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Chapter 42. Ethical Aspects of Psychiatry

Laura Weiss Roberts, M.D., M.A.; Jinger G. Hoop, M.D., M.F.A.; Laura B. Dunn, M.D.
DOI: 10.1176/appi.books.9781585623402.337194

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Excerpt

Ethics is an endeavor. It refers to ways of understanding what is good and right in human experience. It is about discernment, knowledge, and self-reflection, and it is sustained through seeking, clarifying, and translating. It is the concrete expression of moral ideals in everyday life. Ethics is about meaning, and it is about action.

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FIGURE 42–1. A model for ethical decision making.Source. Reprinted from Roberts LW, Dyer AR: Concise Guide to Ethics in Mental Health Care. Washington, DC, American Psychiatric Publishing, 2004, p. 307. Used with permission.

FIGURE 42–2. Elements of informed consent.Source. Reprinted from Roberts LW, Dyer AR: Concise Guide to Ethics in Mental Health Care. Washington, DC, American Psychiatric Publishing, 2004, p. 52. Used with permission.

FIGURE 42–3. The "sliding scale" of consent standards.Source. Reprinted from Roberts LW, Dyer AR: Concise Guide to Ethics in Mental Health Care. Washington, DC, American Psychiatric Publishing, 2004, p. 61. Used with permission.

FIGURE 42–4. Conceptual model of voluntarism: four domains of potential influences.Source. Adapted from Roberts LW: "Informed Consent and the Capacity for Voluntarism." American Journal of Psychiatry 159:705–712, 2002b. Used with permission.
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TABLE 42–1. Definitions of professionalism
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TABLE 42–2. Essential ethics skills in clinical practice
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TABLE 42–3. Ethical tensions in common clinical situations
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TABLE 42–4. Key ethical challenges in special clinical circumstances
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TABLE 42–5. Glossary of ethics terms
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TABLE 42–6. Selections from The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry
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TABLE 42–7. Major codes of research ethics
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TABLE 42–8. Warning signs of problems maintaining therapeutic boundaries
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TABLE 42–9. Working therapeutically in the setting of involuntary treatment
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TABLE 42–10. Eight dos and don'ts for protecting confidentiality
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TABLE 42–11. Requirements for ethical clinical research
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TABLE 42–12. Questions to consider regarding the ethical acceptability of psychiatric research protocols
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Ethical decision making is a skill that can be taught and learned.

Key moral principles that provide a foundation for contemporary discussions of medical ethics are autonomy, respect for persons, beneficence, nonmaleficence, justice, veracity, fidelity, and privacy.

Psychiatrists have an ethical duty to provide competent care, treat patients with respect and dignity, and uphold ethical and professional obligations of confidentiality and truth telling.

Sexual contact with patients and former patients is unethical.

Physicians have an ethical duty to report the improper behavior of colleagues.

Informed consent represents not only a legal and ethical requirement but also an opportunity to enhance physician–patient communication, assess patient preferences and values, and optimize treatment planning through a process of shared decision making.

Individuals with psychiatric diagnoses are heterogeneous in terms of their decision-making abilities for treatment and research and should not be presumed to lack decisional capacity.

Information about decisions should be provided in a manner that is appropriate to the individual patient.

A "sliding scale" approach should be used for assessing decision-making capacity: a higher level of capacity may be needed for higher-risk or risk–benefit ratio decisions.

The ethical use of involuntary treatment and hospitalization balances the duties of trying to do good, avoiding harm, and respecting autonomy.

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1.
Several key principles apply to the exercise of moral behavior and are especially applicable to medical ethics. The movement toward "parity" legislation to ensure that provision of care for mental illness is analogous to care for systemic illness illustrates the ethical principle of
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Principle-based ethics (Beauchamp and Childress 2001) advocates a technique of balancing four ethical principles in the actions of a particular case. Which of the following is not one of the four principles emphasized in this model?
3.
In the "four-topics method" of ethical decision making (Jonsen et al. 1998), data gathering about a particular dilemma is first accomplished and ethical reasoning is then applied. The case of a terminal cancer patient who refuses chemotherapy represents a conflict between which two of this model's four topics?
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