Code of Ethics for Psychiatry
Standing Committee on Ethics and Review, World Psychiatric Association (WPA)
October 2020
Background:
This Code of Ethics is intended to guide the ethical practice of psychiatry by offering a comprehensive approach to the ethical challenges in the profession. The WPA recognizes that psychiatric ethics are part of the ethics of the medical profession as a whole, with additional considerations specific to the practice of psychiatry, and bases this Code on its belief in the universality of ethical principles for the practice of psychiatry. Previous efforts by WPA to outline the principles of ethical behavior for psychiatrists began with the adoption of the Declaration of Hawaii (1977 and 1983), and continued with the Declaration of Athens (1989), the Declaration of Madrid (1996) (most recently amended in 2005 and 2014), the Declaration of Craiova (2004) and Cairo (2006). Those Declarations are important adjuncts to the Code of Ethics. It must be recognized that as cultures and societies change, psychiatric ethics need to develop and change accordingly.
Many member societies of the WPA will have their own codes of ethics that are binding on their members. Member societies are asked to endorse the five principles embodied in this WPA Code and to confirm that their codes are not in conflict with them. Each endorsed principle is enumerated in bold below. The principles are followed by numbered annotations. Those member societies that are developing or revising their codes are encouraged to consider this Code as guidance in that process.
Introduction
Psychiatry is the medical specialty that works with other medical specialties and with other mental health disciplines in the interest of preventing mental disorders, diagnosing and treating people with such disorders, rehabilitating them, managing psychological aspects of non-psychiatric illnesses, and promoting mental health. It also collaborates with families, carers, NGOs and the general public in improving mental health.
Sections
The Code addresses the behavior of psychiatrists in their professional roles and not in their roles as citizens, while acknowledging that the border between these roles is often unclear and that at times conflicts can arise. Advocacy for patients can occur at both professional and personal levels. WPA recognizes that a code in itself is insufficient to guide ethical practice. Psychiatrists need to develop the skills required to recognize ethical dilemmas in their clinical work and seek appropriate specialist ethics input when necessary to help them to resolve these dilemmas. Training for ethics should start at undergraduate level, be explicitly addressed during training, and continue throughout life.
The Code is organized into four sections, dealing respectively with the clinical practice of psychiatry, psychiatric education, psychiatric research, and the participation of psychiatrists in the promotion of public health and public mental health. Within each section, the Code identifies the operative ethical principles and describes major applications.
I Ethics in the Clinical Practice of Psychiatry
The work of psychiatrists in the clinical realm is based on five overarching principles: 1) beneficence, 2) respect for patients (autonomy), 3) non-maleficence, 4) improving standards of psychiatric practice, and 5) applying psychiatric expertise to the service of society (including seeking equity in the prevention, treatment and rehabilitation of psychiatric disorders). Complex ethical dilemmas may arise when these ethical principles come into conflict with one another, at which point consultation with experienced colleagues or ethics committees may be helpful.
Principle 1. Beneficence:
Psychiatrists provide competent and compassionate medical care with devotion to the interests of their patients.
This Code uses the term “patients” to refer to people who receive treatment for psychiatric disorders, recognizing that other terms may be preferred by various groups.
1. Psychiatrists recognize that their primary obligation in the clinical setting is to pursue the wellbeing of their patients, in light of the best available evidence and clinical experience.
2. Psychiatrists are sensitive to the needs of patients’ families, carers, and others who are affected by patients’ disorders. They provide education and support to these groups, empowering them to assist patients in coping with their disorders and achieving their personal goals. Psychiatrists recognize that optimal clinical care is rendered through collaboration among patients, carers, and clinicians, along with other team members and they work to resolve differences and encourage cooperation among them.
3. When appropriate, psychiatrists seek consultation from or refer patients for diagnostic and treatment procedures for which they lack training or experience to practitioners with expertise in these areas.
4. Psychiatrists advocate for patients’ interests in the receipt of appropriate psychiatric care and for respect of human rights, including reproductive rights.
5. Recognizing that providing appropriate care for patients requires up-to-date knowledge of relevant research and treatment approaches, psychiatrists should regularly update and improve their clinical skills, and strive to remain current with other developments in the field that are directly related to their patients’ care. Psychiatrists recognize the importance of evidence, along with clinical experience and respect for patients’ values in their daily practice.
Principle 2. Respect for patients’ autonomy:
Psychiatrists are especially mindful of respect for autonomy given their statutory role in treating a proportion of their patients compulsorily. Compulsory treatment may be justified where a less restrictive intervention cannot achieve safe and adequate care; its purpose is ultimately to promote and re-establish patients’ autonomy and welfare.
1. Psychiatrists build relationships with patients that are based on mutual trust, acknowledging patients’ role as partners in the process of diagnosis, treatment, and rehabilitation. These must take into account all local regulatory matters.
2. Psychiatrists seek the informed consent of their patients whenever possible. However, they recognize that the nature of psychiatric disorders will require exceptions, including when patients are unable to make informed decisions about treatment, when considerations of patients’ health, safety, or public safety call for non-consensual interventions, or when patients do not have the capacity to consent. When family members or guardians have authority to make decisions on patients’ behalf, psychiatrists engage them in the process of obtaining informed consent within the local frameworks of confidentiality. Psychiatrists acknowledge that competent patients have the right to make autonomous choices, including the decision to stop treatment. In such situations, psychiatrists make patients aware of the potential consequences of their decisions. Patient autonomy must be borne in mind bearing cultural constraints. Psychiatrists will avoid coercing patients regarding their decisions about medical interventions as much as possible.
3. In pursuing informed consent, psychiatrists should offer patients accurate information about their diagnoses, proposed treatments, risks, potential benefits, and alternatives. In their discussions, they take into account patients’ abilities to comprehend and appreciate the information, with the goal of facilitating patients’ optimal participation in treatment decision making.
4. Even when patients lack competence to make treatment decisions as a result of psychiatric disorders, psychiatrists nonetheless keep them appropriately informed about their treatment and convey respect for their views. Psychiatrists recognize that when patients regain competence, they can reassume their role as full partners in their psychiatric care.
5. Psychiatrists keep in confidence information concerning their patients. They inform patients at the inception of treatment of relevant limitations on confidentiality of communicated information. Except in emergencies, including an imminent threat to harm other people, or under proper legal compulsion, they do not release information regarding patients without patients’ consent. Even when patients’ consent has been obtained, psychiatrists release only that information necessary for the purpose at hand. When responding to questions from family members and other carers, they provide education about psychiatric disorders and treatments in general, but do not discuss patients’ conditions and treatments unless they have patients’ consent to do so.
6. Psychiatrists oppose all forms of discrimination against persons with psychiatric disorders and avoid behaviors that might promote discrimination.
Principle 3. Non-maleficence:
Psychiatrists avoid actions that may be injurious to their patients.
1. Psychiatrists avoid harm to patients by careful evaluation, prescription, and monitoring of the effects of treatment.
2. Psychiatrists avoid use of diagnostic and therapeutic interventions prior to the availability of appropriate evidence demonstrating their favorable benefit/risk ratios for patients.
3. Psychiatrists respect the boundaries of the clinical relationship. They abstain from sexual relationships with their patients and with patients’ family members, and avoid exploiting patients to meet their own or others’ financial, social, emotional, and other needs.
4. Psychiatrists pay special attention to the probity of their behavior when dealing with vulnerable children and adults. They declare all potential or real conflicts of interest.
5. To avoid subsequent misunderstandings, psychiatrists reach agreement with patients in advance on the nature and scope of the services they are able to provide.
6. Psychiatrists abide by local norms in presenting themselves to the public and are careful not to misrepresent their qualifications and experience.
7. Psychiatrists avoid engaging in relationships with third parties, including but not limited to the pharmaceutical industry, that may compromise their primary focus on the interests of their patients. Relevant financial relationships should always be disclosed.
8. Psychiatrists avoid endorsing patients’ requests for implementing termination of life-sustaining treatment or physician-assisted death, when they recognize that underlying psychopathology drives those requests.
9. Psychiatrists do not engage in abuse of their patients and promptly report to the appropriate authorities instances of abuse that come to their attention.
10. Psychiatrists do not participate in the abuse of psychiatry for political purposes or in torture, and do not participate or assist in any way in the interrogation of persons deprived of liberty by military or civilian investigative agencies or law enforcement authorities. They may, however, participate in forensic evaluations or other interactions with a detainee that have been appropriately authorized by a court or counsel for the detainee.
11. Psychiatrists respect patients’ culture, ethnicity, language and religion. They do not discriminate against patients on any grounds, including age, sex, gender, race, ethnicity, sexual orientation, disability, language, religious or political affiliation, or socioeconomic status; neither do they attempt to impose their own values on patients and patients’ families.
12. Psychiatrists should oppose requests to detect and/or report on the presence of anti-government ideas or radicalization of their patients in religious or political matters.
13. As physicians who are committed to sustaining and improving people’s lives, psychiatrists do not participate in the administration of the death penalty.
Principle 4. Improving standards of mental health care and psychiatric practice:
Psychiatrists recognize a responsibility to promote the continuing development of their profession and their personal professional development.
1. Psychiatrists maintain collegial, professional relationships, based on mutual respect, with their colleagues in psychiatry, general medicine and other mental health professions. However, when collegiality and patients’ interests conflict, fidelity to patients’ interests takes primacy.
2. Psychiatrists practise within accepted standards of care. They take appropriate action when they become aware that psychiatric interventions are being used outside accepted standards of care, when necessary reporting the situation to professional societies or other appropriate authorities.
3. Psychiatrists behave in ways that enhance public trust in the profession.
Principle 5. Applying psychiatric expertise to the service of society:
Psychiatrists, like other physicians, utilize their specialized knowledge and skills to promote mental health and the wellbeing of persons who may be vulnerable to mental illness.
1. Psychiatrists advocate for the interests of people with mental disorders and contribute to the improvement of public health.
2. Psychiatrists provide expert opinions for third parties consistent with ethical principles appropriate to that situation, including respect for persons, truthfulness, and the avoidance of unnecessary harm. In particular, when conducting evaluations on behalf of third parties, they are careful to inform individuals of the purpose of the evaluation, and disclose the party for whom the psychiatrist is working, the absence of a therapeutic relationship, and the limits on confidentiality of communicated information. When access to relevant records is not available, they are careful to note the limitations to their conclusions.
3. Psychiatrists offer accurate information to the media to educate the public about the nature and consequences of psychiatric disorders and their treatment, and to dispel misconceptions about people with psychiatric disorders.
4. Psychiatrists do not succumb to pressure to use their professional expertise to facilitate harmful activities, such as torture.
II. Ethics in Psychiatric Education
Psychiatrists often have roles as teachers, educators and mentors in their discipline. In their educational activities, psychiatrists recognize that the principles of beneficence, respect for patients, improving standards of psychiatric practice, and applying psychiatric expertise to the service of society are intertwined. They communicate the importance of promoting equity in the prevention, treatment, and rehabilitation of psychiatric disorders.
1. Psychiatrists recognize an obligation to share their knowledge of biological, psychological and social determinants of mental health; of psychiatric diagnosis, treatment, and prevention; and of systems of mental health care with trainees and practitioners in psychiatry, other medical specialties, other mental health professions, and the general public. They fulfill this responsibility in a professional manner that reflects up-to-date, evidence-based knowledge of the field.
2. Acknowledging the vulnerable position of students and trainees and the trust that they place in their teachers, psychiatrists avoid exploitation in their educational roles, e.g. they do not take credit for work done by students and trainees, appropriately balance education and requirements for service, and do not abuse their relationship with their students and trainees in any way.
3. Psychiatrists show respect for patients and carers who are involved in teaching by protecting their dignity and guarding their privacy.
4. Patients should be informed when students or trainees will be involved in their treatment. Psychiatrists obtain patients’ consent before presenting them to professionals who are not involved in their care or in publications in ways that would render them recognizable.
5. Psychiatrists are sensitive to and respectful of cultural factors in teaching settings and avoid expressions of bias.
6. Psychiatrists are conscious of their position as role models for trainees and shape their behavior accordingly. When differences of opinion are expressed, psychiatrists share their views in a respectful and professional manner.
7. Since medical education is a powerful tool that delivers influential messages to current and future doctors and other professionals, psychiatrists are aware of the potential for conflicts of interest to affect their teaching and training. These conflicts too should be declared.
III. Ethics in Psychiatric Research and Publication
In their roles as researchers and authors, psychiatrists give particular emphasis to the principles of beneficence, non-maleficence, and respect for patients, equity, and applying psychiatric expertise to the service of society.
1. Psychiatrists recognize that research and publication are vital in improving care for current and future patients and improving the health of the population as a whole. Hence, they acknowledge their responsibility to help advance knowledge about the nature of psychiatric disorders, including risk and protective factors, and their treatment. Not all
psychiatrists will be interested in or carry out research but everyone should be able to understand, interpret and apply research findings, when appropriate, in a manner consistent with psychiatric ethics.
2. To ensure that research involving human participants is conducted in an ethically appropriate manner, psychiatrists engaged in research obtain prospective approval from research ethics committees that are independent of the research team. In the unlikely event that local or national research ethics committees are not available, they seek input from appropriate groups outside their country.
3. In collaboration with the designated research ethics committee, psychiatric researchers select subject populations with attention to the equitable distribution of the benefits and risks of research, and develop approaches that protect subjects from undue risks or discomfort, recognizing that risks must be proportionate to the benefits likely to result from the research. Local research ethics must be followed.
4. Recognizing that research that is unlikely to yield valid results is inherently unethical, psychiatrists ascertain that the research they are proposing incorporates an appropriate research design that is likely to yield meaningful data. They undertake only research that is within the scope of their competence and resources, and ensure that other members of their research team are appropriately trained for their tasks. When reporting their studies, psychiatrists ensure accurate reporting of their methods and results.
5. Psychiatrists provide for appropriate informed consent procedures. This includes ensuring that research subjects are enrolled voluntarily, without undue pressure or influence, including by the treating psychiatrist. When subjects’ capacity is impaired, psychiatrists arrange for appropriate substituted decision making.
6. To protect the privacy of research subjects, psychiatrists take appropriate measures to ensure the security of their data and, when possible, keep identifiers separate from research data. In publications reporting the results of their research, psychiatrists ensure that individual subjects are not identifiable.
7. Psychiatrists present the results of their research fairly, calling attention to both positive and negative results, and focusing both on the potential value of their findings and the limitations of the conclusions that can be drawn from their data.
8. When publishing the results of their research, psychiatrists disclose the sources of their funding and other potential sources of bias; ensure that all those persons who contributed to the study are recognized appropriately in the publications, including with co-authorships and acknowledgments; and seek a consensus of the authors regarding the presentation of the findings.
9. Psychiatrists are aware of the potential that relationships with pharmaceutical and device industries and other interested entities may compromise the integrity of their research designs, analyses, and reporting of results. Hence, they avoid relationships that would compromise their research and publications, disclose relationships that may constitute conflicts of interest, and take measures to prevent distortion of their data.
IV. Ethics in Public Mental Health
The promotion of public mental health calls into play the principles of beneficence, equity (reflected in the promotion of distributive justice), and applying psychiatric expertise to the service of society.
1. Psychiatrists support and participate in public education aimed at the promotion of mental health and the prevention of psychiatric disorders to the extent of their abilities.
2. Given that signs and symptoms of psychiatric disorders often appear early in life and the importance of early detection and intervention, psychiatrists encourage public awareness of the manifestations of psychiatric disorders.
3. In their commitment to advancing mental health, psychiatrists promote distributive justice, including equitable allocation of resources for the prevention, treatment and rehabilitation of psychiatric disorders. Psychiatrists advocate in particular for support for mental health programs, especially in but not limited to developing countries and in areas where care for persons with psychiatric disorders is non-existent or rudimentary.
4. Psychiatrists pay particular attention to the importance of preventing the development of psychiatric disorders in vulnerable groups, and recognize the increased risk for psychiatric disorders associated with heightened stress and psychological trauma.
5. Recognizing that many persons with psychiatric disorders can benefit from active engagement in rehabilitative services, psychiatrists promote the development and availability of such services.
6. Psychiatrists take every opportunity to combat the stigma of psychiatric disorders in the practice of their profession, and participate in public health activities that target the stigma of psychiatric disorders to the extent of their abilities to do so.
7. Psychiatrists are aware of the deleterious consequences of family violence, emotional and sexual abuse on mental health and well-being, especially for women and children, and they work to minimize the occurrence of violence within families.
8. Psychiatrists avoid taking part in governmental, societal, or personal activities that are aimed at discriminating against an ethnic, racial, religious, sexual, or other group.
9. Recognizing that undiagnosed and untreated psychiatric disorders increase the mobidity and mortality of physical illness and impairment, as well as increasing the cost of its treatment, psychiatrists advocate for identification of psychiatric disorders at all levels of general medical or surgical care (primary, secondary and tertiary), and for
appropriate intervention to address psychiatric co-morbidities. Psychiatrists are also alert to medical co-morbidities, implement the necessary diagnostic process and/or refer the patient to the appropriate specialist.
The WPA views this Code as a living document that reflects current knowledge, and anticipates that it will be revised over time as knowledge about mental health and psychiatric disorders increases and the nature of psychiatric care evolves to reflect these new understandings.
