Informed consent in psychiatric research - concepts and challenges

Research involving vulnerable population of mentally impaired persons is raising considerable controversies from its very beginnings. These controversies are created around everlasting tensions between two positive duties: the duty to protect vulnerable subjects, and the duty not to deny them potential benefits. Most of the contemporary ethical guidelines and regulations, including most recent revision of the Declaration of Helsinki, permit these researches under certain ethical conditions. The notion of informed consent as a cornerstone of bioethics emerges as essential requisite of moral research. We are presenting some key concepts and safeguards regarding informed consent that researcher needs to be aware off when conducting a research involving mentally impaired persons. Theoretical and practical challenges that are arising from these safeguards are discussed with an overview of most recent scientific data. Lastly, we briefly address the most important legal standings that will be introduced in 2015, by new Croatian Law on the Protection of Persons with Mental Disorders.

Psychiatry's new manual (DSM-5): ethical and conceptual dimensions

The introduction of the Diagnostic and statistical manual of mental disorders (DSM-5) in May 2013 is being hailed as the biggest event in psychiatry in the last 10 years. In this paper I examine three important issues that arise from the new manual:(1) Expanding nosology: Psychiatry has again broadened its nosology to include human experiences not previously under its purview (eg, binge eating disorder, internet gaming disorder, caffeine use disorder, hoarding disorder, premenstrual dysphoric disorder). Consequence-based ethical concerns about this expansion are addressed, along with conceptual concerns about a confusion of "construct validity" and "conceptual validity" and a failure to distinguish between "disorder" and "non disordered conditions for which we help people."(2) The role of claims about societal impact in changes in nosology: Several changes in the DSM-5 involved claims about societal impact in their rationales. This is due in part to a new online open comment period during DSM development. Examples include advancement of science, greater access to treatment, greater public awareness of condition, loss of identify or harm to those with removed disorders, stigmatization, offensiveness, etc. I identify and evaluate four importantly distinct ways in which claims about societal impact might operate in DSM development. (3) Categorisation nosology to spectrum nosology: The move to "degrees of severity" of mental disorders, a major change for DSM-5, raises concerns about conceptual clarity and uniformity concerning what it means to have a severe form of a disorder, and ethical concerns about communication.

Comparing assessments of the decision-making competencies of psychiatric inpatients as provided by physicians, nurses, relatives and an assessment tool

OBJECTIVE

To compare assessments of the decision-making competencies of psychiatric inpatients as provided by physicians, nurses, relatives and an assessment tool.

METHODS

This study was carried out at the psychiatry clinic of Kocaeli University Hospital from June 2007 to February 2008. The decision-making competence of the 83 patients who participated in the study was assessed by physicians, nurses, relatives and MacCAT-T.

RESULTS

Of the 83 patients, the relatives of 73.8% of them, including the parents of 47.7%, were interviewed during the study. A moderately good consistency between the competency assessments of the nurses versus those of the physicians, but a poor consistency between the assessments of the physicians and nurses versus those of the patients' relatives, was determined. The differences in the competency assessment obtained with the MacCAT-T versus the evaluations of the physicians, nurses and patients' relatives were statistically significant.

CONCLUSIONS

Our findings demonstrate those physicians, nurses and the patients' relatives have difficulty in identifying patients lacking decision-making competence. Therefore, an objective competence assessment tool should be used along with the assessments of physicians and nurses, both of whom can provide clinical data, as well as those of relatives, who can offer insights into the patient's moral values and expectations.

[Between autonomy and coercion: compulsory treatment in psychiatry from an ethical perspective]

The actual decision of the German Supreme Court fueled the old debate of the moral and legal status of compulsory treatment in psychiatry in Germany. This article sheds a light on the background of this debate and reflects on possible justifications for involuntary treatment of mentally ill patients. Furthermore it will examine the significance of psychiatric patients' advance directives and joint crisis plans in the context of medical compulsory treatment and will offer recommendations on an ethical responsible way of dealing with compulsory treatment in German psychiatric practice.

[Handling of patients with dementia--scenario 2050]

The relationship between social attitudes, normative ethics, health care elite's and individual failure has been highlighted in a scenario for patients with dementia. Inhuman abuse may be protected by sense of responsibility, duty to social being, inclusion of psychiatric patients, and the foundation of human dignity.

Methodological and ethical challenges in studying patients' perceptions of coercion: a systematic mixed studies review

BACKGROUND

Despite improvements in psychiatric inpatient care, patient restrictions in psychiatric hospitals are still in use. Studying perceptions among patients who have been secluded or physically restrained during their hospital stay is challenging. We sought to review the methodological and ethical challenges in qualitative and quantitative studies aiming to describe patients' perceptions of coercive measures, especially seclusion and physical restraints during their hospital stay.

METHODS

Systematic mixed studies review was the study method. Studies reporting patients' perceptions of coercive measures, especially seclusion and physical restraints during hospital stay were included. Methodological issues such as study design, data collection and recruitment process, participants, sampling, patient refusal or non-participation, and ethical issues such as informed consent process, and approval were synthesized systematically. Electronic searches of CINALH, MEDLINE, PsychINFO and The Cochrane Library (1976-2012) were carried out.

RESULTS

Out of 846 initial citations, 32 studies were included, 14 qualitative and 18 quantitative studies. A variety of methodological approaches were used, although descriptive and explorative designs were used in most cases. Data were mainly collected in qualitative studies by interviews (n = 13) or in quantitative studies by self-report questionnaires (n = 12). The recruitment process was explained in 59% (n = 19) of the studies. In most cases convenience sampling was used, yet five studies used randomization. Patient's refusal or non-participation was reported in 37% (n = 11) of studies. Of all studies, 56% (n = 18) had reported undergone an ethical review process in an official board or committee. Respondents were informed and consent was requested in 69% studies (n = 22).

CONCLUSIONS

The use of different study designs made comparison methodologically challenging. The timing of data collection (considering bias and confounding factors) and the reasons for non-participation of eligible participants are likewise methodological challenges, e.g. recommended flow charts could aid the information. Other challenges identified were the recruitment of large and representative samples. Ethical challenges included requesting participants' informed consent and respecting ethical procedures.

The placebo effect in psychiatry: problem or solution?

This opinion piece aims to situate the placebo effect within the field of psychiatric treatment. To accomplish this, the placebo is explored at the centre of an often heated debate between three discrete perspectives: the clinical trial researcher, the placebo researcher and the clinician. Each occupational perspective has its own vested interests and practical concerns that drive how the placebo concepts are negotiated and applied. It is argued that because the trial and placebo researchers typically represent opposing viewpoints, clinicians are generally uncomfortable or even baffled by placebo concepts, and this three-way tension has crucial implications for the field's progress.

Clinical research before informed consent

Clinical research with patient-subjects was routinely conducted without informed consent for research participation prior to 1966. The aim of this article is to illuminate the moral climate of clinical research at this time, with particular attention to placebo-controlled trials in which patient-subjects often were not informed that they were participating in research or that they might receive a placebo intervention rather than standard medical treatment or an experimental treatment for their condition. An especially valuable window into the thinking of clinical investigators about their relationship with patient-subjects in the era before informed consent is afforded by reflection on two articles published by psychiatric researchers in 1966 and 1967, at the point of transition between clinical research conducted under the guise of medical care and clinical research based on consent following an invitation to participate and disclosure of material information about the study. Historical inquiry relating to the practice of clinical research without informed consent helps to put into perspective the moral progress associated with soliciting consent following disclosure of pertinent information; it also helps to shed light on an important issue in contemporary research ethics: the conditions under which it is ethical to conduct clinical research without informed consent.

Joint crisis plans and psychiatric advance directives in German psychiatric practice

This study explores the attitude of German psychiatrists in leading positions towards joint crisis plans and psychiatric advance directives. This topic was examined by contacting 473 medical directors of German psychiatric hospitals and departments. They were asked to complete a questionnaire developed by us. That form contained questions about the incidence and acceptance of joint crisis plans and psychiatric advance directives and previous experiences with them. 108 medical directors of psychiatric hospitals and departments responded (response rate: 22.8%). Their answers demonstrate that in their hospitals these documents are rarely used. Among the respondents, joint crisis plans are more accepted than psychiatric advance directives. There is a certain uncertainty when dealing with these instruments. Our main conclusion is that German psychiatry needs an intensified discussion on the use of instruments for patients to constitute procedures for future critical psychiatric events. For this purpose it will be helpful to collect more empirical data. Furthermore, the proposal of joint crisis plans in psychiatric hospitals and departments should be discussed as well as the possibility of consulting an expert during the preparation of a psychiatric advance directive.

[Good clinical practice and the maintenance of ethical standards in medical research: advice for junior researchers working in mental health care]

BACKGROUND

In mental health care, more and more research is being done, particularly in the field of educational programmes. Unfortunately, junior researchers are often not fully informed about the rules and regulations relating to research and about medical ethics. Therefore, they are not in a position to make considered judgements that conform to good clinical practice and acceptable medical ethics.<br/>

AIM

To give practical advice to trainees, stimulating them to think carefully about ethical standards in patient-related research in mental health care. METHODS The article provides a practice-based overview of practical advice and ethical considerations.<br/>

RESULTS

We stress that before beginning their research, researchers should think very carefully about the ethics of medical research. Instructions and guidelines relating to medical and ethical standards are to be found in: directive for good clinical practice compiled by the central committee for human research (CCMO) with the accompanying e-learning module and in the basic course 'rules and organisation for clinical researchers' (BROK). Practical tips, illustrated with examples, provide a framework for stimulating thoughts on medical ethics. Finally, it is important to improve the ways in which research is embedded in the organisational structure of teaching programmes.<br/>

CONCLUSION

Basic information about GCP and the upholding of medical and ethical standards in patient-related research can be obtained from various sources. The main challenge is to ensure that GCP is firmly embedded in patient-related research undertaken by junior researchers.

Examining the ethical boundaries of harm reduction: from addictions to general psychiatry

Harm reduction is a general term for pragmatic interventions aimed at reducing problematic behaviors. Emerging from addiction treatments, it is based on the understanding that people will continue to behave in ways that pose a risk to them and their communities, and that an important goal of any treatment program is to minimize the harm associated with these behaviors. Despite its evidence based background, harm reduction is not readily applied in general psychiatry. This is mainly due to the complex ethical dilemmas arising within harm reduction practices, as well as a lack of scientific knowledge and theoretical frameworks essential for dealing with such ethical dilemmas. In this paper we introduce the fundamental theoretical and scientific base of harm reduction strategies, and present three clinical examples of the complex ethical dilemmas arising when working within a harm reduction practice. We finally present a theoretical framework for dealing with the ethical dilemmas and argue this may make harm reduction strategies more accessible in general psychiatry.

Ethics and the psychiatry journal editor: responsibilities and dilemmas

An array of potential ethical stumbling blocks awaits the editors of scientific journals. There are issues of particular relevance to mental health journals, and others unique to local journals with a relatively small circulation and low impact factor. The blind review system, conflict of interests, redundant publication, fraud and plagiarism, guest and ghost authorship and ghost writing, advertising, language and stigma, patient consent, and "rigging" the Impact Factor are all issues of importance. It is critical that editors are aware and informed of these important issues, and have an accessible forum for evaluating problems as they arise.

The risks and responsible roles for psychiatrists who interact with the media

Journalists often turn to psychiatrists for analysis of medical, social, political, and cultural events that involve human behavior and illness. Once journalists seek their expertise, psychiatrists often rush to be helpful, which can lead to ineffective performance and to statements that may run afoul of principles of professional ethics. In this article, we discuss the bases on which the professionalism of psychiatrists may be impugned when they commit errors in their media presentations. Found within the Principles of Medical Ethics with Special Annotations Especially Applicable to Psychiatry, the Goldwater Rule prohibits certain behaviors when psychiatrists share professional opinions with the public. We first discuss the Goldwater Rule, highlighting the events that led to its development and the professional response to its enactment. We then present a method to guide psychiatrists in their interaction with the media that will help them avoid violating ethics principles or the law. The method encourages knowledge of a framework of ethics principles that in turn guide the psychiatrist's behavior and thinking as he contemplates accepting invitations to interact with the media. The ethics-based roles include the Teacher, the Storyteller, the Celebrity Commentator, the Hollywood Consultant, the Clinician, and the Advertiser.

[Psychometric properties of the Hospital Ethical Climate Survey: a cross-sectional study among Belgian psychiatric nurses]

BACKGROUND

The task of caring for psychiatric patients is so complex that it often leads to ethical dilemmas. The ethical climate on a ward is a crucial factor. This is the first study about the ethical climate in mental healthcare.

AIM

To investigate whether the only instrument currently available for measuring the ethical climate in general hospitals, namely the 'Hospital Ethical Climate Survey' (HECS), is a reliable and valid instrument for use on psychiatric wards.

METHOD

A cross-sectional study was performed in a psychiatric hospital in Belgium. All 320 nurses were invited to participate (response rate = 265). The factor structure of the HECS was examined by means of explorative principal component analysis (PCA) and confirmatory factor analysis (CFA). The reliability of the constructed scale and subscales was investigated.

RESULTS

Five factors were identified. The structure of these factors in the translated list was almost identical to the structure obtained with the original instrument and its underlying theoretical basis. Items relating to several other allied healthcare professions were added. This addition widened the subscale 'relationship with physician' so that it included 'relationship with other disciplines' (medical and allied healthcare workers).

CONCLUSION

The reliability of the instrument appeared to be good and yielded scores comparable to those obtained as a result of earlier research performed in general hospitals. The setting for our investigation produced a significantly higher main score for the ethical climate than did previous studies.

[Werner Leibbrand, Annemarie Wettley and controversies on "euthanasia" the background of medico-historical and ethical debates in the Post World War II era]

Psychiatrists and medical historians Werner Leibbrand (1896 - 1974) and Annemarie Wettley (1913 - 1996) are amongst the most striking figures in the field of history of medicine. Leibbrand was appointed director of the "Heil- und Pflegeanstalt" in Erlangen shortly after the war. Fuelled by his own experiences of suppression and persecution during the Nazi era he promised to unearth the crimes and atrocities which had happened under watch of the Nazi regime. He was joined by Annemarie Wettley, who worked as a physician at the hospital and had developed an increasing interest in the history of medicine. In 1946 they published "Um die Menschenrechte der Geisteskranken" ("Human Rights of the Mentally Ill") about the "euthanasia" campaign of the Nazi regime. Although a number of substantial works followed, Leibbrand and Wettley failed to inform in more depth on crimes and atrocities, for instance killings of patients and forced malnutrition. Doubts and charges against Wettley regarding her role in dietary programmes at the Erlangen hospital and against Leibbrand regarding special expert's reports--both had a short-term arrest warrant--might have contributed to stagnation in their efforts. In 1953 Leibbrand accepted the offer of a chair at the University in Munich, Wettley followed and habilitated in history of medicine; in the year 1962 they married. Contacts and exchange amongst medico-historical experts shed light on developments during the post-war era; still, a critical and fundamental review of the crimes within the medical system of the Nazi regime did not take place during this time.

Paternalism, autonomy and reciprocity: ethical perspectives in encounters with patients in psychiatric in-patient care

BACKGROUND

Psychiatric staff members have the power to decide the options that frame encounters with patients. Intentional as well as unintentional framing can have a crucial impact on patients' opportunities to be heard and participate in the process. We identified three dominant ethical perspectives in the normative medical ethics literature concerning how doctors and other staff members should frame interactions in relation to patients; paternalism, autonomy and reciprocity. The aim of this study was to describe and analyse statements describing real work situations and ethical reflections made by staff members in relation to three central perspectives in medical ethics; paternalism, autonomy and reciprocity.

METHODS

All staff members involved with patients in seven adult psychiatric and six child and adolescent psychiatric clinics were given the opportunity to freely describe ethical considerations in their work by keeping an ethical diary over the course of one week and 173 persons handed in their diaries. Qualitative theory-guided content analysis was used to provide a description of staff encounters with patients and in what way these encounters were consistent with, or contrary to, the three perspectives.

RESULTS

The majority of the statements could be attributed to the perspective of paternalism and several to autonomy. Only a few statements could be attributed to reciprocity, most of which concerned staff members acting contrary to the perspective. The result is presented as three perspectives containing eight values.•Paternalism; 1) promoting and restoring the health of the patient, 2) providing good care and 3) assuming responsibility.•Autonomy; 1) respecting the patient's right to self-determination and information, 2) respecting the patient's integrity and 3) protecting human rights.•Reciprocity; 1) involving patients in the planning and implementation of their care and 2) building trust between staff and patients.

CONCLUSIONS

Paternalism clearly appeared to be the dominant perspective among the participants, but there was also awareness of patients' right to autonomy. Despite a normative trend towards reciprocity in psychiatry throughout the Western world, identifying it proved difficult in this study. This should be borne in mind by clinics when considering the need for ethical education, training and supervision.

Madness, childhood adversity and narrative psychiatry: caring and the moral imagination

The dominance of technological paradigms within psychiatry creates moral and ethical tensions over how to engage with the interpersonal narratives of those experiencing mental distress. This paper argues that such paradigms are poorly suited for fostering principled responses to human suffering, and proposes an alternative approach that considers a view of relationships based in feminist theories about the nature of caring. Four primary characteristics are presented which distinguish caring from technological paradigms: (1) a concern with the particular nature of contexts, (2) embodied practice, (3) the dialogical basis of caring and (4) the existential basis of caring. From this we explore the role of the moral imagination and our ability, through narrative, to acknowledge, engage with and bear witness to the injustices that shape the lives of those who suffer. This, we argue, is at the heart of caring. Clinical implications are discussed, including an exposition of the importance of narrative in recovery from trauma and distress. Narrative Psychiatry, The Sanctuary Model of care, and Soteria, are outlined as examples of this type of practice.

Assessing professionalism and ethics knowledge and skills: preferences of psychiatry residents

BACKGROUND

Professionalism is one of the fundamental expectations and a core competency in residency education. Although programs use a variety of evaluative methods, little is known about residents' views of and preferences regarding various methods of assessment.

METHOD

The authors surveyed residents at seven psychiatry residency programs in the United States regarding their attitudes on professionalism, ethics preparation, and evaluation in psychiatry residency training. This report describes their views on methods of assessing professionalism.

RESULTS

Residents strongly agreed that clinical supervision is an appropriate assessment method. Moreover, they rated clinical supervision more highly than oral examinations, short-answer questions, essays, and standardized patient interactions. Residents also strongly favored direct faculty observation of residents' interactions with actual patients and clinical team members.

CONCLUSION

This study suggests that both direct faculty supervision and other clinically-based assessments are methods accepted by psychiatry residents. Future research on the validity and effectiveness of these modes of assessment is needed.