Medical Ethics and

Professionalism

By Dr. Haymanot Girma (psychiatry R1)

Moderator Dr. Elias Tesfaye(MD,
associate professor and consultant
psychiatrist)
August 2022 G.C
 OUT LINE
• INTRODUCTION TO ETHICS
• ETHICS SCHOOL OF THOUGHTS

• MEDICAL ETHICAL PRINCIPLES

• ETHICAL DILEMMAS
• ETHICAL PRACTICES IN PSYCHIATRY
• MEDICAL LAW AND HEALTH LAW

• PSYCHIATRIC MALPRACTICE

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 Introduction
• Ethics is a scholarly discipline that brings greater understanding
of moral aspects of human experience and action
• Ethics is a broad and complex field of study, Medical Ethics is
a branch from it which is a system of moral principles that
apply values and judgments to the practice of medicine.
• A profession refers to a publicly declared "dedication, promise
or commitment". Medicine is regarded as a "moral enterprise".
Healthcare workers are obligated to act primarily in their
patients' best interests

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 Ethics in Psychiatry

• Separately and together, the fields of ethics and psychiatry

examine human meaning, intention, and consequences

• Thus by their natures, ethics and psychiatry are overlapping

fields of inquiry.

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• it is perhaps surprising that psychiatry enjoys more than its
share of ethical controversy.
 issues related to power and intimacy in psychodynamic–
psychotherapy relationships
 older dilemmas regarding the potential exploitation of
vulnerable individuals in psychiatric research
 patient confidentiality in publishing patient case reports

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• Psychiatrists and psychiatrists-in-training should learn more

about ethics more than other specialist physician

• professionalism, legal concerns, gender-related issues, and

cultural competencies

Because :
• The nature of mental disorders and the impact of stigma
• The influence psychiatrists may have over their patients’ lives
as a result of transference
• Initiate treatment against the patient’s wishes

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 ETHICAL SCHOOLS OF THOUGHT
• Several ethical schools of thought have influenced how
physicians understand ethical aspects of medical practice.
• Virtue-based theory has contributed greatly to the ethical
framework of medicine and the key concepts of
professionalism
• John Gregory (1724 to 1773) was a Scottish physician–
ethicist, and Thomas Percival (1740 to 1804) was an English
physician–ethicist.

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 Table 1 Ethical models of thought
Model Major Figure(s) Key Strengths Limitations
  Features
Deontology, or Immanuel There is an Some moral Conflicting
the ethics of Kant absolute good judgments apply obligations. Too
duty and right. in almost all much emphasis on
To be ethical, circumstances to obligation, not
persons must fulfil everyone (e.g., enough on
these respect for consequences or
absolute duties persons). relationships.
Unconditionally. Very abstract.

Utilitarianism, or John Weigh the Useful in Difficult to

the ethics of Stewart consequences of formulating translate into
consequences Mill actions and public policy Practice. Practices
Jeremy rules. because it that harm
Bentham Those that bring requires impartial individuals and
about the greatest groups may be
assessment of all ethically justifiable
good Interests. Has
for the most in this model.
beneficence as a May demand that
people are most goal.
ethical. the minority
sacrifice too
much for the
majority.
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 Cont’d
Model Major Figure(s) Key Strengths Limitations
  Features
Justice-based John Rawls Decisions should Demonstrates Neglects
ethics be made with respect for the principles
respect and individual person. beyond fairness in
fairness in relation Has equality as a clinical decision
to each individual. goal making

Virtue-based John Ethical decisions Internal values Virtue may be too

ethics Gregory are rooted in and unclear or
Thomas qualities or habits rather than pluralistic
Percival character, such external rules and to serve as a basis
as honesty and Imperatives. for judgment.
Faithfulness.
Highlights Persons may act
Actions are right importance of wrongly out of
only if they are qualities of the virtue (e.g.
what a virtuous individual, of withhold the truth
person would do personal from a dying
in the same character patient to avoid
situation emotional upset).

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 BASIC ETHICAL PRINCIPLES
• The modern field of biomedical ethics takes primarily a
principle-based approach.
• In their influential text Principles of Biomedical Ethics,
Beauchamp and Childress defined the most critical among the
principles to be
• autonomy, beneficence, non maleficence, and justice.
• Other principles, such as compassion, confidentiality, fidelity,
integrity, and veracity, are also central to the practice of
psychiatry.
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 Table 2 examples of biomedical ethics
Autonomy The notion of self-rule; the capacity to make authentic decisions related to
one’s body and mind.
Beneficence Doing good ; the commitment to seek to bring about benefit.
Compassion Deep regard for the experiences and suffering of others.

Confidentiality A legal privilege associated with the right of privacy; the obligation not to
disclose information obtained from a patient or observed or gathered in
caring for a patient.
Fidelity “Faithfulness” or loyalty to ethical ideals.

Integrity The notion of being whole or complete; the capacity to adhere wholly to the
principles of the profession.
Justice Equitable distribution of benefits and burdens in society.

Nonmaleficence Avoiding harm or injury to others.

Respect for the law The obligation to adhere to the law.

 
Respect for persons Fundamental regard for the dignity, sacredness, and value of the individual.
 
Veracity “Honesty,” involving the positive duty to tell the truth and the negative duty
to avoid deception.
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 APPROACHING ETHICAL DILEMMAS
• Ethical dilemmas do not typically emerge in simple situations
of doing good versus doing bad.
• Indeed, ethical dilemmas come when two seemingly good
things are at stake.

• Dilemmas often come when two or more of the basic bioethics

principles are in conflict or cannot be completely fulfilled

given the circumstances of a particular situation.

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• For example: a psychiatrist receives a request from a worried
and loving mother to provide information about issues arising
in her son’s therapy sessions. The son has a good relationship
with his mother but has been bullied at school, feels
embarrassed, and does not want his parents to know what is
bothering him.

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 Recognizing Ethical Issues and Tensions

• The ability to identify ethical issues and tensions present in the

patient care situation is the first and most basic of the ethics
skills
• Recognizing the ethical features of a patient’s case requires
sensitivity
• This capacity is enhanced by knowledge of ethical principles
and how they may come into conflict.

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• For Example: consider the case of a newly diagnosed cancer
patient who, overwhelmed and fearful, attempts suicide by
overdose. She requests aid in dying from her oncologist, who
also feels overwhelmed and fearful because of the patient’s
reaction and refers the patient for a psychiatric evaluation. The
psychiatrist learns that the patient’s mother died from cancer
and that she was her mother’s only caregiver over the long and
difficult course of her illness. The psychiatrist finds that the
patient likely had a pre-existing depression before learning of
her cancer diagnosis. The patient is decisionally capable,
despite her distress, and the psychiatrist feels great empathy
for the patient.

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• In this example, many principles are in play and several are in
tension: most clearly,
1. Honoring the patient’s wish to die (autonomy)
2. The physician’s responsibility to avoid harm (non
maleficence)
• A superficial analysis would suggest that the patient’s right,
especially in an autonomy-oriented society, would trump all
other considerations.
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 In this case the psychiatrist suggests

• identifying ways of reducing the patient’s physical and

psychological suffering,
• treating her pre-existing condition,

• providing accurate information about the nature of her condition

and potential treatments, and
• adhering to legal requirements all may contribute to an improved
physical and mental health outcome for the patient.

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 EXAMPLES OF ETHICAL DILEMMAS
ENCOUNTERED BY HEALTH WORKER
• Allocation of scarce resource – priority setting
• Culture, Religion, passive Euthanasia
• Refusal of Blood transfusion among the Jehovah Witnesses,
the Konso culture,
• Refusal to eat or take medication any more at terminal stage of
illness
• Not in state of mind/situation to decide
• Adolescents under the age of consent in the case of sensitive
sexual reproductive health issues hidden from parents

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 Gathering Additional Information and Expertise

• Additional information or broadened and deepened expertise

may lead to a ready resolution of the problems at hand.
• Data or expert guidance could come from the patient’s prior
medical records or clinical practice and ethics guidelines.
• In addition speaking with an experienced supervisor, seeking
advice from a colleague with specialized expertise, requesting
an ethics or a legal consultation

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• E.g. Consultation-liaison psychiatrists can be consulted about
a patient who is declining potentially life-saving care for what
appears to be an irrational reason and is demanding to return
home against medical advice.
• A psychiatric evaluation may reveal an underlying condition,
such as an addiction, delirium, early dementia, or poor pain
control, interfering with the patient’s decision making.

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• Thus, in approaching an ethically complex clinical situation

1. recognizing the ethical dimensions of a patient’s care and

2. seeking additional information or expertise

are the two initial steps to take in resolving dilemmas and

developing ethically astute treatment plans.

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 Working within One’s Scope of Practice
• Working within once scope of clinical competence is
considered ethically important
• Psychiatrists need general medicine including specialized
knowledge in the care of individuals with mental disorders.
 When confronted with patient care situations that are outside
their scope of competence, then referral or, at the very least,
consultation and supervision are appropriate.
• In training settings, close supervision of early-career
physicians helps ensure an appropriate.
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• In emergencies, even if clinicians are outside the scope of their
usual practice, they are expected to do their best effort and
certainly not to abandon the patient in extreme need
 responsibility to continue to learning

• Remaining aware of advances in one’s field is critical to optimal

patient care and ensures that the clinician’s scope of practice
and domains of competence remain within community
standards
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 DECISION-MAKING STRATEGIES
• All health sectors adopted a 4 part model

(1) Clinical indications

(2) Patient preferences

(3) Quality of life, and

(4) Socioeconomic or external factors

• Clinical indications, has the greatest weight

• In psychiatry, this step is the same as in other areas of

medicine.
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• Second model: patient preferences, is grounded in the
principles of respect for persons and autonomy
• In the practice of psychiatry, the nature of mental
disorders may interfere with the ability of patients to
identify or express their preferences or affect
decisional capacity or authentic voluntarism

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• Quality of life is the third element in the model. It refers to the
sense of personal satisfaction individuals express and/or
experience with regard to their physical, mental, and social
situations.
• Perhaps the most important consideration in assessing quality
of life is direct engagement with patients regarding their
values and points of view.

• Clinical indications and patient preferences are weighted more

heavily than quality of life in the decision-making model.

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• The fourth element in this clinical decision-making model
entails socioeconomic or external factors include the interests
of society, the role of family members, cultural factors, and
costs and limitations in access to care.

• This element is last primarily because of the obligations of

beneficence.

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 Medical Ethical Practices
Medical
Ethical
principles
4 decision
School of making
thoughts
models

Ethical
practice

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 EXAMPLES OF ETHICAL PRACTICE
STANDARDS IN PSYCHIATRY
• The presence or absence of a mental health or cognitive
disorder may significantly impact the manner that ethical/legal
issue, whether civil or criminal, is perceived and ultimately
managed
• The interplay between psychiatry and the law can be broadly
divided into situations involving clinical treatment interactions
and situations involving specific legal matters that require the
input of psychiatrists to settle a contested legal issue.
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• Clinical-legal issues such as patient confidentiality, informed

consent, the right to refuse treatment, and medical standards of

care are ubiquitous in the psychiatrist–patient therapeutic

relationship.

• Potential involvement by psychiatrists as experts in contested

legal matters, such as criminal cases, personal injury lawsuits,

employment-related claims, testamentary disputes, or child

custody cases requires familiarity with legal principles and

jurisdictional laws.
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THE DOCTOR–PATIENT RELATIONSHIP
• In ancient time physicians were not distinguished as priests,
magicians, or other ancient healers.
• During the 4th century B.C.,the Hippocratic Oath set forth a
code of ethics outlining principles that remain essential
features of modern-day medical ethics, including patient
confidentiality, abstaining from sexual contact with patients,
and preventing harm to patients.

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• Hippocratic Oath, swears: “… I will prescribe regimen for the good of

my patients according to my ability and my judgment and never do

harm to anyone. To please no one will I prescribe a deadly drug, nor

give advice which may cause his death. Nor will I give a woman a

pessary to procure abortion… in every house where I come I will enter

only for good of my patients, keeping myself far from all intentional ill

doing… all that may come to my knowledge in the exercise of my

profession or outside of my profession or in daily commerce with men,

which ought not to be spread abroad, I will keep secret and will never
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reveal….”
• The familiar dictum, Primum non nocere or
• first, do no harm, further distilled the fundamental ethical
principle at the core of the doctor–patient relationship.
• The late 19th and early 20th century, there was a growing
sentiment that patients had the right to actively influence the
course of their medical care.

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• Patient autonomy was clearly endorsed in the 1914 case,
Schloendorff v. Society of New York Hospital
• “Every human being of adult years and sound mind has a right
to determine what shall be done with his own body…”
• in the 1957 Salgo v. Leland Stanford Jr. University Board of
Trustees case. Legal informed consent requirement doctrine
would become a more clearly defined.

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• The shift away from medical paternalism toward the
incorporation of patient autonomy permitted a more
appropriate balance within the therapeutic relationship.
• however, there are clinical situations that call for prioritizing
medical benefit over patient autonomy.
• significant psychiatric symptoms that temporarily
deemphasize autonomy concerns

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 The Therapeutic Relationship and Professional
Boundaries
• Therapeutic relationship: presupposes that the physician is
worthy of the trust of the patient
• The physician’s expertise and the physician’s intention to do
good, avoid harm, and place the patient’s best interest above
all other interests are the basis of that trust
• Professional boundaries are behaviours that align with these
fundamental commitments to serve the well-being of the
patient.
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• Therapeutic boundary violations are behaviors that
subordinate the interests of the patient to the interests of the
physician.
 Sexual relationship(present or former)
 influence the political views of the patient

 Accepting expensive gifts directly from patients

 Engaging in business activities with a current patient or
former patient

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• Therapeutic boundary crossings are behaviors that are
intended to serve the interests of the patient but differ from
usual ethical practices.
• Should be viewed as exceptions but are often ethically
acceptable.

1. A psychiatrist disclosing personal information to build

rapport with a distant and troubled patient or
2. Accepting a small gift at the holidays to demonstrate respect
for a patient’s culture and origin
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 Confidentiality

• Confidentiality refers to the physician’s duty to not release

information learned in the course of treatment.
• information may relate to disclosures by the patient,
observations of the physician, or laboratory findings or notes
from prior treatment in the medical record.
• Protection of patient confidentiality fosters the therapeutic
alliance

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• In teaching and research one should not unnecessarily release
patients’ names or information that might allow others to
identify them.
• Presenters of patient material in ward rounds and case
conferences should remind attendees not to repeat what they
hear.
• Confidentiality and the ethical obligation to withhold
information endure even after a patient’s death.

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 Examples of Optimal Approaches to
Confidentiality in Clinical Practice
► Provide accurate information to patients about the realities of confidentiality in the
clinical setting.
► When appropriate, remind patients that the purpose of the medical record is to be
shared as a way of providing optimal care by a team of health professionals.
► Openly discuss with patients the legal limitations of confidentiality and avoid
assuring patients that their disclosures will be “completely” confidential.
► Do not speak to others or, if working in a team-based care setting, avoid talking
with others beyond the health care team, about patients’ care without explicit, written
permission to do so.
► Actively work within organizations and professional societies to develop state-of-
the-art
confidentiality safeguards as science, clinical care, health policy, the law, and health
care systems evolve.
► Seek consultation and expert guidance when confidentiality safeguard questions
arise.
► Model best practices in confidentiality to colleagues, team members, and trainees .

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• Physicians may be held liable for breaches of patient
confidentiality
• Exceptions in psychiatry
 In emergency situations

 When acting to protect third parties from a potentially

dangerous patient
 reporting requirements involving concerns such as, child or
elder abuse, unsafe drivers, or impaired health care
professionals.
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 CONFIDENTIALITY vs PRIVILEGE

• Confidentiality represents physicians’ obligation to their

patients to not disclose information to third parties without a
patient’s consent.

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• Privilege also deals with the protection of patient information;
however, it refers to the more specific protection against
physicians being compelled to provide protected patient
information during court proceedings.
• The physician–patient and psychotherapist–patient privilege
facilitates a more open and effective therapeutic alliance.
• The privilege belongs solely to the patient

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• However, the privilege is not absolute and may be pierced under a
number of circumstances
1. Patients may lose the privilege in cases where they raise their
mental status as an issue in a civil or criminal matter
2. Medical malpractice claims initiated by patients against their
psychiatrists
3. In child custody cases

4. if the patient shared the information in question with their

physician in the presence of a third party who is not involved in
the patient’s care.
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 Informed Consent

• Informed consent is the idea that capable and knowledgeable

individuals may freely choose a course of action pertaining to
their health.
• involves three components: information- sharing, decisional
capacity, and voluntarism.

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 Information sharing
• With respect to information-sharing, physicians should

provide patients accurate and balanced information regarding

(1) the nature of their illness or condition;

(2) the need for intervention;

(3) the anticipated risks or benefits and their relative likelihood,

including rare but very serious risks;

(4) appropriate alternatives and their attendant risks and benefits;

and (5) future consequences of the different choices, to the

extent possible.
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 Decisional capacity
1. Physical and mental ability to communicate
2. The ability to understand relevant factual information.

3. Sub capacity is the ability to reason, that is, to weigh the

different factors and risks and to think through the choice at
hand in an objective and flexible manner.
4. to appreciate the meaning of the decision and to evaluate the
choices in the context of one’s life.

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 Voluntarism

• is the capacity that relates to one’s ability to act freely, in the

absence of coercion, in expressing one’s authentic wishes.
“Deliberateness, purposefulness of intent, clarity, genuineness,
and coherence with prior life decisions” are key elements of the
capacity for voluntarism.

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• When an individual is not capable of informed consent or
refusal, others who are legally authorized may make decisions
for the patient.

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• Exceptions to the informed consent requirement include
o medical emergency,
o The patient waives of the physician’s disclosure requirement

o invocation of therapeutic privilege in situations where the

disclosed information would be detrimental to the patient.

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 INVOLUNTARY HOSPITALIZATION
AND TREATMENT
• Two traditional legal justifications, parens patriae and police
power, provide state jurisdictions with the authority to
involuntarily hospitalize,
• Parens patriae refers to governmental power to care for
individuals who are unable to care for themselves.
• The police power principle refers to the societal interest of
permitting governmental authority to protect the general
public from potential harm.

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• involuntary psychiatric hospitalization vary from state to state,
but generally require the presence of a mental illness and a
degree of risk of harm to the patient or to others due to the
patient’s symptoms of mental illness.

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• It is important to note that involuntary hospitalization does not

per se permit medical treatment over patients’ objections.

Some jurisdictions require additional legal proceedings to

permit the involuntary administration of medication over

patients’ objections.

• The psychiatrist continues to bear the ethical obligation of

avoiding unnecessary breaches of patient confidentiality.

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 LAW AND THE HEALTH PROFESSIONAL

• Medical Ethics and law are related. While ethics prescribes

high standard of behavior the law specifies how health
professionals are expected to deal with ethical issues in patient
care.
• Health provision and service delivery by health professionals in
Ethiopia is general speaking regulated by law and the legal
system. Accordingly, an understanding of law and the legal
system is fundamental to the provision of competent and safe
patient care

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• Ethiopia has a codified legal system, meaning that there is a
primary source where the law originates and can be found. The
sources of law mainly are the Constitution; proclamations;
regulations; directives; case laws (Federal Supreme court
decisions at a cassation level); and customary laws.

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 MEDICAL LAW VS HEALTH LAW
• Broadly speaking, medical law relates to the legal aspects of
medical practice. rules of law relating to:
(a) Medical profession;
(b) the relationship between the doctor or hospital on the one hand
and the patient on the other;
(c) the relationship between the medical profession and other
healthcare workers; and
(d) the relationship between the doctor and the health care legislation.

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• Health law, on the other hand, is broader in scope. It
encompasses medical law and also all other health-related
policy and law matters that go beyond being applicable to just
doctors. In terms of applicability, health law pertains to all
those involved in health research and health service delivery.
• Ethiopia doesn’t have a separate health or medical law;
medical malpractice is seen in civil code under the category of
professional fault (Article 2031).
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HEALTHCARE PROFESSIONAL RIGHT
AND RESPONSIBILITY
1. REFUSE TO PARTICIPATE IN PATIENTS CARE
Except medical emergencies, caregivers have a right to refuse to
participate in certain aspects of patient care and treatment. This
can occur when there is conflict with one's cultural, ethical,
and/or religious beliefs, such as the administration of blood or
blood products. participation in elective abortions, and end-or-life
issues such as disconnecting a respirator

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• “The physician may not discontinue treatment of a patient as long
as further treatment is medically indicated, without giving the
patient reasonable assistance and sufficient opportunity to make
alter- native arrangements for care.”—World Medical Association,
Declaration on the Rights of the Patient
• However, a doctor’s unreasonable refusal to treat a patient in a non-
emergency context, for example on the basis of patient’s religion,
ethnicity and gender, could be deemed unethical conduct

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2. Healthcare professional has no duty incumbent on them to
treat individuals who are not already their patient. This is because
in a law there is no liability for an omission (a failure to act)
unless there is a duty to act
• In emergency context, health professionals are under a legal
and ethical obligation to render medical assistance.

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3, Disclosure: For the patient to be well informed and to make
informed choices (i.e., autonomy), the doctor must disclose
information that is materially relevant to the patient's
understanding of their condition, their treatment options and likely
outcomes. This would include, for example, information on
medical errors made in their care. As the American College of
Physicians says: "Errors do not necessarily constitute improper,
negligent, or unethical behavior, but failure to disclose them
may."

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 DUTIES OF PATIENTS
From a statutory perspective, a user must
• (a) adhere to the rules of the health establishment when receiving
treatment or using health services at the health establishment;
• (b) provide the healthcare provider with accurate information
pertaining to his or her health status and cooperate with healthcare
providers when using health services;
• (c) treat healthcare providers and health workers with dignity and
respect; and
• (d) sign a discharge certificate or release of liability if he or she
refuses to accept the recommended treatment.
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 Professional malpractice
• It may also be defined as the failure of a professional person to
act in accordance with the prevailing professional standards or
the failure to foresee consequences that a professional person,
having the necessary skills and education should foresee.

• malpractice, in general, fall under the legal division of tort law

which essentially concerns legal wrongs committed by one
person against another person or against the property of
another person.
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 PSYCHIATRIC MALPRACTICE
• Across all medical specialties there has been a major reduction
in the rate of paid malpractice
• The theory of medical malpractice refers to professional
negligence that falls within the civil law domain
• If patients or their representatives may file lawsuits for
personal injury or wrongful death against health care
providers. In those malpractice actions, plaintiffs must prove
by a preponderance of the evidence that the actions of the
provider represented a breach of the prevailing professional
standard of care.
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• A bad outcome does not per se equate to bad care
• An exception to this rule is the legal concept,
res ipso locquitor or the thing speaks for itself, where the
commission of an egregious error
E.g-
-Failing to remove an abdominal clamp during surgery,
-Sexual misconduct during a therapy session under the guise of
treatment.
• In case of suicidal lawsuits both the plaintiff and the
defendant bring psychiatrist expert for testimony

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Case D
Mr. D. was a man with depression and chronic,
intermittent suicidal ideas. He was treated for depression
as a psychiatric inpatient. At the time of his
discharge, Mr.D. still had some symptoms of depression,
but denied suicidal ideas. Upon discharge, Mr.
D.’s psychiatrist scheduled him for a follow-up appointment
approximately two months later. One day
after discharge, Mr. D. committed suicide. The
plaintiff’s expert opined that Mr. D.’s psychiatrist fell
below the standard of care by giving such a late follow-
up appointment.
In this case ‘ even if a two-month outpatient follow-
up appointment is a clear departure from the
relevant standard of care, there can be no liability
unless the expert is willing to testify that failure to
give a follow-up appointment less than 24 hours after
discharge falls below the standard of care. Mr. D.
killed himself the day after discharge, and so, hypothetically,
the suicide could only have been prevented
if he had been seen within that brief window of time.
A more plausible deviation may exist in the area of
premature discharge, and more analysis would be
needed to determine whether it could be considered
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the proximate cause of Mr. D.’s suicide’.
 Reference
• Benjamin J. Sadock, Virginia A. Sadock, Pedro Ruiz, Kaplan &
Sadock’s Comprehensive Text Book Of Psychiatry, New York,
2017,10th Edition, Page 11274- 11312
• Dominic A. Sisti, Arthur L. Caplan, And Hila Rimon-greenspan,
Applied Ethics In Mental Health Care, USA, 2013
• James Knoll ,Joan Gerbasi, Psychiatric Malpractice Case
Analysis: J Am Acad Psychiatry Law, 2006, Volume 34: 215-223
• Geremew Tarekegne(MD), Frehiwot Brehane(DM), Ethiopian
Medical Association Ethics And Medico-legal Basic Training For
Healthcare Professional, 2017, Page 1-51
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Q, What is the ethical responsibility when you have definite
proof that a colleague of yours, who is practicing psychiatry is:
(a) A severe substance addict or psychotic
(b) indulging in sexual activities with his patients

Q, What is your ethical responsibility when you know one of

your patients is embezzling, and he/she refuses to do anything
about it?

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 Thank you

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