Ethics from the lens of the social dimension of psychiatry

From a historical perspective, Engel¹ conceptualized psychopathology as resulting from an interaction of three orders of factors: biological, psychological and social. The first half of the 20th century has been mostly devoted to conceptualizing the psychological component of mental disorders, the second half to the understanding of the biological component. We are now, in the 21st century, busy at better understanding the role of social processes that impact treatment approaches to psychopathology as well as the psychiatrist-patient relationship.

Even more than other medical disciplines, psychiatry is influenced by external events that plague society, such as epidemics, natural disasters and wars. These events often require the involvement of ethics committees that will determine the duties and rights of the physician in potentially conflictual ethical contexts, such as triage situations (i.e., choosing whom to treat first). The COVID-19 pandemic has shown how deeply interwoven the epidemiology of mental disorders and the access to mental health services are with both social factors and somatic health. Grief, isolation, loss of income and fear exacerbate existing mental health problems or create new ones. The pandemic has demonstrated that the biological and social dimensions of medicine and public health are inextricably linked².

Profound changes in social values and norms, such as the legitimization of medical procedures for transgender individuals, or the availability of euthanasia in some countries, require a redefinition of the psychiatrist's role within the medical staff, and the development of ethical guidelines that take into account a variety of emotional, religious and ideological aspects pertaining to both the patient and the physician.

This changing scenario is extensively reflected in Galderisi et al's paper³. I will focus here on three of the issues discussed by the authors. The first is stigma related to mental disorders in society in general, and particularly in the medical world. Studies documenting the importance of social/environmental components in the development of psychopathology⁴, as well as those showing the close relationship between physical illness and emotional states, have contributed to reduce that stigma. The inclusion of psychiatric wards within general hospitals has been both a consequence and a further determinant of this evolution. Likewise, the importance of the psychiatrist's presence in transdisciplinary medical teams, as well as in hospital ethics committees, has become more obvious than in the past. It is also increasingly clear that codes of ethics of physical medicine and psychiatry overlap to a large extent, especially with regard to the therapist-patient relationship.

The second topic I wish to emphasize is the changing relationship between psychiatrists and representatives of patients and families. In the recent past, we witnessed against-psychiatry demonstrations by former hospitalized patients, their families and human rights organizations. Our involvement at the societal level has led to a move from a paternalistic stance to a more listening, egalitarian position. We have started to invite those demonstrators to “cross the street”, to come and participate in our meetings to share with us their point of view and to discuss with us the dilemmas regarding issues of quality of life, patients’ rights, effectiveness of our treatments versus side effects, and coercive situations, in a context marked by mutual respect. Today, in many countries, representatives of psychiatric patients are invited to participate in committees that discuss these issues and allocate resources for research. In some countries, former patients and/or their relatives also participate in teaching medical students and residents. This collaboration has increased the transparency of our ways of thinking and working, and is contributing to reduce the stigma attached to psychiatry. This change of attitude is clearly reflected in the WPA Code of Ethics².

One of the issues that remain conflictual, and feed the stigma towards the psychiatric profession, is the use of coercive measures, that seems to deny the patient's right to autonomy, one of the four basic principles of any medical code of ethics, along with beneficence, non-maleficence and justice⁴. The term autonomy reflects the patient's right to refuse medical treatment. In the case of a psychotic patient, the definition of “autonomy” is very complex, as the patient's “free” will is colored by his/her psychotic symptoms and lack of insight. The goal of treatment, including coercion, is to restore the patient's judgment capacity necessary for independent functioning. The growing attention to this issue has already led in many countries to a decrease in the number of involuntary hospitalizations and physical coercive measures, and the increasing use of alternative treatment solutions, such as the development of crisis units and “balancing houses” in the community, as an alternative to hospitalization^{5, 6}.

Another issue related to the patient's right to autonomy is that of euthanasia. What is the psychiatrist's role, if any, in the process of fulfilling a patient's desire to end his/her life while freely choosing to prioritize quality of life over longevity? The renowned surgeon C. Bernard stated: “I have learned in my many years that death is not always the enemy. Sometimes it is the right medical treatment. It often achieves what medicine could no longer offer – an end to suffering”⁷. In my opinion, the psychiatrist has two roles in this respect: the first is to make sure that the patient's request is given out of “clarity of mind”, the second is to ascertain that the patient's wish to die is not a masked suicidal intent secondary to the psychopathology from which he/she suffers. Unfortunately, tools for a truly reliable assessment of these issues are not available.

A recent development regarding euthanasia is the ethical legitimation for the psychiatrist to act in accordance with his/her moral and/or religious views, possibly (but not necessarily) deferring the question to a colleague who agrees to be part of the medical team that is supposed to examine the request. It is important to discuss this issue with medical students and residents during their professional training.

Unfortunately, teaching of ethics does not occupy an adequate place in professional curricula, in psychiatry as in other medical disciplines. Also, the number of national psychiatric associations that have produced their own code of ethics is minimal, probably also due to the feeling that the existence of a code of ethics is a coercive factor that limits the clinician's freedom of action. We need to emphasize the advantages of having a code of ethics, such as the personal moral and legal protection that a set of guidelines provides to the psychiatrist in the implementation of his/her values and expertise. This protection is very important, especially in situations where the patient's best interest is not clear or is in conflict with the professional best practice.

Particularly neglected in psychiatry and other medical professions is the ethics of clinical management in children and adolescents. For example, to whom should the psychiatrist extend fidelity: to the child, to the guardian, to the family as a whole, to the referring agency, to the institution that pays him/her? Even though the child's consent is clinically essential, it is not required by law. Nevertheless, the psychiatrist should aspire for the child to have a good understanding of the therapeutic process, according to his/her age and cognitive and emotional development.

In conclusion, we better appreciate nowadays the interplay between society and psychiatry. National and international ethics committees must be involved in this “dialogue” between the patient's rights and the psychiatrist's duties and rights. Increasing transparency of the diagnostic and treatment processes can lead to a partial, but very significant, reduction of the stigma attached to mental disorders and our profession.