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Codes of ethics in medicine have an ancient tradition, extending back to the Oath of Hippocrates. Yet it was only in the early 1970s that the speciality of psychiatry developed a specific code to address the unique ethical dilemmas and complexities arising in psychiatric practice. As the 50th anniversary of the publication of psychiatry's first code of ethics approaches, it is timely to reflect on the progress, role, and impact of such codes.
Our aim is to provide a historically informed review of codes of ethics in psychiatry – their origins and evolution, the current picture, and the possibilities for future development.
We conducted a selective review of relevant literature (including all codes of ethics accessible on the websites of World Psychiatric Association members states), analysis of the form and content of codes and related documents in psychiatry, and interviews of psychiatrists who have played central roles in their evolution.
Of the 143 WPA member states, only 15 codes of ethics for psychiatrists were identified, and few of these were associated with professional disciplinary processes. We found that these codes are rarely revised and sometimes supplemented with other statements and guidelines.
While there are difficulties in measuring the direct effectiveness of codes of ethics on the practice of psychiatrists, we conclude that these codes help to (1) promote professional solidarity and autonomy, (2) enhance moral sensitivity, and (3) aid in psychiatric education and training.
This chapter describes the psychiatric disorders of menses, pregnancy, postpartum and menopause in women. An understanding of hormonal influences on mood is important in trying to tie together those women who appear to be an increased risk of depression premenstrually, postnatally and at menopause. Maternal anxiety and depression in pregnancy may have particular effects on the foetus. A woman suffering from premenstual dysphoric disorder (PMDD) must experience at least five premenstrual symptoms and functional impairment due to the symptoms. Women in the Western world are living longer and are consequently spending more of their lives postmenopause. Oestrogen therapy has also been used in the management of psychological/ psychiatric and cognitive symptoms associated with the menopause. However, it has been argued that these symptoms may be more related to comorbid physical and psychosocial factors rather than the effects of ovarian failure.
Mrs. J, a 22-year-old secretary, began to exhibit restlessness, perplexity, and remoteness from her husband, Mr. K, following the birth of her first baby 10 weeks earlier. A psychiatrist was summoned after she had visited several neighbors without obvious purpose. He found a reticent, detached woman complaining that, “They have been out to get me from the beginning,” and alluding to “world famine and starving children.” Mental status examination revealed vague, paranoid thinking but firm denial of suicidal and homicidal impulses; she was not obviously delirious. Mrs. J resisted the psychiatrist's recommendation that she be admitted to the local psychiatric hospital. Mr. K supported her in this, insisting that he did not regard his wife as mentally ill and feared she would deteriorate if placed alongside genuinely disturbed patients.
What is psychiatric ethics?
Psychiatric ethics is concerned with the application of moral rules to situations and relationships specific to the field of psychiatry. Resolution of ethical dilemmas confronting psychiatrists, as illustrated by the above case, requires deliberation grounded in a moral theoretical framework that provides methods and justifications for clinical decision making. An outline of such theories is covered in the introductory chapter of the book. We will focus exclusively on ethical aspects of clinical practice that are especially challenging to psychiatrists and briefly offer a preferred theoretical framework to deal with them.
Objective: Our purpose was to determine the frequency of
psychiatric morbidity and to assess the quality of life of women with
advanced breast cancer.
Methods: The 227 women in the sample were recruited in
Melbourne, Australia, and were interviewed (prior to intervention) for a
randomized controlled trial of supportive-expressive group therapy. The
main outcome measures were DSM–IV psychiatric diagnoses plus quality
of life data based on the EORTC QLQ-C30 (core) and QLQ-BR23 (breast
Results: Forty-two percent of the women (97/227) had a
psychiatric disorder; 35.7% (81) of these had depression or anxiety or
both. Specific diagnoses were minor depression in 58 women (25.6%), major
depression in 16 (7%), anxiety disorder in 14 (6.2%), and phobic disorder
in 9 (4%). Seventeen (7.5%) women had more than one disorder. In terms of
quality of life, one-third felt less attractive, one-quarter were
dissatisfied with their body image, and, in most, sexual interest had
waned. Menopausal symptoms such as hot flashes affected less than
one-third, whereas symptoms of lymphedema were experienced by 26
Significance: Women with advanced breast cancer have high
rates of psychiatric and psychological disturbance. Quality of life is
substantially affected. Clinicians need to be vigilant in monitoring
psychological adjustment as part of a comprehensive biopsychosocial
Psychiatry has not reached a consensus hitherto concerning an optimal
theoretical framework for ethical decision-making and corresponding action.
Various theories have been considered, but found wanting. Moreover, classic
theories may contradict one another, contribute to confusion and immobilise
the clinician. We have examined major theories commonly applied in
bioethics, conferred with moral philosophers and psychiatrists and striven
to apply more recent insights drawn from moral philosophy. We report that
instead of pursuing a single theoretical framework, we should garner the
strengths of compatible approaches in a synergistic way. We propose a
particular complementarity of principlism – with its pragmatic focus on
respect for autonomy, beneficence, non-maleficence and justice – and care
ethics, avariant of virtue theory, which highlights character traits
pertinent to caring for vulnerable psychiatric patients.
When I received the invitation to contribute to the ‘Ten Books' series, I resonated more with the phrase ‘sources of inspiration’ than with the guideline to select books that have had ‘a significant impact on my professional life’. It so happens that this rather unusual challenge is the second to have come my way in recent times. We initiated a similar project for medical students at the University of Melbourne in which faculty members select a text that ‘matters' to them, ostensibly in a professional way, although the request is left intentionally vague. Then, as now, I surmised that the books that have influenced us professionally are not dissimilar to those that occupy a central place in our lives generally.
There is ample scope to devise forms of psychotherapy in consultation–liaison psychiatry, including the newly evolving area of psycho-oncology.
To highlight the development of psychotherapy in psycho-oncology, providing two illustrations.
We report on conceptual and clinical research in the context of oncology and palliative care, focusing on (a) an approach for families at risk of maladaptive bereavement; and (b) a group programme for women newly diagnosed with early-stage breast cancer.
We were able to introduce new forms of psychological treatment for specific clinical groups, and anecdotal evidence points to useful benefits for participants.
Psychotherapists should grasp the opportunity to bring their skills to the medical arena, but need to subject newly devised interventions to well-designed and methodologically rigorous research.
While studies investigating factors associated with carer burden
intellectual impairment and behavioural disturbance in the care recipient
more demanding for the carer than physical impairment, comparative
research findings are equivocal. Family carers of people with a long-term
illness or disability were identified through a survey of 26,000 households
Victoria, Australia. Focusing on carers of those aged over 50 years, three
subsamples were selected: 186 carers of relatives with physical impairment
only, 182 carers of those with diagnosed memory loss and 117 carers of
with intellectual impairment diagnosed as dementia. Carers of physically
impaired relatives reported better health, greater life satisfaction, and
overload, negative affect, family conflict, anger and resentment than carers
those with intellectual impairment, whether labelled as dementia or not.
Despite lower impairment levels in the care recipient, carers of those
undiagnosed memory loss reported more resentment about their caring role
than carers of those with a diagnosed dementia. The effects on the carer
significantly greater impairment in the dementia care recipient group may
ameliorated by having a diagnosis, bringing with it the potential for increased
understanding and tolerance. Fortunately, negative feelings predictive
sense of burden are subject to a range of interventions: providing information
to promote understanding; counselling to tackle negative feelings and family
conflict; guidelines to deal with behaviour problems and physical aspects
caring; and community services to reduce overload.
As part of a wider study of family caregiving, a sample of 297 women caring
for an ageing parent were identified through a random statewide telephone
survey involving over 26,000 households in Victoria, Australia. In addition to
elder care, half these women were in paid employment and a third had
dependent children. Overload was highest for carers with multiple roles,
particularly those of parent or worker. Resentment in the caring role was
highest for those who had fewer roles apart from elder care, particularly those
who had quit work, and those without a partner. Life satisfaction was higher
for partnered and working carers. These findings highlight the need for
structures to support carers to maintain multiple roles, including greater
flexibility in the workplace and encouragement of greater reliance on informal
networks and formal services, both of which require increased societal
acknowledgment of the elder care role.
As grief is both an individual and shared experience, adopting a systemic perspective is most appropriate for health-care professionals seeking to assist the bereaved. Within this framework, the family virtually always constitutes the most significant social group in which grief is experienced. In this paper we review the literature on family grief, covering clinical case reports, the observations of family therapists, systematic family bereavement research and family intervention studies. An understanding of patterns of family grief and vulnerability factors for morbid grief is pivotal to both preventive intervention and treatment of an established disorder.
The place of family therapy in adult clinical psychiatry remains unclear, despite considerable theoretical developments in the subject. In order to delineate the potential role of a family therapeutic approach, a study was conducted of the first 50 families treated in a newly established family-therapy clinic located in an adult psychiatric hospital.
The recent Eighth World Congress of the World Psychiatric Association (WPA), held between 12 and 19 October 1989 in Athens, was reminiscent of the previous World Congress in 1983 in Vienna, and the one before that in 1977 in Honolulu. Once again the issue of the Soviet political misuse of psychiatry reared its ugly head, and dominated the Association's proceedings. In 1977 the critical debate revolved around what position the WPA should adopt concerning the abuse. In a cliff-hanger vote, the WPA passed a resolution condemning the political misuse of psychiatry but explicitly citing the Soviet case (Bloch & Reddaway, 1984). In the absence of any improvement in the situation by the time of Vienna and in the virtual certainty that the Russians would have been expelled from the organisation, the Soviet Psychiatric Society resigned from its membership in January 1983. In order to forestall a precipitous and premature readmission, the Royal College of Psychiatrists proposed at the Vienna Congress that the Soviets would be welcomed back into the fold but only when they had demonstrated “sincere co-operation”, and when there had been concrete evidence of “amelioration” of the abuse.