penalty The Declaration of Hawaii, prepared by Clarence Blomquist and adopted by the General Assembly of the WPA in Hawaii in 1977, was the first position statement of the psychiatric profession aiming to encourage psychiatrists in conflicts of loyalty in contemporary societies and to help them in conflicts of psychiatric decision-making. A major trigger was the political misuse of psychiatry in countries such as Nazi Germany, the former Soviet Union, Romania, and South Africa that came to public awareness during the early 1970s. The rationale for physicians to be a state tool against individuals recognized by the state as enemies is reminiscent of how German physicians justified their involvement in the torture and killing of thousands of inno- cent human beings and carried out the Nazi programs of sterilization and ``euthanasia'' by murdering countless children and adults. The very first paragraph of the Declaration is concerned with the ethical problem of the political misuse of psychiatric concepts, knowledge and techniques, stating that the psychiatrist shall serve the best interests of the patient and treat every patient with the solicitude and respect due to the dignity of all human beings, and that psychiatrists must refuse to cooperate if some third party demands actions contrary to ethical principles [43]. Other ethical statements have underlined the same principles. The UN Principles of Medical Ethics (1982) states in its second principle that it is a gross contravention of medical ethics as well as an offense under applicable international instruments for health personnel, particularly physicians, to engage actively or passively in acts which constitute participation in, com- plicity in, incitement to or attempts to inflict torture or other cruel, inhuman or degrading treatment or punishment [44]. The WPA Declaration on the Participation of Psychiatrists in the Death Penalty states that psychiatrists are physicians and must adhere to the Hippocratic oath; they must practice for the good of their patients and never do harm [45]. They should therefore refuse to enter into any relationship with prisoners other than one directed at evaluating, protecting or improving their physical and mental health. The Madrid Declaration (1996) states clearly that a psychiatrist should not take part in any process of mental or physical torture, even when authorities attempt to force their involvement in such acts [1]. While those statements seem to be stressing the obvious, considering psychiatrists' commitment to the well-being of their patients, the issue has not been without controversy, especially when it comes to the death penalty. Appelbaum argues that a forensic psychiatrist in truth does not act as a physician: ``If the essence of the physician's role is to promote healing and/ or to relieve suffering, it is apparent that the forensic psychiatrist operates outside the scope of that role. Were we to call such a person a forensicist or some similar appellation, it might more easily be apparent that a different 120 PSYCHIATRY IN SOCIETY non-medical role with its own ethical values is involved'' [46]. In response, a joint monograph issued by the American College of Physicians, Human Rights Watch, Physicians for Human Rights and the National Coalition to Abolish the Death Penalty objects that ``this claim ignores the reality that forensic practitioners . . . are physicians in the eyes of the public, the courts and even their examinees. Equally worrisome is the open-endedness of the claim that forensic physicians do not function as doctors.'' Psychiatrists may indeed be torn between traditional ethical principles and strong pressures from society, particularly certain segments of the legal profession, to compromise ethically and become collaborators with the demands of the law [47]. Freedman and Halpern argue that rather than look for compromises, psychiatrists must return to traditional concepts of medicine and psychiatry as a profession of care, compassion and healing. They should join in the struggle to uphold ethical and moral principles, or they will reap a whirl- wind of public condemnation [48]. RELATIONSHIP WITH THE MEDIA Over the past years, it has been within the mandate of the WPA, its member societies and the APA to erase the stigma against mentally ill subjects. While the tools for undertaking this mission certainly include conveying correct informative messages and educational material to both patients and their families, psychiatrists also have an obligation to create a public understand- ing of mental illness, acceptance of the mentally ill and rejection of social or other forms of discrimination based on mental illness. Major steps have been taken internationally in that respect regarding physical disability. However, the social attitude toward mental disability has not followed at the same pace. One important tool in this aspect is the mass media. The media has a key role in shaping the perceptions and attitudes of the community, and an important role of psychiatrists is to advocate those people who suffer from mental disorders. Affirmative use of the media by psychiatrists is important for a variety of goals of good mental health care, for the destigmatization of mental disorder and that of mental patients. In all interactions with the media, the primary role of psychiatrists is to be advocates of the mentally ill and to maintain the dignity of the profession. They should be mindful of the effect of their statements on the public perception of the profession and patients, and abstain from making state- ments or undertaking public activities that may be demeaning to either. Psychiatrists should ensure that people with mental illness are presented in a manner which preserves their dignity and privacy, and which redu- ces stigma and discrimination against them. As the public perception of THE NEW ETHICAL CONTEXT OF PSYCHIATRY 121 [...]... collectivity of decision-making, 124 PSYCHIATRY IN SOCIETY Table 5. 1 Main differences concerning the positions of individuals within their community in a traditional vs a Western society Traditional society Family and group oriented Extended family (not so geographical as before, but conceptual) Status determined by age and position in the family; care of elderly Relationship between kin obligatory Arranged... would thereby be approaching the issue of consent in a broader framework than on the concrete day-to-day information In any case, the patient's wishes should be respected Allowing patients to choose a family-centered decisionmaking style does not mean abandoning our commitment to individual autonomy or its legal expression in the doctrine of informed consent Rather, it means broadening our view of autonomy... time, increasing numbers of people in industrial nations were confined in psychiatric hospitals in a movement that resulted in a peak inpatient population in the mid 20th century Even then, probably half of all people who had received a diagnosis of schizophrenia would have been living in ordinary households, although it must be said they received relatively limited professional care In developing countries,... (1991) Principles for Policy in Mental Health UN General Assembly, December 17 Slovenko R (1999) Malpractice in psychotherapy: an overview Psychiatr Clin North Am., 22: 33±36 Veatch R.M (19 95) Abandoning informed consent Hastings Cent Rep., 25: 71 Lederer S.E (19 95) Human Experimentation in America Before the Second World War Johns Hopkins University Press, Baltimore Weisstub D.N (1998) Roles in clinical... 132 PSYCHIATRY IN SOCIETY Over the last 50 years, there has been a progression of increasingly complex ideas about the nature of community psychiatry, starting from the simple relocation of old structures and hierarchies outside hospital, to the refinement by professionals of treatment arrangements in the community and, finally, to the conceptualisation of treatment provided within systems involving... of these trials [ 25, 50 53 ] were disappointing Like ACT, they did not deliver consistent improvements in clinical or social outcome, but did improve the numbers of patients remaining in contact with services If anything, costs were increased So, for example, the UK700 trial included 708 patients with psychotic disorders and a history of frequent hospital admission in four centres [54 ] They were randomised... communal level, in the best perceived collective interest The belief in the universality of implementing similar ethical codes in all cultures and societies is a mirage Informed consent, involuntary admission and confidentiality are not so empowering in some traditional and Eastern societies, representing two-thirds of the world's population Autonomy versus family-centered decision is one of the main areas... of ethics Aust N Z J Psychiatry, 32: 7 85 793 Szmukler G (1999) Ethics in community psychiatry Aust N Z J Psychiatry, 33: 328±338 Felthous A.R (1992) The clinician's duty to protect third parties Psychiatr Clin North Am., 22: 49 55 Jonas C (1999) The psychiatrist, information and confidentiality Ann Med Psychol (Paris), 157 : 263±268 Grunwald M., Veyrat J (1999) The psychiatrist, information and confidentialityÐDiscussion... is invariably defined in contrast to what preceded it, that is, the incarceration of huge numbers of mentally ill people in large psychiatric institutions Although the initial impulse towards the creation of these institutions in the 19th century was humane and therapeutic, this was lost as the numbers of people that were accommodated increased [4, 5] In both the USA and the UK, the numbers peaked in. .. demands of social interaction [16]) By being obliged to cope with these things repeatedly, people discharged after a long stay in hospital would recover old skills and develop new ones These beliefs about the benefits of community living were the initial drivers of the reduction in long-term psychiatric hospital bed use seen in the USA and the UK in the two decades from 1 955 to 19 75 They presuppose . required. 114 PSYCHIATRY IN SOCIETY 3. Specialist psychotherapy, which aims at making fundamental and long- term changes in the patient's way of thinking, feeling and behaving. This form. third parties: e.g., to paying third parties/ insurance companies, to other (supervising) colleagues, or in scientific pub- lications of individual cases. THE NEW ETHICAL CONTEXT OF PSYCHIATRY 1 15 Involuntary. repre- sent the profession of psychiatry with dignity. In presenting research find- ings to the media, psychiatrists should ensure the scientific integrity of the information given and be mindful