The Canadian Medical Association Code of Ethics Annotated for Psychiatrists

Prepared by Clive Mellor, MD

This paper was prepared for the Professional Standards and Practice Council, chaired by Dr. E Lipinski, and was approved by the Board of Directors of the Canadian Psychiatric Association in October 1978.

Introduction

Some ethical problems which arise in psychiatric practice are rarely experienced by other medical specialities, although the principles of medical ethics are the same. The Canadian Psychiatric Association (CPA) has recognized this problem which it has attempted to solve by annotating for psychiatrists the Canadian Medical Association (CMA) Code of Ethics.

The Professional Standards and Practice Council of CPA has, since its inception, had the question of medical ethics in psychiatry under consideration. The Constitution of the CPA makes no reference to a code of ethics for its membership. Therefore, the Council recommended to the Board of Directors of CPA that the CMA Code of Ethics be accepted by the members of the Association as the guide to ethical practice in psychiatry. The Council also recommended that the CMA's guide to the Code of Ethics should be specifically annotated for psychiatrists. Both these recommendations were accepted by the Board.

During the period following these decisions there have been several developments. The CMA's guide to medical ethics has undergone several changes since it was first introduced in its present format in 1970. There were minor revisions in 1975 and Section 16 was changed in 1977 and 1978.

At the General Assembly of the World Psychiatric Association in 1977, the Board of Directors of CPA endorsed, on behalf of the Association, the "Declaration of Hawaii" (2) which set forth ethical guidelines for psychiatrists. The "Declaration of Hawaii" is largely concerned with defining ethical conduct in relation to patients' rights and reflects the concern of those at this meeting with the issue of psychiatry and civil liberties.

The CMA Code of Ethics (1)

The current CMA code of ethics appears at first sight to be a somewhat complex statement, when compared with others such as that of the American Medical Association. It has three main parts: a "Code of Ethics," a "Guide to the Ethical Behaviour of Physicians," and a lengthy interpretation of these principles. In order to understand this arrangement, it helps to consider the distinctions which moral philosophers make between ethos, ethical code, medical ethics and morality.

Ethos encompasses the particular values and distinctive attitudes which characterize the culture of a profession. It is founded upon a definite tradition and implies membership of a group with a particular system of values. The ethos originates historically from the conduct of those members who exemplify that which is considered best in the profession.

An ethical code serves as a general guide to ethical behaviour. It represents an attempt to identify the ethos by providing norms for the profession. It does not seek to deal with all moral principles, and it is not a complete ethical system.

Medical ethics is the systematic amplification of the ethical code specifically for the medical profession. It is an elaboration of the perspectives and norms of the profession. Changes in medical ethics are made as a constructive response to changes in the nature of medical practice.

Morality in this context must rest upon the physician's subjective and personal realization of what is the proper ethical approach to the practice of psychiatry. It is then the capacity to make concrete decisions according to a well-informed conscience.

The Canadian Medical Association, Code of Ethics conforms to the description of a general ethical code given below.

Code of Ethics

I. Consider first the well-being of the patient.

II. Honour your profession and its traditions.

III. Recognize your limitations and the special skills of others in the prevention and treatment of disease.

IV. Protect the patient's secrets.

V. Teach and be taught.

VI. Remember that integrity and professional ability should be your only advertisement.

VII. Be responsible in setting a value on your services.

The CMA gives then a brief explanation of the method of interpreting these principles. The interpretations which follow are given as a guide for individual physicians and provincial authorities. These interpretations constitute medical ethics as defined above. They are divided into three main areas: responsibility to the patient, to the profession and to society.

A. Responsibilities to the Patient

Standard of Care

1. Will practice the art and science of medicine to the best of his ability.

2. Will continue his education to improve his standard of medical care. These statements do not require amplification.

Respect for the Patient

3. Will ensure that his conduct in the practice of his profession is above reproach, and that he will take neither physical, emotional nor financial advantage of his patient.

Annotation #1: Respect for the Patient

The practice of psychiatry rests upon the relationship between the patient and psychiatrist. This relationship is to varying degrees part of the therapeutic process and may become an intensely emotional one. Many of the ways in which a patient deals with these feelings, give the psychiatrist a considerable, potential capacity for influencing the patient's decisions.

The ethical psychiatrist will scrupulously avoid using this relationship to gratify his own emotional, financial and sexual needs. He will avoid influencing the patient in any way which does not bear directly upon the treatment goals. Patient's Rights

4. Will recognize his limitations and, when indicated, recommend to the patient that additional opinions and services be obtained.

5. Will recognize that the patient has the right to accept or reject any physician and any medical care recommended to him. The patient, having chosen his physician, has the right to request of that physician opinions from other physicians of the patient's choice.

6. Will keep in confidence information derived from his patient, or from a colleague, regarding a patient and divulge it only with the permission of the patient except when the law requires him to do so.

7. When acting on behalf of a third party will assure himself that the patient understands the physician's legal responsibility to the third party before proceeding with the examination.

8. Will recommend only those diagnostic procedures which he believes necessary to assist him in the care of the patient, and therapy which he believes necessary for the well-being of the patient. He will recognize his responsibility in advising the patient of his findings and recommendations.

9. Will, on the patient's request, assist him by supplying the information required to enable the patient to receive any benefits to which the patient may be entitled.

10. Will be considerate of the anxiety of the patient's next-of- kin and cooperate with him in the patient's interest.

Annotation #2: Patient's Rights

The psychiatrist recognizes that all patients have the right to ask for a consultation with another physician. Where the patient is not competent to make such a request then the rights of the next-of-kin in this regard must be recognized. In doubtful or difficult cases, it is incumbent upon the psychiatrist to seek another opinion and this should be scrupulously adhered to, particularly when the patient is not competent to make such a request on his own behalf. Psychiatrists need to be vigilant in safeguarding the confidentiality of the patient's communications. These confidences are given because both parties believe in the traditional ethics of the physician-patient relationship. However, in psychiatry the nature of this relationship leads to disclosures which are often more sensitive and private in content than those encountered in routine medical practice. Confidential information can only be revealed at the request of the patient, or when in law it is mandatory for the psychiatrist to do so.

When the psychiatrist is requested by a patient to supply information to some other person or agency, he should first discuss with the patient, at the level he feels appropriate to the patient's understanding, the nature of the information he is asked to supply. He should then obtain the patient's formal consent to this. The psychiatrist should ensure that the information revealed is pertinent to the patient's requirements, and consonant with the recipient's knowledge of psychiatry. (If the patient is unable to understand the nature of the request then the psychiatrist should deal in the same way with the agent who is responsible for safeguarding the patient's interests.) The revelation of gratuitous information should be carefully avoided.

Sometimes a psychiatrist is asked to examine a patient as the agent of another party, usually to satisfy legal or employment requirements (#7 above). The psychiatrist is ethically obliged, at the beginning of the interview, to describe the special nature of the psychiatrist-patient relationship in these particular circumstances. This description should include the purpose of the examination, the nature of the information being sought and the obligation to disclose it to the third party. It is ethical to reveal confidential information when, in the opinion of the psychiatrist, the patient`s behaviour is likely to endanger himself and others, and no alternative course will procure their safety. The need to obtain the cooperation of relatives and to allay their anxiety is in the best tradition of psychiatric treatment (#10 above). However, the needs of the relatives come second to the obligation to maintain confidentiality. When patients are minors under the law, then careful judgement is required to balance the need for confidentiality against the rights both moral and legal of the parents, or guardians.

The Hawaii Declaration draws attention to the need to obtain the patient's consent before he is presented to a class or meeting. All reasonable measures should be taken to ensure that the anonymity and reputation of the patient is preserved.

Choice of Patient and Continuity of Care

11. Will recognize that he has a responsibility to render medical service to any person regardless of colour, religion or political belief.

12. Shall, except in an emergency, have the right to refuse to accept a patient.

13. Will render all assistance in his power to any patient, where an urgent need for medical care exists.

14. Will, when the patient is unable, and an agent unavailable, to give consent, render such therapy as he believes to be in the patient's interest.

15. Will, when he has accepted professional responsibility for an acutely ill patient, continue to provide his services until they are no longer required, or until he has arranged for the services of another suitable physician. In any other situation, he may withdraw from his responsibility for the care of any patient provided that he gives the patient adequate notice of his intention.

Annotation #3

The psychiatrist's rights to refuse to accept a patient, to discontinue, or arrange alternative treatment cannot be disputed. However, given the nature of certain psychiatric disorders and the psychiatrist-patient relationship these rights cannot be exercised carelessly. The refusal to accept a patient, or the discontinuation of care, should be adequately explained to a patient beforehand, and the alternatives which are available to the patient discussed.

Personal Morality

16. When his morality or religious conscience alone prevents him from recommending some form of therapy he will so acquaint the patient.

Annotation #4

When a psychiatrist has knowledge that colleagues might recommend treatment in a given case, which he finds unacceptable on moral, or religious grounds, he is obliged to inform the patient of this. The information about this treatment should be given objectively in non-judgmental terms. The patient should recognize that he has the option of availing himself of this treatment and no attempt should be made to influence his decision. Only when the patient specifically requests it, should the psychiatrist, if he feels it is appropriate, enlarge upon his personal beliefs.

If the patient opts for this treatment then no obstacles should be placed in the way of the patient's seeing another physician. All the relevant information should be placed at this colleague`s disposal. It would be erroneous to assume that this question of personal morality involved only abortion.

Section 16 is the latest version of the CMA's statement on personal morality. The difficulties which arose with the previous statement are attributable to the failure to recognize that a physician's moral beliefs are paramount. A code of ethics can never require someone to carry out what he believes to be an immoral act. However, it is not unknown for physicians who carry out acts which they believe are morally correct, but flout medical ethics, to be required to leave the profession.

Clinical Research

17. Will, before initiating any clinical research involving human beings, ensure that such clinical research is appraised scientifically and ethically and approved by a responsible committee, and is sufficiently planned and supervised that the individuals are unlikely to suffer any harm. He will ascertain that the previous research and the purpose of the experiment justify this additional method of investigation. Before proceeding he will obtain the consent of those individuals or their agents, and will do so only after explaining the purpose of the clinical research and any possible health hazard which he can foresee.

Annotation #5

The psychiatrist has a special duty to ensure that patients suffering from mental illness should be competent to give informed consent to research procedures. The use of patients who are incapable of giving informed consent for clinical research is ethically unacceptable, unless the experimentation holds the promise of being to the patient's benefit, or a harmless procedure which will significantly advance medical knowledge and holds the promise of benefits for others. In this instance informed consent should be obtained from an appropriate person who is close to the patient.

The remaining clauses, 18 through 24, which come under this heading of "Responsibilities to the Patient" do not raise any issues which are particular to psychiatry.

B. Responsibilities to the Profession

There are three statements on medical ethics under this heading which are important to psychiatry.

Reporting Medical Research

10. Will first communicate to his confreres, through recognized scientific channels, the results of any medical research, in order that those confreres may establish an opinion of its merits, before he, or they present it to the public.

Annotation #6

Psychiatrists are aware that certain areas of psychiatric research lend themselves to sensational treatment in the hands of the public media. This unfortunately cannot always be avoided. The ethical requirement that research findings should be evaluated first by one's colleagues in the specialty, diminishes the chances of bringing disrepute to the profession and earning the opprobrium of one`s peers.

Addressing the Public

11. Will recognize his responsibility to give the generally held opinions of the profession when interpreting scientific knowledge to the public and in presenting any opinion which is contrary to the generally held opinion of the profession he will indicate he is doing so, and will avoid any attempt to enhance his own professional reputation.

Annotation #7

Expositions by psychiatrists on mental illness have an important and valuable part to play in the education of the general public, when expertly done. Psychiatrists are also citizens and may as informed citizens feel obliged to comment on certain social issues. It is important for the profession that they distinguish between these two roles, and ensure that their audience understands from which of these two positions they are speaking.

Psychiatrists are sometimes asked to comment upon the mental status of public figures. It is unethical for them to do so unless they have personally examined the individual. They would then of course require the patient`s consent to do this. This is not to deny the time honoured and academically acceptable pursuit of pathography, exemplified by Freud's analysis of the Schreiber memoirs. However, a psychiatric commentary upon a deceased former patient is an ethically unacceptable activity. This patient cannot safeguard his interests and these public disclosures may contaminate with suspicion current relationships between psychiatrists and patients.

Patient Care

17. Will cooperate with those individuals who, in the opinion of the physician, may assist in the care of that patient.

Annotation #8

Psychiatrists are often required in the best interests of their patients to work closely with other non-medical professionals in the mental health field. These include, amongst others, psychologists, social workers, counsellors, public health nurses and others. Before referring a patient to one of these co-workers, the psychiatrist should ensure that the following conditions are satisfied

a) Patients should be informed of this course of action, the reasons for the decision, and they should give their consent as far as is consistent with their condition.

b) The division of professional responsibilities should be clearly specified and understood by all the parties to the decision.

Three separate forms of this may exist:

  • The psychiatrist may relinquish all responsibility and be no longer involved in the patient's management. The psychiatrist has a duty to inform the medical practitioner, who made the initial referral, of this intended course of action. The psychiatrist has also an obligation to resume these responsibilities should the non-medical colleagues request this.

  • The psychiatrist may collaborate with the co- worker, each assuming specific areas of responsibility.

  • The psychiatrist may retain responsibility, for all aspects of the patient's management.

c) The psychiatrist must be satisfied that the co-worker has the training, skills, and professional standing necessary to manage the problem for which the patient is being referred. d) The psychiatrist should also ensure that the co-worker has a code of professional behaviour which is ethically acceptable to the medical profession. Psychiatrists have a special obligation to their patients, some of whom are particularly vulnerable, to safeguard them from therapeutic programs which are perpetrated by persons with unknown or inappropriate training, or employ a mode of treatment not recognized by the profession. It is unethical to refer patients to such persons or to endorse such activities.

C. Responsibilities to Society

There is one clause under this heading which has relevance for psychiatrists.

2. When a witness will recognize his responsibility to assist the Court in arriving at a "just decision."

Annotation #9

A psychiatrist should testify in a court of law as to the mental state of a person only if he has examined that person. Such testimony should not be given solely as a result of observations made in the court room.

Acknowledgements

These "Annotations" were developed over a period by the Professional Standards and Practice Council first under the Chairmanship of Dr. Harry Prosen and then Dr. Ed Lipinski. All the committee members contributed and those who served during this time were Drs. Frank Coburn, J.D. Earp, M.K. Hall, Antonie Lepage, H. Penner, J. Stanley, J.J. Waldron, M.N. Beck and W.J. Pankratz. The Code of Ethics uses the masculine pronoun throughout and the annotations conformed to this convention so that there might be some uniformity of style. It implies no preferences or prejudices as to the gender of the psychiatrist of patients.

References

1. Canadian Medical Association Code of Ethics: Canadian Medical Association. Ottawa, June 1978.

2. Declaration of Hawaii: Br Med J, 2:1204-5, 1977.