Psychiatry entails ethical dilemmas in defining normal and abnormal, diagnosis and treatment, individual freedom, con? dentiality, competency, commitment and other complex issues.

Some ethical guiding principles change with time and the place of practice. Fundamentally concerned with conceptual analysis rather than the collection of empirical data, ethics may not provide direct or definite answers on every issue (1).

Systematic understanding of psychiatric ethics is of recent origin. The American Psychiatric Association appointed a committee to develop a code of ethics only in 1970 (2). The World Psychiatric Association developed a code of ethics in 1977. A committee was appointed by the Indian Psychiatric Society to prepare the code of ethics for psychiatrists in India. The code was approved at its annual conference in Cuttack in 1989. It has been reviewed by Agarwal and Gupta. (3)

Current ethical issues in day to day practice

1. The definition of mental illness and the scope of psychiatry remain a dilemma. Agarwal (4) feels that ‘psychiatrists are trained to identify and treat mental disorders and they should restrict themselves to it.’ Violence, aggression, misery, criminal behaviour, developmental problems in children, adolescent crisis, marital problems are better managed by teams of experts from many related fields with psychiatrists as members.
2. Doctor-patient relationship The highly personal and intensely emotional relationship makes the psychiatric patient especially vulnerable. Hence the paramount need for the psychiatrist not to gratify his personal financial and sexual needs by exploiting the patient.
3. The professional environment
1. Selection of trainees Entrance examinations try to pick up intelligent students but do not include tests to ensure that they will become good physicians with compassion for fellow human beings. Admission of individuals lacking the required motivation to professional colleges calls for review to reverse the current slide in moral standards.
2. Private hospitals Entry of the for-profit, corporate hospitals has brought in their wake significant ethical dilemmas. Patients are made to pay for costly tests that are not indicated. Fee splitting by nursing homes, laboratories and doctors, unnecessary tests and procedures, prolonged treatment, spending more time and effort on the rich and powerful (V. I. P. syndrome) and the neglect of poor patients are some examples of ethical misconduct. Psychiatrists face divided loyaltiesthat pose ethical conflicts in student mental health services, the armed forces, prison and other governmental appointments. Conflicts also arise when dealing with victims of violence and torture and when judging competence. The distinction between issues related to treatment and those in administration is blurred.
3. Involuntary treatment, consent, confidentiality: Most patients have little knowledge of mental illnesses. Myths abound. Most patients are not offered options in treatment. Patients and relatives expect the therapist to make decisions, thus leading to absolute paternalism. As a corollary, doctors feel that no one should question their decisions. Fairness and justice entail providing enough information at the appropriate time. When and how much information can pose ethical dilemmas.

Violation of confidentiality, as when called for by courts raises ethical concerns. The new Mental Health Act permits study of patients’ records by lay inspectors. Should we then record all psychotherapeutic details?

4. Technique of treatment and methods of research:

Many treatment modalities are in vogue in psychiatry, some complementary, others contradictory. Whether treatment is best carried out using any one modality or an appropriate mix can be debated.

Polypharmacy, use of costly drugs, drugs for which lavish claims are made and several research techniques call for ethical analysis. Emphasis on particular schools like psychodynamic, biological, behavioural must be avoided with judicious use of the bio-psycho-social model using holistic approach. Surrogate decision making for patients, use of surrogates in sex therapy, the patient’s right to die or refuse treatment and the rights of the mentally retarded are other major areas of ethical concern.

Conclusions

Since we have few legal regulations and medical practice breeds unbridled paternalism, higher and rigidly enforced ethical standards are called for if we wish to gain and retain public confidence (3). Sensitization to ethical issues should begin at the medical colleges with emphasis on scientific and humane medicine attuned to our culture and values.