Déclaration de Madrid

In 1977, the World Psychiatric Association approved the Declaration of Hawaii, setting out ethical guidelines for the practice of psychiatry. The Declaration was updated in Vienna in 1983. To reflect the impact of changing social attitudes and new medical developments on the psychiatric profession, the Word Psychiatric Association has once again examined and revised some of these ethical standards.

Medicine is both a healing art and a science. The dynamics of this combination are best reflected in psychiatry, the branch of medicine that specializes in the care and protection of those who are ill and infirm because of a mental disorder or impairment. Although there may be cultural, social, and national differences, the need for ethical conduct and continual review of ethical standards is universal.

As practitioners of medicine, psychiatrists must be aware of the ethical implications of being a physician and of the specific ethical demands of the specialty of psychiatry. As members of society, psychiatrists must advocate for fair and equal treatment of the mentally ill, for social justice and equity for all.

Ethical behavior is based on the psychiatrist's individual sense of responsibility towards the patient and their judgement in determining what is correct and appropriate conduct. External standards and influences such as professional codes of conduct, the study of ethics, or the rule of law by themselves will not guarantee the ethical practice of medicine.

Psychiatrists should at all times, keep in mind the boundaries of the psychiatrist-patient relationship, and be guided primarily by the respect for patients and concern for their welfare and integrity.

It is in this spirit that the World Psychiatric Association approved by the General Assembly, on August 25, 1996, the following ethical standards that should govern the conduct of psychiatrists worldwide.

1. Psychiatry is a medical discipline concerned with the provision of the best treatment for mental disorders ; with the rehabilitation of individuals suffering from mental illness and with the promotion of mental health. Psychiatrists serve patients by providing the best therapy available consistent with accepted scientific knowledge and ethical principles. Psychiatrists should devise therapeutic interventions that are least restrictive to the freedom of the patient and seek advice in areas of their work about which they do not have primary expertise. While doing so, psychiatrists should be aware of and concerned with the equitable allocation of health resources.



2. It is the duty of psychiatrists to keep abreast scientific developments of the specialty and to convey updated knowledge to others. Psychiatrists trained in research should seek to advance the scientific frontiers of psychiatry.



3. The patient should be accepted as a partner by right in therapeutic process. The therapist-patient relationship must be based on mutual trust and respect to allow the patient to make free and informed decisions. It is the duty of psychiatrists to provide the patient with relevant information so as to empower the patient to come to a rational decision according to his or her personal values and preferences.



4. When the patient is incapacitated and/or unable to exercise proper judgement because of a mental disorder, the psychiatrists should consult with the family and, if appropriate, seek legal counsel, to safeguard the human dignity and the legal right of the patient. No treatment should be provided against the patient's will, unless withholding treatment would endanger the life of the patient and/or those who surround him or her. Treatment must always be in the best interest of the patient.



5. When psychiatrists are requested to assess a person, it is their duty first to inform and advice the person being assessed about the purpose of the intervention, the use of the findings, and the possible repercussions of the assessment. This isparticularly important when the psychiatrists are involved in third party situations.



6. Information obtained in the therapeutic relationship should be kept in confidence and used, only and exclusively, for the purpose of improving the mental health of the patient. Psychiatrists are prohibited from making use of such information for personal reasons, or financial or academic benefits. Breach of confidentially may only be appropriate when serious physical or mental harm to the patient or to the third person could ensue if confidentiality were maintained ; in these circumstances, psychiatrists should whenever possible, first advice the patient about the action to be taken.



7. Research that is not conducted in accordance with the canons of science is unethical. Research activities should be approved by an appropriately constituted ethical committee. Psychiatrists should follow national and international rules for the conduct of research. Only individuals properly trained for research should undertake or direct it. Because psychiatric patients are particularly vulnerable research subjects, extra caution should be taken to safeguard their autonomy as well as their mental and physical integrity. Ethical standards should also be applied in the selection of population groups, in all types of research including epidemiological and sociological studies and in collaborative research involving other disciplines or several investigating centers.

Concerning Specific Situations

The World Psychiatric Association Ethics Committee recognizes the need to develop a number of specific guidelines on a number of specific situations. Five such specific guidelines are stated below. In the future, the committee will address other critical issues such as the ethics of psychotherapy, new therapeutic alliances, relationship with the pharmaceutical industry, sex change and the ethics of managed care.

1. EUTHANASIA : A physician's duty, first and foremost, is the promotion of health, the reduction of suffering, and the protection of life. The psychiatrist, among whose patientare some who are severely incapacitated and incompetent to reach an informed decision, should be particularly careful of actions that could lead to the death of those who cannot protect themselves because of their disability. The psychiatrist should be aware that the views of a patient may be distorted by mental illness such as depression. In such situations, the psychiatrist's role is to treat the illness.



2. TORTURE : Psychiatrists shall not take part in any process of mental or physical torture, even when authorities attempt to force their involvement in such acts.



3. DEATH PENALTY : Under no circumstances should psychiatrists participate in legally authorized executions nor participate in assessments of competency to be executed.



4. SELECTION OF SEX : Under no circumstances should a psychiatrist participate in decisions to terminate pregnancy for the purpose of sex selection.



5. ORGAN TRANSPLANTATION : The role of the psychiatrist is to clarify the issues surrounding organ donations and to advise on religious, cultural, social and family factors to ensure that informed and proper decisions be made by all concerned. The psychiatrists should not act as a proxy decision maker for patients nor use psychotherapeutic skills to influence the decision of a patient in these matters. Psychiatrists should seek to protect their patients and help them exercise self-determination to the fullest extent possible in situation of organ transplantation.