Interview conducted by Lyzia Zarda and published in the World Congress News, Official Newspaper of the 19 th WPA World Congress of Psichiatry.
During a plenary session this morning, João Marques Teixeira (Faculty of Psychology and Educational Sciences, and Faculty of Medicine of the University of Porto) discussed ethics and care of people with mental illness. Ahead of the meeting, he discussed some of the ethical issues facing contemporary psychiatry.
In ‘Modern Psychiatry Ethics”, Welsh and Deahl (2002) write that, while other specialties see a rise in patient autonomy, “power over individuals and its consequent restriction of freedom will always distinguish psychiatry from other medical specialties. The power to detain and treat a person against their will forms the backbone of the psychiatric profession.” Does this hold today?
The exceptional character of the psychiatrist’s relationship with his patient is dependent on the characteristics of mental illness.
Related to this, we have to divide the patients into two groups: those whose illness only results in a mild decrease in their degrees of freedom of the being (e.g. patients with generalised anxiety disorders or reactive depressions), and others whose consequences are a profound attenuation of the degrees of freedom of being (e.g. psychotic patients).
With regard to the former, their weaknesses are equivalent to those of all other patients and result from their inability to be normative about personal or social conditions. We can look at these casesas we look at a patient with a pathology of any other specialty.
The problem arises in relation to the second group of patients. These present serious changes in their degrees of freedom of being, which result in the loss of freedom to behave. This has serious consequences, like the loss of awareness of needs, the loss of ability to ask for help and support, the loss of ability to participate in the community, the loss of ability to function independently, the loss of capacity for vocational participation, the loss of ability to play significant social roles and the loss of autonomy. They have what we might call a ‘pathology of freedom’.
The specific vulnerabilities of this type of patients require not only a very strong code of ethics, specific and rigorous, but also a virtuous character of the psychiatrist to supplement and augment the ethical code with an emphasis on personal responsibility and proper moral psychology. To deal with these patients in such a way as to give them as much autonomy as possible will require emphasising the issues of character formation and moral psychology in the framework of a theory of virtue, which will improve our understanding of the ethical requirements of psychiatric practice. This seems to me to be the way to overcome the issues of abuse of power. In short: not just doing the right thing, but also for the right reason.
How are these issues influenced by the provisions of the Convention on the Rights of Persons with Disabilities, where at present we witness an impasse over how obligations in relation to non-consensual treatment are implemented?2.3 How should the psychiatry community respond?
This question is very delicate. It is a matter of reconciling one need with one right (the need to guarantee the issues of autonomy with the right of patients to be treated well). The issue becomes extreme in relation to compulsive treatment and informed consent.
Let us analyse the act of consent. Any of us, to consent to anything, need clear and understandable information about it, a willingness to make a free choice, and the ability to do so. This varies depending on the degree of autonomy or decision-making ability.
The question today is less whether compulsive treatment should or should not exist, but more under what circumstances it should occur.
João Marques Teixeira
In the case of patients who have their autonomy impaired together with an absence of disorder awareness, how to act on the principle of beneficence? On what basis can compulsive treatment be based?
Obviously, the protectionist intention is a double-edged sword: while it must be acknowledged that there are good reasons for regulating interventional practices for the severely mentally ill, the therapeutic purpose of increasing patient autonomy is lost.
In this respect,the law should be specific where ethics should be generic. However, this specificity has risks: the best interests of a particular patient may not be achieved by procedures for the psychiatric population as a whole. Moreover, the deduction of moral rules that must be applied must be made without regard to the uniqueness of the persons involved. However, the clinic is essentially individual, where practitioners usually make appropriate and defensible decisions from the point of view of moral evaluation.
Border cases are the ones that have raised the most problems. Do these patients have the capacity to exercise their autonomy in all its fullness? Are there well-established criteria for defining them? Is the impairment of understanding and, consequently, of decision making capacity permanent or transient? Is the compromise of the reality judgment, transient or not, a condition capable of just
These issues claim that informed consent will need to be adjusted to the degree of autonomy of patients. Different levels or degrees of consent should be defined and thus try to maintain the relative autonomy of the patient by deciding on the degree of their competence.
It is therefore up to the physician, in assessing the patient’s ability to consent, to attempt to define the patient’s degree of autonomy and competence in order to specify what level of consent should be required (see, e.g., Appelbaum (2007)5 for assessment of consent in general medicine). The purpose of imposing beneficence is justified because this act will prevent suffering or pain to anyone; that of nonmaleficence is justified, because this act will remove a suffering or a pain from the other. That is, they propitiate well-being to the other.
In the field of psychiatry, there is much work to be done in terms of concrete medical ethics in defining and assessing the degrees of freedom/autonomy of psychiatric patients with borderline pathologies, long before moving to legislation. Therefore, the question today is less whether compulsive treatment should or should not exist but more under what circumstances it should occur.
Is the thematic shift in psychiatry that we are currently witnessing, from the biomedical to a greater emphasis of the social and cultural, interlinked with this question?
I think there is no connection between theoretical movements within psychiatry and ethical issues. Violation of medical ethics has more to do with praxis than theory.
What concerns me on this plane is the reductionist view, whether biological or psycho-social. If consideration of psycho-social variables comes at the expense of excluding biological variables, then we are not rendering the best service to the patient, as the opposite is also true. A mind does not fall ill out of a body and mental illnesses are specifically behavioral disorders. And behavior always results from the interaction between a body and a mind within a socioecological context.
The law should be specific where ethics should be generic. However, this specificity has risks.
João Marques Teixeira
What would you like readers to think about, given that many of them are psychiatrists and therapists at the edge of these ethical debates surrounding the psychiatrist-patient relationship and the care system. Should they be advocates or allies, and is there any conflict there? In ‘Working in a Flawed Mental Health Care System: An Ethical Challenge’, Green and Bloch argue that “since flawed systems undermine fidelity, threatening the patient’s interests, psychiatrists are morally responsible for working to improve such systems.” Would you agree?
Completely. But the question is another: How can they do it?
I think they can do it only by one way: by developing their virtuous character. And this is only possible if they apply themselves in their training, along with technical-cognitive training, their development as a person. That is to say that, like any other doctor, they have a deontological duty to always be up to date theoretically, but perhaps more than any other physician they also have a duty to bear the virtue that seems to me to be a very appropriate way of observing ethical principles in clinical praxis.
In this sense we will have psychiatrists in the true accession of the word:
■ they are not only to deal with mental disorder, but also to take care of the suffering of the person who has it, either in relation to the means used, or in view of the aims to which they aspire;
■ they should aim at achieving the greater good (principle of beneficence), which best represents the result of his intervention, or non-intervention, while maintaining respect for the degree of autonomy of the patient, who is responsible for deciding what seems best to him, or to the best of their ability, by their lucid (or as lucid as possible) consideration and deliberation, from the explanations provided to them with sufficient exemption;
■ they should remain zealous and serene, continually under the sign of methodical doubt, of Cartesian inspiration;
■ under the categorical imperative of the Hippocratic primum non nocere (principle of nonmaleficence), to rescue or maintain the innate quality of human potential, which implies, among others, to treat the mentally ill without narrowing the inner space of their imagination and that of its affectiveconative dimension;
■ under the precautionary principle, weigh the supposed benefit/harm of new technologies or therapeutic resources of validity or safety not yet proven;
■ and preserve the mind even of a tempting cosmetic artificiality.
With this type of procedures we will have a psychiatrist caring for the interests of patients, focused on the real possibilities of updating the potential of each of their patients.
References
1. Welsh S, Deahl MP. Modern psychiatric ethics. Lancet. 2002 Jan 19;359(9302):253-5.
2. Martin W. Gurbailnt S. Surveying the Geneva impasse: Coercive care and human rights. J Law Psychiatry. 2019 May-Jun;64:117-28.
3. Szmukler G. “Capacity”, “best interests”, “will and preferences” and the UN Convention on the Rights Of Persons With Disabilities, World Psychiatry, 2019 Feb; 18(1):34-41
4. Green SA, Bloch S.Working in a flawed mental health care system: an ethical challenge. Am J Psychiatry. 2001 Sep;158(9):1378-83.
5. Appelbaum P. Assessment of Patients’ Competence to Consent to Treatment. N Engl J Med 2007;357:1834-40.