Law and Ethics in Psychiatry
Psychiatry as a medical science tends to focus on the diagnosis and treatment of mental illness and the promotion of mental health. But, true to its origins in philosophy and psychology, it also addresses many other aspects of human experience, including emotions, perception, cognition, normal and abnormal behaviour, value systems, causation, and psychodynamics.
Like psychiatry, ethics is also a child of philosophy, but its domain is the study of the meaning of moral terms and principles, theories of goodness, and right conduct, obligation, and duty.
The law is concerned with the rules and principles that govern acceptable conduct. Its raison d’ętre is the maintenance of order and the administration of justice. The law defines what is legal or illegal, but good law cannot simply be arbitrary. According to the theory of natural law, legal validity requires a corresponding moral validity to assure its legitimacy. The law sets out in operational terms that which is right or wrong, in a way that is logical, sensible, and ultimately in the public interest.
As fields of endeavour, psychiatry, ethics, and the law are themselves governed by the rules of ethics and law; their methods and goals, however, are different. Lawyers and ethicists study, weigh, and evaluate actions, using criteria that ultimately determine legality or morality. Their specific goal is to reach a judgement or verdict that is as categorical and unequivocal as possible. In contrast, psychiatrists aspire to be nonjudgemental. Their goal is not to reach a specific decision but, rather, to initiate a process aimed at increasing another person’s capacity to adapt through understanding, insight, and the acquisition of new coping skills. This therapeutic process is developmental, ongoing, and longitudinal. It generally has no clear end point, is fraught with contradictions and ambiguities, and requires its practitioners to abstain from moral judgements or blame.
Yet, despite such important differences, these 3 disciplines share many similar values. Each seeks the common good, espouses what is rational and just, addresses issues fundamental to the human condition, and strives to create a context within which individuals and society may achieve the highest possible level of order and harmony.
At their interface, we discover a multitude of challenging questions, problems, ambiguities, and conflicts. It is here that we see the dynamic interaction between basic human values, individual and societal needs, politics, economics, culture, morality, and religion. Here we find few absolutes and must contend with a landscape that is continually shifting and transforming. What was considered ethical, legal, and scientifically valid only a few years ago may well be regarded today as unacceptable or even reprehensible. Problems that did not even exist a decade ago become apparent as new situations arise, values change, knowledge increases, and technology advances.
Within the fields of medical ethics and forensic psychiatry, several controversial topics are currently stimulating much discussion. They include questions about the nature and boundaries of the therapist–patient relationship, professional responsibility, informed consent, the patient’s right to receive or to refuse treatment, the limitations of memory, and the privacy of health-related information.
Psychiatrists as scientists, as caregivers, as teachers, and as members of society have an important role to play in these discussions. It is our task to learn how people function best, individually and in groups, and to apply this knowledge ethically and creatively to real-life situations. By so doing, we help to define standards and assure a healthy and realistic discourse; within such a discourse, the resolution of social and personal conflicts arising from a maze of complex situations may be attempted.
Psychiatrists are regularly asked to join research review boards, hospital ethics committees, or service-planning groups. Those who seek to improve and humanize medical care or manage the allocation of expensive or limited resources seek our opinions. We are called upon to serve as experts in judicial procedures where our clinical judgements may have a significant impact on the outcome. We are often expected to consider not only the needs of our patients but also the well-being of others—a mandate that may create serious therapeutic dilemmas.
Unfortunately, many mental health professionals lack adequate training in the areas of ethics and law. This deficiency is gradually being corrected, but all of us can benefit from learning more about the legal and ethical challenges currently facing our profession.
In this issue of the Journal, we will find an excellent article by Dr Cheryl Regehr and her colleagues, who address the topic of research ethics and forensic patients. The issues here involve free consent, diminished capacity, and institutional constraints with respect to a particularly vulnerable population, but the basic principles are relevant to all researchers and to all research subjects.
A second article, by Dr Gary Chaimowitz and his colleagues, examines the psychiatrist’s duty to warn, inform, and protect. Ever since the Tarasoff decisions in the US, clinicians have agonized over the conflict between their responsibility to respect and preserve the confidentiality of a patient’s communications and their duty to protect potential victims from harm. Even now, laws and practices with respect to the duty to warn and protect differ considerably from one jurisdiction to another. The debate continues at many levels and in many different contexts and circumstances.
Over the past couple of years, the Canadian Psychiatric Association has been concerned with the issue of guarding the privacy of patient records. Its Standing Committee on Professional Standards and Practice has prepared a position statement that stresses both the importance of maintaining the integrity of the therapist–patient relationship and the need for clear guidelines regarding any and all breaches of confidentiality. As we work to achieve a reasonable and practical balance between patients’ rights to privacy and the interests of justice, we welcome feedback and suggestions from our readers.
Philip R Beck, MD, FRCPC