The practice of psychiatry throws multitude of ethical challenges and dilemmas for a clinician in making decisions. Historically, doctors follow the well-established principles of medical ethics – namely justice, autonomy, beneficience and non-maleficience in medical practice. Along with these, clinical practice in psychiatry in England and Wales is governed by the principles outlined in the Mental Health Act 1983.

Whilst general ethical guidances are available as principles mentioned above, there are no clear directives in a complex clinical presentation when the various principles are in conflict themselves. Example, it is difficult to assess whether autonomy takes precedence over beneficience or vice versa when they are in conflict. In such cases, clinicians are left to exercise their own judgment.

We undertook a literature search to look for instances of published cases about hierarchy in different principles of medical ethics in the context of complex clinical presentations in psychiatry that pose conflict in the aforementioned principles. The results are outlined. We illustrate this in relation to a complex clinical presentation we came across in our practice that deals with detention, capacity and consent. The case exemplifies conflict is different ethical principles.

Psychiatric practice is complex without set rule. No clear consensus exists in the application of ethical principles specifically when they appear to be conflict. It is imperative there is a debate to agree on a hierarchy of ethical principles such that practitioners bias and prejudices are not brought in to practice in times of ethical conflicts.