Ethics from the lens of the social dimension of psychiatry

IF 73.3 1区 医学 Q1 Medicine
World Psychiatry Pub Date : 2024-09-16 DOI:10.1002/wps.21238
Sam Tyano
{"title":"Ethics from the lens of the social dimension of psychiatry","authors":"Sam Tyano","doi":"10.1002/wps.21238","DOIUrl":null,"url":null,"abstract":"<p>From a historical perspective, Engel<span><sup>1</sup></span> conceptualized psychopathology as resulting from an interaction of three orders of factors: biological, psychological and social. The first half of the 20th century has been mostly devoted to conceptualizing the psychological component of mental disorders, the second half to the understanding of the biological component. We are now, in the 21st century, busy at better understanding the role of social processes that impact treatment approaches to psychopathology as well as the psychiatrist-patient relationship.</p>\n<p>Even more than other medical disciplines, psychiatry is influenced by external events that plague society, such as epidemics, natural disasters and wars. These events often require the involvement of ethics committees that will determine the duties and rights of the physician in potentially conflictual ethical contexts, such as triage situations (i.e., choosing whom to treat first). The COVID-19 pandemic has shown how deeply interwoven the epidemiology of mental disorders and the access to mental health services are with both social factors and somatic health. Grief, isolation, loss of income and fear exacerbate existing mental health problems or create new ones. The pandemic has demonstrated that the biological and social dimensions of medicine and public health are inextricably linked<span><sup>2</sup></span>.</p>\n<p>Profound changes in social values and norms, such as the legitimization of medical procedures for transgender individuals, or the availability of euthanasia in some countries, require a redefinition of the psychiatrist's role within the medical staff, and the development of ethical guidelines that take into account a variety of emotional, religious and ideological aspects pertaining to both the patient and the physician.</p>\n<p>This changing scenario is extensively reflected in Galderisi et al's paper<span><sup>3</sup></span>. I will focus here on three of the issues discussed by the authors. The first is stigma related to mental disorders in society in general, and particularly in the medical world. Studies documenting the importance of social/environmental components in the development of psychopathology<span><sup>4</sup></span>, as well as those showing the close relationship between physical illness and emotional states, have contributed to reduce that stigma. The inclusion of psychiatric wards within general hospitals has been both a consequence and a further determinant of this evolution. Likewise, the importance of the psychiatrist's presence in transdisciplinary medical teams, as well as in hospital ethics committees, has become more obvious than in the past. It is also increasingly clear that codes of ethics of physical medicine and psychiatry overlap to a large extent, especially with regard to the therapist-patient relationship.</p>\n<p>The second topic I wish to emphasize is the changing relationship between psychiatrists and representatives of patients and families. In the recent past, we witnessed against-psychiatry demonstrations by former hospitalized patients, their families and human rights organizations. Our involvement at the societal level has led to a move from a paternalistic stance to a more listening, egalitarian position. We have started to invite those demonstrators to “cross the street”, to come and participate in our meetings to share with us their point of view and to discuss with us the dilemmas regarding issues of quality of life, patients’ rights, effectiveness of our treatments versus side effects, and coercive situations, in a context marked by mutual respect. Today, in many countries, representatives of psychiatric patients are invited to participate in committees that discuss these issues and allocate resources for research. In some countries, former patients and/or their relatives also participate in teaching medical students and residents. This collaboration has increased the transparency of our ways of thinking and working, and is contributing to reduce the stigma attached to psychiatry. This change of attitude is clearly reflected in the WPA Code of Ethics<span><sup>2</sup></span>.</p>\n<p>One of the issues that remain conflictual, and feed the stigma towards the psychiatric profession, is the use of coercive measures, that seems to deny the patient's right to autonomy, one of the four basic principles of any medical code of ethics, along with beneficence, non-maleficence and justice<span><sup>4</sup></span>. The term autonomy reflects the patient's right to refuse medical treatment. In the case of a psychotic patient, the definition of “autonomy” is very complex, as the patient's “free” will is colored by his/her psychotic symptoms and lack of insight. The goal of treatment, including coercion, is to restore the patient's judgment capacity necessary for independent functioning. The growing attention to this issue has already led in many countries to a decrease in the number of involuntary hospitalizations and physical coercive measures, and the increasing use of alternative treatment solutions, such as the development of crisis units and “balancing houses” in the community, as an alternative to hospitalization<span><sup>5, 6</sup></span>.</p>\n<p>Another issue related to the patient's right to autonomy is that of euthanasia. What is the psychiatrist's role, if any, in the process of fulfilling a patient's desire to end his/her life while freely choosing to prioritize quality of life over longevity? The renowned surgeon C. Bernard stated: “I have learned in my many years that death is not always the enemy. Sometimes it is the right medical treatment. It often achieves what medicine could no longer offer – an end to suffering”<span><sup>7</sup></span>. In my opinion, the psychiatrist has two roles in this respect: the first is to make sure that the patient's request is given out of “clarity of mind”, the second is to ascertain that the patient's wish to die is not a masked suicidal intent secondary to the psychopathology from which he/she suffers. Unfortunately, tools for a truly reliable assessment of these issues are not available.</p>\n<p>A recent development regarding euthanasia is the ethical legitimation for the psychiatrist to act in accordance with his/her moral and/or religious views, possibly (but not necessarily) deferring the question to a colleague who agrees to be part of the medical team that is supposed to examine the request. It is important to discuss this issue with medical students and residents during their professional training.</p>\n<p>Unfortunately, teaching of ethics does not occupy an adequate place in professional curricula, in psychiatry as in other medical disciplines. Also, the number of national psychiatric associations that have produced their own code of ethics is minimal, probably also due to the feeling that the existence of a code of ethics is a coercive factor that limits the clinician's freedom of action. We need to emphasize the advantages of having a code of ethics, such as the personal moral and legal protection that a set of guidelines provides to the psychiatrist in the implementation of his/her values and expertise. This protection is very important, especially in situations where the patient's best interest is not clear or is in conflict with the professional best practice.</p>\n<p>Particularly neglected in psychiatry and other medical professions is the ethics of clinical management in children and adolescents. For example, to whom should the psychiatrist extend fidelity: to the child, to the guardian, to the family as a whole, to the referring agency, to the institution that pays him/her? Even though the child's consent is clinically essential, it is not required by law. Nevertheless, the psychiatrist should aspire for the child to have a good understanding of the therapeutic process, according to his/her age and cognitive and emotional development.</p>\n<p>In conclusion, we better appreciate nowadays the interplay between society and psychiatry. National and international ethics committees must be involved in this “dialogue” between the patient's rights and the psychiatrist's duties and rights. Increasing transparency of the diagnostic and treatment processes can lead to a partial, but very significant, reduction of the stigma attached to mental disorders and our profession.</p>","PeriodicalId":23858,"journal":{"name":"World Psychiatry","volume":null,"pages":null},"PeriodicalIF":73.3000,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"World Psychiatry","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1002/wps.21238","RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q1","JCRName":"Medicine","Score":null,"Total":0}
引用次数: 0

Abstract

From a historical perspective, Engel1 conceptualized psychopathology as resulting from an interaction of three orders of factors: biological, psychological and social. The first half of the 20th century has been mostly devoted to conceptualizing the psychological component of mental disorders, the second half to the understanding of the biological component. We are now, in the 21st century, busy at better understanding the role of social processes that impact treatment approaches to psychopathology as well as the psychiatrist-patient relationship.

Even more than other medical disciplines, psychiatry is influenced by external events that plague society, such as epidemics, natural disasters and wars. These events often require the involvement of ethics committees that will determine the duties and rights of the physician in potentially conflictual ethical contexts, such as triage situations (i.e., choosing whom to treat first). The COVID-19 pandemic has shown how deeply interwoven the epidemiology of mental disorders and the access to mental health services are with both social factors and somatic health. Grief, isolation, loss of income and fear exacerbate existing mental health problems or create new ones. The pandemic has demonstrated that the biological and social dimensions of medicine and public health are inextricably linked2.

Profound changes in social values and norms, such as the legitimization of medical procedures for transgender individuals, or the availability of euthanasia in some countries, require a redefinition of the psychiatrist's role within the medical staff, and the development of ethical guidelines that take into account a variety of emotional, religious and ideological aspects pertaining to both the patient and the physician.

This changing scenario is extensively reflected in Galderisi et al's paper3. I will focus here on three of the issues discussed by the authors. The first is stigma related to mental disorders in society in general, and particularly in the medical world. Studies documenting the importance of social/environmental components in the development of psychopathology4, as well as those showing the close relationship between physical illness and emotional states, have contributed to reduce that stigma. The inclusion of psychiatric wards within general hospitals has been both a consequence and a further determinant of this evolution. Likewise, the importance of the psychiatrist's presence in transdisciplinary medical teams, as well as in hospital ethics committees, has become more obvious than in the past. It is also increasingly clear that codes of ethics of physical medicine and psychiatry overlap to a large extent, especially with regard to the therapist-patient relationship.

The second topic I wish to emphasize is the changing relationship between psychiatrists and representatives of patients and families. In the recent past, we witnessed against-psychiatry demonstrations by former hospitalized patients, their families and human rights organizations. Our involvement at the societal level has led to a move from a paternalistic stance to a more listening, egalitarian position. We have started to invite those demonstrators to “cross the street”, to come and participate in our meetings to share with us their point of view and to discuss with us the dilemmas regarding issues of quality of life, patients’ rights, effectiveness of our treatments versus side effects, and coercive situations, in a context marked by mutual respect. Today, in many countries, representatives of psychiatric patients are invited to participate in committees that discuss these issues and allocate resources for research. In some countries, former patients and/or their relatives also participate in teaching medical students and residents. This collaboration has increased the transparency of our ways of thinking and working, and is contributing to reduce the stigma attached to psychiatry. This change of attitude is clearly reflected in the WPA Code of Ethics2.

One of the issues that remain conflictual, and feed the stigma towards the psychiatric profession, is the use of coercive measures, that seems to deny the patient's right to autonomy, one of the four basic principles of any medical code of ethics, along with beneficence, non-maleficence and justice4. The term autonomy reflects the patient's right to refuse medical treatment. In the case of a psychotic patient, the definition of “autonomy” is very complex, as the patient's “free” will is colored by his/her psychotic symptoms and lack of insight. The goal of treatment, including coercion, is to restore the patient's judgment capacity necessary for independent functioning. The growing attention to this issue has already led in many countries to a decrease in the number of involuntary hospitalizations and physical coercive measures, and the increasing use of alternative treatment solutions, such as the development of crisis units and “balancing houses” in the community, as an alternative to hospitalization5, 6.

Another issue related to the patient's right to autonomy is that of euthanasia. What is the psychiatrist's role, if any, in the process of fulfilling a patient's desire to end his/her life while freely choosing to prioritize quality of life over longevity? The renowned surgeon C. Bernard stated: “I have learned in my many years that death is not always the enemy. Sometimes it is the right medical treatment. It often achieves what medicine could no longer offer – an end to suffering”7. In my opinion, the psychiatrist has two roles in this respect: the first is to make sure that the patient's request is given out of “clarity of mind”, the second is to ascertain that the patient's wish to die is not a masked suicidal intent secondary to the psychopathology from which he/she suffers. Unfortunately, tools for a truly reliable assessment of these issues are not available.

A recent development regarding euthanasia is the ethical legitimation for the psychiatrist to act in accordance with his/her moral and/or religious views, possibly (but not necessarily) deferring the question to a colleague who agrees to be part of the medical team that is supposed to examine the request. It is important to discuss this issue with medical students and residents during their professional training.

Unfortunately, teaching of ethics does not occupy an adequate place in professional curricula, in psychiatry as in other medical disciplines. Also, the number of national psychiatric associations that have produced their own code of ethics is minimal, probably also due to the feeling that the existence of a code of ethics is a coercive factor that limits the clinician's freedom of action. We need to emphasize the advantages of having a code of ethics, such as the personal moral and legal protection that a set of guidelines provides to the psychiatrist in the implementation of his/her values and expertise. This protection is very important, especially in situations where the patient's best interest is not clear or is in conflict with the professional best practice.

Particularly neglected in psychiatry and other medical professions is the ethics of clinical management in children and adolescents. For example, to whom should the psychiatrist extend fidelity: to the child, to the guardian, to the family as a whole, to the referring agency, to the institution that pays him/her? Even though the child's consent is clinically essential, it is not required by law. Nevertheless, the psychiatrist should aspire for the child to have a good understanding of the therapeutic process, according to his/her age and cognitive and emotional development.

In conclusion, we better appreciate nowadays the interplay between society and psychiatry. National and international ethics committees must be involved in this “dialogue” between the patient's rights and the psychiatrist's duties and rights. Increasing transparency of the diagnostic and treatment processes can lead to a partial, but very significant, reduction of the stigma attached to mental disorders and our profession.

从精神病学的社会维度透视伦理学
从历史的角度来看,恩格尔1 将精神病理学概念化为生物、心理和社会三种因素相互作用的结果。20 世纪上半叶主要致力于精神障碍的心理因素的概念化,下半叶则致力于对生物因素的理解。进入 21 世纪,我们正忙于更好地理解社会进程的作用,这些进程影响着精神病理学的治疗方法以及精神科医生与患者之间的关系。这些事件往往需要伦理委员会的参与,委员会将决定医生在分流(即选择先治疗谁)等可能发生冲突的伦理环境中的职责和权利。COVID-19 大流行表明,精神障碍的流行病学和心理健康服务的获取与社会因素和躯体健 康是多么紧密地交织在一起。悲伤、孤独、失去收入和恐惧会加剧现有的心理健康问题或产生新的问题。大流行病表明,医学和公共卫生的生物和社会层面有着千丝万缕的联系2。社会价值观和规范的深刻变化,如变性人医疗程序的合法化,或某些国家安乐死的可用性,都要求重新定义精神科医生在医务人员中的角色,并制定考虑到病人和医生情感、宗教和意识形态等多方面因素的伦理准则3。在此,我将重点讨论作者所讨论的三个问题。首先是整个社会,尤其是医学界对精神障碍的成见。有研究表明,社会/环境因素在精神病理学的发展过程中具有重要作用4 ,还有研究表明,身体疾病与情绪状态之间存在密切关系,这些都有助于减少这种成见。将精神科病房纳入综合医院既是这一演变的结果,也是其进一步的决定因素。同样,与过去相比,精神科医生在跨学科医疗团队以及医院伦理委员会中的重要性也变得更加明显。我想强调的第二个话题是精神科医生与患者和家属代表之间不断变化的关系。最近,我们目睹了前住院病人、他们的家人和人权组织举行的反对精神病学的示威活动。我们在社会层面的参与使得我们从家长式的立场转变为更加倾听、平等的立场。我们开始邀请这些示威者 "过马路",来参加我们的会议,与我们分享他们的观点,并在相互尊重的背景下,与我们讨论有关生活质量、患者权利、治疗效果与副作用以及胁迫情况等问题的困境。如今,在许多国家,精神病患者的代表被邀请参加讨论这些问题和分配研究资源的委员会。在一些国家,曾经的患者和/或其亲属也会参与医学生和住院医生的教学工作。这种合作提高了我们思维和工作方式的透明度,有助于减少精神病学所带来的耻辱感。这种态度的转变清楚地反映在了WPA的职业道德规范中2。其中一个仍然存在冲突并助长对精神科职业偏见的问题是强制措施的使用,这似乎剥夺了病人的自主权,而自主权是任何医疗职业道德规范的四项基本原则之一,其他三项原则分别是受益原则、非渎职原则和公正原则4。 自主权一词反映了病人拒绝接受治疗的权利。对于精神病患者而言,"自主 "的定义非常复杂,因为患者的 "自由 "意志受到其精神病症状和缺乏洞察力的影响。治疗(包括强制治疗)的目的是恢复病人独立工作所需的判断能力。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
求助全文
约1分钟内获得全文 求助全文
来源期刊
World Psychiatry
World Psychiatry Nursing-Psychiatric Mental Health
CiteScore
64.10
自引率
7.40%
发文量
124
期刊介绍: World Psychiatry is the official journal of the World Psychiatric Association. It aims to disseminate information on significant clinical, service, and research developments in the mental health field. World Psychiatry is published three times per year and is sent free of charge to psychiatrists.The recipient psychiatrists' names and addresses are provided by WPA member societies and sections.The language used in the journal is designed to be understandable by the majority of mental health professionals worldwide.
×
引用
GB/T 7714-2015
复制
MLA
复制
APA
复制
导出至
BibTeX EndNote RefMan NoteFirst NoteExpress
×
提示
您的信息不完整,为了账户安全,请先补充。
现在去补充
×
提示
您因"违规操作"
具体请查看互助需知
我知道了
×
提示
确定
请完成安全验证×
copy
已复制链接
快去分享给好友吧!
我知道了
右上角分享
点击右上角分享
0
联系我们:info@booksci.cn Book学术提供免费学术资源搜索服务,方便国内外学者检索中英文文献。致力于提供最便捷和优质的服务体验。 Copyright © 2023 布克学术 All rights reserved.
京ICP备2023020795号-1
ghs 京公网安备 11010802042870号
Book学术文献互助
Book学术文献互助群
群 号:481959085
Book学术官方微信