Ethics in Psychiatry

Australian psychiatrist, Professor Sidney Bloch, argues that ethics is a difficult area in psychiatry, as it has been historically neglected in their teaching and training. In the podcast below by The University of Melbourne, Bloch says: “Psychiatrists have been derailed from the job of helping those who are mentally ill.”

Here, I discuss Bloch’s key arguments, which relate to the historical misuse of psychiatry, issues of informed consent and how to teach ethical behaviour amongst psychiatry students and practitioners. I then discuss Bloch’s research on the competing theories of ethical care. In particular, he suggests a framework for how psychiatry might draw on several ethical principles, character traits and emotional knowledge in order to deliver better mental health treatment.

Dangerous misuse of psychiatry

In the podcast, Bloch talks through various historical examples where psychiatry has been misused, particularly by repressive regimes such as the use by the KGB in Russia and by the Nazi army. Bloch was part of the 1970s movement to change ethical practices within psychiatry. While many national and international psychiatric associations eventually adopted ethical codes, there are still some national associations that do not have an official code of ethics. This means that historical misuses in the field are not uniformly regulated around the world.

Bloch argues that psychiatry presents many ethical dilemmas that are “blurry”:

“We have to be vigilant, always. Psychiatry is a field of medicine where the boundaries are very blurred. Who’s mad and who’s not mad. Mad versus bad… The other problem which is awesome is that we have the power to detain people by law…. The power of that coupled with the blurred boundaries makes our job tough.”

Empathy: The missing piece of psychiatry

Bloch discusses how teaching ethics in psychiatry was largely absent in courses up until recent decades. In Australasia, psychiatrists have only had a standard code of ethics since 1994. It is now in its third edition. The code covers confidentiality as well as other issues of morality, such as crossing professional boundaries. For example, it was once considered permissible to marry a former patient, but today it is against the code of ethics to develop a sexual relationships with patients or former patients.

Bloch also about talks about maintaining professional and social boundaries in everyday settings, such as when a psychiatrist might help out a patient they see outside the office.

Informed consent

Informed consent is another thorny issue. Informed consent is about ensuring that a patient fully understands all the options available to them as well as the consequences of different forms of treatment. Informed consent has been abused in the past, in particular with testing new drugs. Patients who are mentally ill may be especially vulnerable to being manipulated or they may not have the mental and emotional capacity to give their full informed consent.

Bloch uses electroconvulsive therapy (“shock therapy”) as an example where informed consent is important because of the social anxiety this word conjures. This needs to be weighed against the patient’s needs and the potential for this treatment to improve their mental health. How does a psychiatrist suggest a course of treatment in a way that helps the patient be fully aware of their options without scaring them into one course of action over another? Empathy is important in navigating this tricky terrain.

Learning (and re-learning) empathy

Another important issue for ethics is keeping up with current scientific innovations. If a psychiatrist qualified 20 years a go, it is an ethical imperative that they continue reading the literature. Understanding new theories of treatment as well as new medicines takes ethical commitment.

Bloch argues that ethical training and ethical practice within psychiatry is ultimately a human rights issue. A code of practice might provide guidelines for ethical behaviour, but how does this work in everyday psychiatric encounters?

Bloch argues that empathy is central to ethical psychiatric practice. By empathy, Bloch means “putting oneself in the shoes of the patient. Not getting burdened by that but experiencing what they’re experiencing.” He suggests that training should make use of arts and literature to help psychiatry students learn how to exercise empathy. He suggests using stories like Leo Tolstoy’s “The Death of Ivan Ilych” to help develop students’ ability to understand how to read emotional responses. Bloch notes that psychiatrists are prone to getting hardened and distanced from patients’ emotional responses. He sees that this is counter-productive to understand the “needs of the patient.”

Bloch notes that there are an average of 200,000 medical encounters with patients over a psychiatrist’s career. Many of these are distressing. Nevertheless, Bloch advises:

“Don’t become routinised [sic]. Don’t become stereotyped. Don’t pigeon-hole yourself. Allow yourself to reflect constantly on what you’re doing. What impact somebody’s suffering is having on you. To remain always curious and interested. Find out about your patients beyond their symptoms. Learn about them as human beings.”

Theories of ethical practice

In an article published by the British Journal of Psychiatry, Bloch included a useful case study to illustrate the types of ethical dilemmas that psychiatrists may face. Issues of self-harm are not cut and dry. What are the rights of a patient who is acting erratically? If the patient is a mother who does not want to be hospitalised but there are small children involved is it better to put this woman into a facility? Or should a psychiatrist observe the patient’s right to self-determination? That is, to what extent should a psychiatrist listen to what the patient says they need versus what the people around them say?

There are competing psychiatric theories that dictate different courses of action. Deontological theory follows the work of German philosopher Immanuel Kant. This theory privileges the ‘moral dignity’ of the patient.

Utilitarian theory by J. S. Mill states that the ethical course of action is not really about balancing some fixed idea of right and wrong, but rather trying to maximise the best possible outcome or the “least worst” outcome. Bloch argues this is difficult to measure because benefits and risks in a given situation are often qualitative.

The theory of principlism (also known as principle-based ethics) was introduced by Beauchamp and Childress. It tries to blend four principles: “non-maleficence (first do no harm), beneficence (acting to benefit others), respect for autonomy (acting to acknowledge a person’s right to ‘ self-government’) and justice (treating people fairly).” The problem is that many of these tenets will conflict in practice. Should you lie to a patient if it will stop them from potentially harming themselves or those around them, even if they have not actually hurt anyone yet? What will this lie do the patient’s psyche later down the track?

Virtue theory draws on the work of Greek philosopher Aristotle. Rather than focusing on rules and principles that do not always fit different situations, this theory advocates the teaching of virtues. That is, promoting certain personal qualities in order to help psychiatrists behave ethically. These virtues include being generous, wise and approachable while also being cautious. Virtue theory also teaches that psychiatrists should maintain an active connection to scientific knowledge and routinely develop technical skills. The problems with this theory is that research is inconclusive about whether these virtues can be taught successfully to all psychiatrists. Are these virtues innate or can they be learned. And if they can be taught, can all psychiatrists successfully exercise these virtues? Being compassionate and conscientious are positive ideals to aspire to, but again, the needs of the patient may conflict with the interests of their partner, children and community.

Finally, the ethics of care theory draws on feminist and psychological developments on emotion research. This theory advocates teaching psychiatrists to recognise the complexity of human emotion, while reflexively developing the psychiatrist’s emotional training. The focus here is on “sympathy, compassion and patience.” Bloch writes: “In the clinical sphere we may illustrate this by empathising with patients’ emotions in order to understand more clearly their fears, wishes and needs, and then shaping treatment according to a unique life narrative.” This theory has been criticised for lacking “objective criteria” that psychiatrists can be trained to follow.

Bloch argues that one way to blend lessons from these varied perspectives is to use Scottish philosopher David Hume’s model of ethics. It blends the ideas of ethical rules together with character building. Its central idea is about learning to foster trust by exercising “patience, tact, honesty and discretion.” In the case of a disturbed mother and her family, a psychiatrist will need to listen to everybody’s concerns and carefully consider their conflicting emotional needs. The course of action needs to balance the benefits for the patient that will not be harmful later down the track. If it sounds a lot like the theories above, that’s because it draws on and extends the previous theories. The difference is that rather than teaching principles and ideals, psychiatrists are trained to read and respond to complex human emotions. It is by developing this emotional literacy first, that ethical training can then be put into effect.

Working ethically

Bloch argues that psychiatry is difficult in practice not simply because delivering mental health treatment is emotionally draining on the psychiatrist, their patient and their families. Psychiatry is also challenging because ethical care is not straight-forward. Rather than acting as an all-knowing force, Bloch encourages psychiatrists to consider multiple treatment options for their patients. At the same time, he argues that psychiatrists should take the time to ensure patients fully understand the various course of action for their treatment and their consequences.

Ethical psychiatry also demands ongoing emotion work. It means getting into the habit of thinking ethically, learning to read and respond to emotions rather than simply treating symptoms. It also means seeking advice from peers, as well as keeping abreast of the literature and community needs.

What other ethical considerations should psychiatrists be encouraged to learn?