Stigma in psychiatry

nema

[Psychiatry and neuroethics]

Neuroscientific knowledge have enter to psychiatry in a new era, however, new technology for viewing images, brain function, psychopharmacology, non-invasive methodology requires an ethical approach, framed in the bioethical environment. The field of neuroethics has evolved to address many of the specific concerns and what neuroenhancement and neuroimaging provide us, is necessary to extend the scope of ethical things to consider the clinical implications for the psychiatric work.

Survey of sensitive information written in patient notes by psychiatry trainees

OBJECTIVE

Allowing psychiatric patients access to their electronic medical record (EMR) may cause difficulty related to the sensitivity of the note content. The authors investigated whether notes written by psychiatry trainees were ready for release to patients.

METHODS

Authors conducted a review of 128 PGY-3 to PGY-5 outpatient notes not explicitly marked as "highly confidential." One psychiatrist and one non-psychiatrist read each note from the patient's perspective. Reviewers assigned a score of 0-2 (0: No Concern; 1: Some Concern; 2: Major Concern) for each note.

RESULTS

Eighty-nine notes (70%) were assessed as "No Concern" by both reviewers; 30 (23%) were of "Some Concern;" and 9 (7%) were of "Major Concern;" 92 (72%) were deemed of "No Concern" by a psychiatrist, as compared with 120 (94%) by the non-psychiatrist.

CONCLUSIONS

Trainee EMR outpatient notes are not likely to cause major concerns for patients who read them. Psychiatrist-reviewers identified more concerns than non-psychiatrist-reviewers.

Ethical considerations during times of conflict: challenges and pitfalls for the psychiatrist

Despite the advances of civilization, conflict remains in many areas around the world. Often psychiatry finds itself playing an essential role in dealing with the consequences of conflict or influencing the process. Along with this involvement comes great responsibility as well as many associated ethical dilemmas. Although bound by professional medical oaths, many physicians disregard fundamental medical ethical principles during times of conflict and situations of "dual loyalty." The phenomenon should be addressed so that ethical awareness and sensitivity to these issues are nurtured. Important factors for psychiatrists during times of conflict to consider include their "social contract" with the community, dangers of boundary violations, the ethics of media contact, involvement in governmental and political activities and confidentiality. In addition, their role in conflict resolution and unique ethical considerations in the military should be considered. While as regular citizens, psychiatrists in their individual capacity may involve themselves in political activism, at an organizational level it should be discouraged. A physician's skills should only be exploited to save lives and provide comfort as entrusted by society, and any other pursuit, even in the name of the state, should be proscribed. Rather than engage in political activism, psychiatrists can promote the rights of patients, especially if these rights are limited during conflict. Responsibility and ethically-driven commitment needs to be primary for the psychiatrist who involves himself either directly or indirectly with patients during times of conflict. Trauma and its effects during conflict should be addressed without any unbalanced attention to pathological responses.

Dual agency and ethics conflicts in correctional practice: sources and solutions

Psychiatrists working in corrections, particularly in areas that have a shortage of forensic practitioners, may encounter a variety of ethics-related conflicts, especially when working both as clinicians and forensic evaluators within smaller systems. Such conflicts may include unavoidable dual treating and forensic evaluator relationships, and awareness of information that may complicate patient treatment or influence forensic opinions. Additional conflicts may arise if the psychiatrist is also retained privately to conduct forensic evaluations involving inmates in the same facility or facilities where the psychiatrist is otherwise employed, specifically because he may have duties to both a retaining party and an employer. Early-career psychiatrists, those who are completing their training in forensic psychiatry, and general psychiatrists who practice in corrections may be unfamiliar with the ethics-related dilemmas that arise in jails or prisons. Ethics courses during medical school and residency, while required, rarely discuss dilemmas specific to correctional settings. Furthermore, many psychiatrists practicing in corrections do not undergo formal training in forensic psychiatry, and even among different fellowship programs, the amount of time devoted to corrections varies significantly. The authors discuss hypothetical cases that reflect situations encountered, particularly by psychiatric fellows, forensic psychiatrists new to correctional work, and nonforensic clinicians working in corrections, a setting where dual agency is common and at times in conflict with core principles of ethics, including beneficence, nonmaleficence, neutrality, objectivity, and justice.

On the nature of mental disorder: towards an objectivist account

According to the predominant view within contemporary philosophy of psychiatry, mental disorders involve essentially personal and societal values, and thus, the concept of mental disorder cannot, even in principle, be elucidated in a thoroughly objective manner. Several arguments have been adduced in support of this impossibility thesis. My critical examination of two master arguments advanced to this effect by Derek Bolton and Jerome Wakefield, respectively, raises serious doubts about their soundness. Furthermore, I articulate an alternative, thoroughly objective, though in part normative, framework for the elucidation of the concept of mental disorder. The concepts of mental dysfunction and impairment of basic psychological capacities to satisfy one's basic needs are the building blocks of this framework. I provide an argument for the objective harmfulness of genuine mental disorders as patterns of mental dysfunctions with objectively negative biotic values, as well as a formally correct definition of the concept of mental disorder. Contrary to the received view, this objective framework allows for the possibility of genuine mental disorders due to adverse social conditions, as well as for quasi-universal mental disorders. I conclude that overall, the project of providing an objective account of the concept of mental disorder is far from impossible, and moreover, that it is, at least in principle, feasible.

Impact of destruction of classic moral principles on ethical questions in psychiatry

Society's treatment of psychiatric patients was always a reflection of social development and social awareness, as well as of ethical principles dominating a certain time period in that society. Over the last two and a half millennia, during which principles of Hippocratic ethics applied, attitudes towards psychiatric patients, from an ethical and practical standpoint, were and still are controversial to say the least. During this period thousands of people with mental disorders were abused, tortured, or killed, all of this in accordance to the existing ethical and legislative norms (Malleus Maleficarum, eugenic laws of totalitarian regimes...). In the last forty years many international organizations and associations brought forth a number of resolutions and declarations warning of the position and of the rights of psychiatric patients and giving instructions on the humane, that is to say ethical, treatment of this category of patients. In almost all the western countries laws are passed to protect the rights of people with mental disorders. Thanks to this and maybe even more to the development of psychiatry as a medical and scientific profession, the position of those with mental disorders is improving. However, at the same time over the last 40 years we are witnesses to the destruction of the classic moral principles and the establishment of certain "new" ethics which put psychiatric patients at a disadvantage, only in a more subtle way then before. This is why it is important to reexamine many of the ethical questions in psychiatry in the context of present ethical controversy.

The gap between voluntary admission and detention in mental health units

This paper presents the case of a young man with a diagnosis of schizophrenia, who agreed to inpatient treatment primarily to avoid being formally detained. I draw on Peter Breggin's early critique of coercion of informal patients to supply an updated discussion of the ethical issues raised. Central questions are whether the admission was coercive, and if so, whether unethical. Whether or not involuntary admission would be justified, moral discomfort surrounds its appearance as a threat. This arises in part from ambivalence about autonomy: although a 'choice' is made, the threat of detention impinges on the patient's choice. Recent legal developments provide some experience of safeguarding those whose consent is not obtained. This highlights the lack of safeguards in this 'gap' and suggests that we have the tools with which to begin to deal with the problem.