The Royal College of Psychiatrists’ continuing professional development (CPD) module on clinical ethics in psychiatry by Pearce & Tan describes some common ethical dilemmas in psychiatric practice and the work of clinical ethics committees in analysing these dilemmas. In this article we build upon their work and offer additional exploration of the nature of ethical dilemmas in psychiatry. We also build upon the models of reasoning that are described in the module and suggest ways for psychiatrists to think about ethical dilemmas when a clinical ethics committee is not available.

Confidentiality in child and adolescent mental health is a complex and often challenging matter. Not only do young people frequently present to services in situations of risk, they often prefer to keep information confidential from parents and/or other professionals. This article explores confidentiality in the context of child and adolescent mental health services (CAMHS), particularly when the clinician is having to make decisions on whether to maintain or to breach it. Ethical principles (both deontological and consequentialist) and legal and regulatory frameworks (relating to human rights, case law and General Medical Council guidance) are outlined. Four hypothetical case scenarios are used to illustrate how to apply such principles: when a young person seeks confidential access to treatment, and when he or she discloses information that could signify a risk to self, to others or from others. Finally, practical suggestions on how to share information are explored.

Since 2013, hoarding disorder has been recognised as a standalone diagnosis in the DSM, affecting an estimated 2–6% of the general population. This article outlines the arguments for and against this separate classification and considers the differentiation of hoarding disorder from normative collecting. It then discusses aetiology, assessment, course and treatment (both psychological and pharmacological interventions). It concludes with a discussion of ethical and legal considerations, in particular the fact that the inclusion of hoarding disorder as a distinct diagnosis in DSM-5 confers specific protections for people with the disorder under the Equality Act 2010.

‘Digital’ is an omnipresent yet often vague, misunderstood or feared topic in health services. There are many current and potential gains for individual patients and local populations, clinicians and organisations through optimisation of digital technologies. We argue that understanding the various aspects of digital psychiatry is an essential contemporary need. This is the first of two articles on the subject, exploring the gains and challenges of virtual/online assessments, including ethical considerations and the use of virtual reality and electronic prescribing.

The expert witness practice of psychiatrists is under constant scrutiny by the courts and, in the UK, the General Medical Council, as well as within appraisal and revalidation as part of a doctor's overall practice. Regulation and appraisal of expert witness practice must address not only technical competence, including demonstration of a real understanding of the interface between medicine and law, but also ethical probity, including in respect of bias, which is the most challenging appraisal focus. In psychiatry, there is much room for ‘values expression’, and therefore bias, in the offering of expert opinion. This article first describes various legal and psychological definitions of bias; then addresses the sources and routes to expression of bias within expert witness practice, viewed legally, psychologically and neuroscientifically. Finally, it proposes ways in which inevitable bias can be minimised by the individual practitioner.

In this overview we discuss the palliative psychiatric care of older people towards the end of life. We briefly consider ethics, dementia care, delirium, depression, anxiety, grief and physician-assisted suicide. We also discuss hope, dignity, spirituality and existentialism. We hope that this article will encourage clinicians to reflect on the effects of terminal illnesses on the mental health of dying people and the current provision of palliative psychiatric care.

Psychiatrist Thomas Szasz fought coercion (compulsory detention) and denied that mental illness existed. Although he was regarded as a maverick, his ideas are much more plausible when one discovers that between 1939 and 1941, up to 100 000 mentally ill people, including 5000 children, were killed in Nazi Germany. In the course of the Nazi regime, over 400 000 forced sterilisations took place, mainly of people with mental illnesses. Other countries, including Denmark, Norway, Sweden and Switzerland, had active forced sterilisation programmes and eugenics laws. Similar laws were implemented in the USA, with up to 25 000 forced sterilisations. These atrocities were enabled and facilitated by psychiatrists of the time and are only one example of the dark side of the profession. This article reviews some of these aspects of the history of psychiatry, including Germany's eugenics programme and the former USSR's detention of dissidents under the guise of psychiatric treatment.

If a Mental Health Act section 136 lapses at 24 h because no in-patient bed is available, the legal grounds to continue holding an individual in the place of safety are dubious. Duty of candour and a senior clinical review are essential. The use of common law and the Mental Capacity Act have limitations, the latter also raising a question about whether deprivation of liberty safeguards would also apply. Clarity of this dilemma is needed through legislation.

When embarking on mental health research it is often necessary to apply for approvals from one or more review bodies to ensure that the research is ethical and that the safety and well-being of participants are safeguarded. This can be complicated and time consuming, particularly to those unfamiliar with the process. In this article we describe the approvals commonly required for National Health Service-based research involving patients and endeavour to clearly explain what is involved at each stage. We then highlight some of the main considerations, including ethical aspects, which are particularly pertinent to conducting research in the field of mental health, and finish with general advice and considerations for future developments in the area.

The widespread nature of child sexual abuse is increasingly recognised and in the public domain following high-profile cases. Children and vulnerable people need protecting from such abuse. At the heart of the dilemma facing clinicians is the need to feel supported by the legislative framework to maintain confidentiality and use their clinical discretion in the best interests of their patients, ensuring that they receive the help they need, but also protecting others at risk. There are compelling arguments both for and against strengthening legislation to improve child protection.

This article considers sexuality in older adults and the associated stereotypes and stigmas that lead to this area being underappreciated. Normal physiological changes in ageing are discussed and how they can cause sexual dysfunction. The elderly population has a higher burden of comorbid physical illness and this review considers evidence on the interplay between physical health and sexual health. Mental illness is also strongly linked with sexual functioning and is discussed, as is the evidence on psychotropics and sexual side-effects. Attitudes on sexuality in long-term care settings are highlighted and approaches to managing sexual disinhibition are included.

The concept of an ‘at-risk mental state’ for psychosis arose from previous work attempting to identify a putative psychosis prodrome. In this article we summarise the current criteria used to identify ‘at-risk’ individuals, such as the ultra-high-risk (UHR) criteria, and the further identification of important clinical risk factors or biomarkers to improve prediction of who might develop a psychotic disorder. We also discuss important ethical issues in classifying and treating at-risk individuals, current treatment trials in this area and what treatment current services can offer.

Body integrity identity disorder (BIID) is a rare and complex identity disorder described by the desire to acquire a physical disability and an associated sense of incompleteness at being able-bodied. Individuals with the disorder often delay presentation until later in life because of perceived stigma about wishing to acquire a physical disability, and may have sought amputation already through ‘underground’ means or self-harm (attempts at self-amputation). In this article we present an account of the recent history and origins of the disorder, from its early descriptions and case reports through to the current neuropsychiatric theory of right superior parietal lobe dysfunction as basis for the disorder. We consider the epidemiology, pathogenesis and clinical features of this identity disorder of bodily integrity, highlighting the associations with conditions such as gender identity disorder. With this we then discuss the ethical considerations for available treatment options, mainly elective surgical amputation.

This article examines notions of hedonism, altruism and conscience in relation to the activity of four neurotransmitter pathways: the dopamine reward, noradrenaline fight or flight, serotonin calming and glutamine learning pathways. Associated brain areas that modulate behaviour are highlighted: the prefrontal cortex (activity planning, risk mitigation), the hippocampus (memory retrieval) and the insular cortex (integration of information to decide on action). Putative epigenetic changes influencing adult behaviours after childhood privation are discussed. Pharmacological and psychological means of mitigating harmful behaviours are summarised, alongside the ethics of epigenetic screening to predict future addictive and violent tendencies.

Understanding the philosophical foundations of cognitive–behavioural therapy (CBT) is vital to drive theory and research forwards and to effectively conduct therapy using varied methods and techniques from different CBT models that may be rooted in distinct philosophical tenets. In the evolution of CBT as the most empirically validated form of psychotherapy, each of its three waves (behavioural therapy, cognitive therapy and acceptance-based therapies) has brought unique contributions to improve its effectiveness. Although some of the philosophical assumptions underlying the different CBT waves may be considerably dissimilar, in this clinical reflection I review the distinctive and cross-cutting features of such backgrounds, while suggesting a conciliation of epistemological perspectives that is capable of informing the practice of CBT in a consistent manner.

Philosophy both influences and is influenced by clinical and legal practice relating to suicide. This article begins with a brief history of attitudes in the UK and Europe towards those who attempt suicide. It describes the main philosophical positions regarding suicide, including the principle of respect for life, the utilitarian position, the theological principle, and the principles of autonomy and duty to others. It concludes that short-term interventions are justified in most cases, for example when the suicide attempt is a ‘cry for help’ and/or the individual is ambivalent in their attempt or likely to have a mental illness.

In the wake of the deinstitutionalisation of mental health services, community treatment orders (CTOs) have been introduced in around 75 jurisdictions worldwide. They make it a legal requirement for patients to adhere to treatment plans outside of hospital. To date, about 60 CTO outcome studies have been conducted. All studies with a methodology strong enough to infer causality conclude that CTOs do not have the intended effect of preventing relapse and reducing hospital admissions. Despite this, CTOs are still debated, possibly reflecting different attitudes to the role of evidence-based practice in community psychiatry. There are clinical, ethical, legal, economic and professional reasons why the current use of CTOs should be reconsidered.

Many ethical dilemmas in medicine are associated with highly unusual clinical situations and are an almost daily challenge for mental health teams. We describe the ethical issues that arose in relation to a significant difference of opinion between team members about using nasogastric clozapine in the treatment of a severely ill patient. We discuss how conflicting emotions and perspectives within teams acquire ethical significance and how negotiation and reflection are essential for good-quality ethical reasoning to take place.

Should the law be changed to allow health professionals to assist mentally competent, terminally ill people to end their own lives? In this article Philip Graham (P.G.) puts the arguments in favour of such a change in the law and Julian Hughes (J.H.) opposes these arguments. J.H. then sets out why he believes such a law should not be passed and P.G., in turn, sets out counterarguments. Before concluding comments, both P.G. and J.H. independently make brief closing statements supporting their own positions.

Peer reviewing is a hugely important part of the scientific process that ensures published articles are of sufficient quality to deserve dissemination to the wider scientific community. Building on a previous article published in this journal, this article addresses topics that potential or practising peer reviewers may find useful. These include what peer reviewing is, why do peer reviews, how to become a reviewer, what to write in a review and where to find more information. It includes a template for writing a review, and lists various websites and guidelines that can help ease the entire process depending on what type of article is being reviewed. Peer reviewing can be enormously rewarding and help clinicians diversify their scope of work while also benefiting the scientific community by contributing to the quality control of published work.