Ethics and Law

BACKGROUND The fundamental concept and understanding of ethics started to be evolving for the last half a century when American Psychiatric Association (APA) developed a code of ethics in 1970. The World Psychiatric Association (WPA) developed it in 1977 and the Indian Psychiatric Society (IPS) adopted it at the Annual National Conference of IPS (ANCIPS), Cuttack in 1989.[12] The committee members which comprises Prof. J. S. Neki, Prof. D. N. Nandi, Prof. A. K. Agarwal, Dr. V. N. Vahia and Dr. J. K. Trivedi and others formulated the code of ethics in ANCIPS Cuttack 1989. This guideline covered the various aspects of duties and responsibilities of a psychiatrist as a practitioner, scientist as well as dealt with their social responsibilities. The professional competence of being a life-time learner even has been echoed in the recently formulated Competency-Based Medical Education issued by Medical Council of India, now National Medical Commission. The benevolence of the patients and their welfare, maintaining highest moral standards and safeguarding the interests of the patient had been given top priorities. The initial draft formulated by the pioneers of IPS.[3] The details of the draft are summarized in Table 1.Table 1: Ancillary rules of consent formulated by expert group of Indian Psychiatric SocietyThe purpose of updating the guidelines has become an eventuality to establish high-quality ethical standards of current practices in changing era. The therapists should have the required skills, knowledge, training, and supervised experiences as well as they should be aware of the emotional state of the patients. They should also take opinion from their professional colleagues, other experts, and specialists whenever necessary. Ethics and law are the different forms of rules by which humans are expected to behave themselves in the society. Ethics represents internal system of controls, and Law refers to an external mechanism of control. Both these controls ar essential for optimal behavior, which includes seeking and dispensing treatment. Salient points The fraud and abuse of psychiatry (such as upgrading, Ganging, Touting, Self advertisement, unavailability, publishing research or report to press, unethical drug trials, teaching unprepared topics, not upgrading self through CMEs, selling of sample medicines, prescribing unscientific drug formulations, practicing quackery, dichotomy or fee-splitting, offering or receiving kickbacks, steering the patient to a particular pharmacy, non-capping, out of proportion, and illegitimate claim for professional services) must be dealt on a serious note to maintain highest possible ethical and professional standards. Ethics is the term used interchangeably with science of morality which represents a body of knowledge that contains principles or standards for value-based human behavior whereas law refers to a system of rules which are enforced through social institutions or the state. Empathetic mode has been the universal method of deciding ethical questions. It is done by placing oneself in the place of the other person and then deciding whether he would like it or not.[4] The guiding principles of Ethics are all that is “good” or “right” have varied with respect to the time, place and the context whereas Laws of the land are made more on the reality considerations based on what is required, aspired for and is practically possible. The term “Ethics” was derived from the Greek word ethikos, which means “rules of conduct that govern natural disposition in human beings.” To put simply, ETHICS means principles of right conduct. In oxford dictionary, it has been defined as “moral principles that govern a person’s behavior or an activity. The ethics is inclusive of active participation in amoral community which deals with problem solving activity is an educational process. However, it does not include personal reliance, expert authorities, interminable disputes, or the dilemma.[56] Philosophical foundations of the ethical principles Utilitarianism (consequentialism) which states “the ends justify the means.” That is, whatever be the method used, if the final outcome of any act turns out to be “good,” then the act is considered justifiable. Deontologism (rule-based ethics), which states that every act has to be done according to particular rules or laws. Irrespective of the outcome, these rules have to be followed, and violation is not acceptable at any time. Both these apparently contrasting viewpoints on ethics have their individual pros and cons but can be taken together. It is the “Rule-based utilitarianism” which forms the pillar of modern medical ethics. Besides utilitarianism and deontologism, virtue-based ethics is having a resurgence in medical ethics. It posits that to safeguard against ethical problems, certain attributes or “virtues” are essential for health care professionals which are related to their field.[3] Salient points There are certain ethical theories, for example, (i) Deontology-which is the basis of all actions. (ii) Teleology-actions can be judged on the consequences. (iii) Utilitarianism-“general welfare” instead of “individual welfare.” TIMELINE The earliest code of ethics could be found in Charaka Samhita. In 5th century BC, the Code of Medical Ethics was postulated by Hippocrates. Down the lane, it was the mistreatment of human subjects in Nazi experiments led to the development of Nuremberg code (1949) which includes voluntary consent, withdrawals of human subjects from the study, and balance between benefits and risks. In the declaration of Helsinki (1964), it was unanimously decided for the first time that greater care is needed to protect the individual Human rights and was set a standard in Medical Research Ethics. The Tuskegee syphilis study (1932-1972) withholding treatment of syphilis to negro males, Willowbrook hepatitis study (1956-70) by allowing hepatitis and depriving intellectually disabled children the protective gamma globulin and Jewish Chronic Disease Hospital (JCDH) study in Brooklyn (1963) where cancer cells injected to noncancerous patients without their consent are some of the dark zones of unethical research in previous century. This was followed by 18th Declaration of Helsinki (1964) which has been modified for five times and ultimately incorporated in 58th WMA (World Medical Assembly) in 2000. The ancient code of ethics and its trajectory is summarized in Table 2.Table 2: Chronological development of different codes of ethicsCode of ethics in Psychiatry was introduced by the APA in 1973. WPA introduced a code of ethics in 1977. In 1979, Tom Beauchamp and James Childress issued the first Edition of “Principles of Biomedical Ethics.” Declaration of Madrid was done by WPA in 1996. Later, a committee was allotted by the IPS to prepare the code of ethics for the Indian Psychiatrists. It was approved in ANCIPS, Cuttack in 1989. Further, Medical council of India has published its ethical rules in 2002.[5] Recommendations The ethical principles guiding research are (i) respect for human dignity, (ii) respect for free and informed consent, (iii) respect for vulnerable persons, (iv) respect for confidentiality and privacy, (v) respect for justice, (vi) judging for potential harms and benefits, (vii) minimizing harm, (viii) maximizing benefits. There are lacunae of resident training decades back in ethics, research, and law in tertiary medical colleges (both in Government and private institutions), especially while working in General Hospital Psychiatry Units. The most of the residents do not have any first-hand knowledge of appearing in the court of law, and forensic psychiatry training should be prioritized in PG training. It is recommended that residents should be involved to attend medical boards, discharge committee meetings, certification procedures.[5] There are other unethical practices mentioned anecdotally, which are summarized in Table 3.Table 3: Common examples of unethical practicesIn view of the development of Bioethics jurisprudence of India, it can be stated that bioethics has now emerged as professional discourse nowadays, and with changing milieu and domains of research these significant points have been added on. Ethics and morals are everybody’s concern. Human rights are said to be universal, inviolable, and indivisible. It is a matter of perception, interpretation, and experience. This makes bioethics a fertile area for inquiry, comparison, conceptualization, and application. Lawyers know little of science and technology, particularly the frontier science of biomedical research. However, law cannot be totally avoided so long as technology can be abused and exploitation can happen in the name of experimentation.[78] Medical ethics are defined as moral principles which guide the members of medical profession in their dealing with each other, their patients and state. These ethical codes guide each others to regulate their relationships. The medical etiquette is self-induced duties upon each other.[9] Four widely accepted principles of health care ethics, extracted from Beauchamp and Childress publications.[10] This is summarized in Table 4.Table 4: Principles of medical ethics Principle of respect for autonomy Principle of nonmaleficence Principle of beneficence Principle of justice. CODE OF ETHICS FOR PSYCHIATRISTS IN INDIA (INDIAN PSYCHIATRIC SOCIETY 1989) IPS, the largest professional body of psychiatrists in India with current membership strength more than 7000, formulated code of ethics in 1989 which is guided by the following principles.[11] 1. Responsibility The psychiatrist must know that he carries a high social responsibility because he deals with disturbed human behavior and intimacies of life. He would also serve the society through observation, investigation, experimentation, and research. 2. Competence Psychiatrists are responsible for their continued education and should understand that lifetime learning is needed. 3. Benevolence Patient’s interest and their health should be given the prime importance in professional practices. 4. Moral standards Consider all the moral codes and expectations of the community they serve and will not let their behavior in anyway damage their profession. 5. Patient welfare They will not treat any case that does not fall within their competence. 6. Confidentiality The psychiatrists should safeguard the information obtained from their patients, relatives, and informants during their clinical work, teaching, or research. Ethics and morals are concerns of all of us, and human rights are said to be inviolable, indivisible, and global which is a matter of perception, interpretation, and experience. Thus bioethics is a fertile area for application with comparison, conceptualization, and inquiry. The science and technology, the frontier of biomedical research is not known to the lawyers in general; however, technology can be abused, and exploitation can happen in the name of experimentation.[12] GOOD PSYCHIATRIC PRACTICE (CODE OF ETHICS) College report CR 186 of Royal College of Psychiatrists suggests 12 principles in 2014.[13] The essential dignity and humanity of every patient should be maintained by the treating psychiatrist Psychiatrists shall not exploit patients’ vulnerability Patients should receive the best attainable care for their treating psychiatrist Psychiatrists shall maintain the confidentiality of patients and their families The valid informed consent must be obtained from the patients undergoing procedures The best available treatment options should be discussed and provided to the patients and their caregivers The misuse of professional skills should not be done for personal or monetary gain While doing research work, the psychiatrist should follow national and international guidelines and should not disclose the identity of their patient and publish photographs without the consent of the patient They should continuously develop, maintain and share their knowledge, expertise, and skills with medical colleagues, trainees, and students through CME and medical Psychiatrists have a to attend to the health and of their colleagues, and students the professional should be maintained Psychiatrists shall to health and community of and its treatment and and the of and unanimously the and was approved by of India on In the and ethical aspects related to consent to the to consent, and of the are set The Ethics of the IPS issued of the code of ethics for Indian in It principles which include competence in the of maintaining with when maintaining patient rights and updating knowledge if a or professional the dignity of the medical the to ethical principles of conduct when involved in medical education and in OF PSYCHIATRIC ETHICS To and with patients and within the of Consider the rights and autonomy of patients. to the community and society. consent, Human psychiatrist is the between the individual and the society. He to with the ethics and law, to The of cannot be as and The human as and on the and as well as There are of research, and of is of in ethics can be defined as moral principles which guide the members of the medical profession in their dealing with each other, their patients and state. These ethical codes guide each other to regulate their relationships. The medical etiquette is self-induced duties on each They should and follow the There had been published as found in by the It was not found to be a for by the Indian related to ethics as found in a published in the Indian of Psychiatry in In a is by can the pros and cons and whether to or the in the long However, the have other to to their emotional and of the development of a psychiatrist should have to and with their patients. the time, it is to whether their could have a and while treating a consent The concept of informed consent has also been as are of that has as a of from the to are and that are by of and are more than and be as a of are and that in the court of law during The consent should not be a consent as it is in The procedures of the consent are not followed and not discussed with the It is to take consent for each The voluntary informed consent is essential for research human which include (i) of the of research, (ii) that the consent is voluntary and the individual can consent at any time, (iii) of pros and cons of the research, (iv) of the confidentiality will be of (v) information that the will share with the and (vi) the name with will be responsible for with the research Confidentiality to The patient has given consent to share information to or the act has potential to it is the of treating psychiatrist to The is on treating psychiatrist with that had been which has or to the confidentiality In case of abuse or violation of the right to of The patient must be informed and if the patient the that has also to be informed to the court the patient had the psychiatrist has the right to share information the court of law which is to the Principles to follow while the patient and consent the that is to share with what the for Competence and responsibilities The competence and responsibilities of a are They should be aware of their responsibilities self and They should maintain their and to their as summarized in Table Competence and responsibilities of a conduct The behavior and practices of a which is considered as and which can be judged as abuse of professional is which includes for example, with in professional and This includes 1. with 3. and 4. treatment on the basis of 5. doing in and like 6. treatment in of act Human rights of and case without consent of and professional should be It is a made on any matter by a to the as a the community or state at The interest of cannot be at or for interest of a particular patient the of of society. can be defined as the of care and or of a medical in the treatment of a which or of the The is of professional when is to discharge the The professional can be of (i) and (ii) However, professional cannot be with professional In the of care and with damage has to be and has to be done in court of law, whereas in the act is considered and is being done by state medical The between and are summarized in Table of and The damage of patient and or which added on which has the damage to Medical It to of individual to by This can be and certain are and procedures are being done the and any or certain procedures these and and certain procedures can have but the should and certain become as and or The that that is in the of the or damage would not have The had treatment or and the patient was not of in the The is when the is not responsible for but also the of the This is when the is not responsible for but also for the of the which is the This should be the of and while on It is to an for a especially for professionals as and However, the is not responsible for the of and Medical etiquette The of the medical etiquette is that the psychiatrist should treat their with respect and patient can be to a professional or institutions or of the or different by a psychiatrist for a opinion or treatment. It is the on each other, the of between the members of the medical profession. In case of some treatment of a psychiatrist should their patient to for a The to the health like the other medical are and some are now The psychiatrist should their patients at the of the treatment their professional and human right The word Human in a means claim which every individual has or should have upon the society in which The dealt with human right of with The ethical and safeguard and have been for vulnerable group in and research The of ethical standard of care and for patients have also taken care The confidentiality and have also been judged with of the as health care The right to and treatment The right to be informed the treatment The right to consent The right to The fundamental rights as other the right to a as as possible against exploitation and or treatment to protect their OF be defined as the of professional behavior, of which the out of the clinical or the clinical In other It is the and social by the patient in the clinical and of and is a from activity which is and of the the other a violation is to the patient and the It exploitation of the and violation from the or from the This to or or all health professionals to be aware of psychiatrist have an responsibility for various as mentioned is for for of by oneself and in to patients Psychiatric patients are more vulnerable to can to emotional the treating is aware that he or is to or it The to be and or In as the is and more personal as are is of emotional This to activity by patients are not in India The ethical in have to be and FOR of and and in some patients and in training of knowledge on between and patients. all the health care patients, and caregivers certain in clinical ethical guidelines in India to the guidelines for all involved patient and for on (IPS) The declaration group had formulated guideline which had been to the Medical Council of India the had been given between and patients Code of conduct for and patients of should not exploit the for or gain if the patient to the it will be against medical for a to a of activity would to and would be to the law of the land and should be done and which a should be a with a patient is of IPS the time as at the the of the can it is for all to should be used should not exploit the for These guidelines are for the of patients and their members in following the if to the IPS will be to the Ethics care should be by the while with colleagues, and other professionals can and the should The IPS that are not to any particular group of not to but in all professional The of and rights of community with respect to and IPS are a the The with with respect to health than of have and the psychiatrists are on the of pros and cons in their of last the of should in the and should follow the law of the ethical and are as well as The confidentiality the for the and of confidentiality is and unethical in with and educational are more with to which makes in initial The procedures of had the with care given to the human right which is summarized in Table of of training with respect to health in set is The patients, having and have more of having behavior, and they can be provided with which are most acceptable which can be with and The for has to be provided in with to with The have been on and and in of The of certification at health care is now a The of interest when the interest as welfare and of research is being by interest of of of care in The has been which the responsibility of a especially when it to the related to confidentiality and In person have as Indian patients are more by of their which also to relationships. However, in the of a the patients are being to follow for the of the patients and their APA it as to be followed if at all in person is required in the of a In the current the voluntary by and are considered as However, the of are for example, in the information the to in and when as a patient all the of the treating The Medical Council of India by of recommended that all the professionals should their to their knowledge and should in their treating a patient and other than in are There are other unethical practices in these practices also but the by a could not be in medical the and the of the to maintain highest professional ethical standards to in the where information are at the The should in education and in training in standards of and aspects of psychiatry should be and to all from time to time The should most and best The ethical guidelines are continuously evolving and has to in should not do any act which should not like to receive from others The of all these is that patients should be with dignity and respect should in the and should follow the law of the ethical and are as well as The confidentiality the for the patient and of confidentiality is and unethical in and of interest There are of