Ethics and civil law in

psychiatry
By
Dr. Zainab Ali Hassan
Arabic Board Psychiatric degree achiever
Iraq/Basra medical college
 Ethical principles
• Three ethical principles are widely adopted in medical ethics :
1. Beneficence (and non-malevolence): doing what is best for patients
(and not doing harm).
2. Respect for autonomy: involving patients in health care decisions,
informing them so that they can make the decisions, and respecting
their views.
3. Justice: acting fairly and balancing the interests of different people.
Ethical problems in psychiatric
practice
• Ethical problems in psychiatry can rise in relation to:
1. the doctor–patient relationship
2. confidentiality
3. consent
4. compulsory treatment
5. research.
The doctor–patient relationship
• A relationship of trust between doctor and patient is the basis of
ethical medical practice. This relationship should be in the patient’s
interests and based on the principles outlined above .
• Therapists abuse the doctor–patient relationship when they:
1. Impose their own values and beliefs on their patients.
2. Put the interests of third parties before those of patients.
3. Exploit patients sexually.
4. Exploit patients for financial gain.
 confidentiality
• A long-held premise of medical ethics binds physicians to hold secret all information given by
patients.
• Ethical principles relating to confidentiality :
Safeguarding information:
Personal information must be safeguarded and records kept securely, and consideration must be
given to the security of mobile phones or email.
Consent to disclosure of information:
Confidentiality is not breached when a patient has given informed consent to
disclosure. Informed consent implies consent based on a full understanding
of the reasons for disclosure, what will be disclosed, and the likely
consequences of disclosure.
Confidentiality in the care of children
It is sufficient to note that children over a stated age (usually 16 years) have the same rights of
confidentiality as adults. For younger children, clinical information is usually shared with parents,
who have a legal duty to act in their children’s best interests and therefore need to be properly
informed.
 Situations in which there may be
problems regarding confidentiality
• Seeking information from others
• As a rule, patients’ permission should be obtained before information is sought from
other individuals.
• Disclosing information to others
• Information should be disclosed only with the patient’s consent, except in the
special circumstances.
• Assessment on behalf of a third party
• Often a patient is assessed on behalf of a third party; for example, an assessment of
fitness to work carried out for an employer. It is essential to ensure at the outset
that the patient understands the purpose of the assessment and the obligations of
the doctor towards the third party. Written consent should be obtained
• Care in the community
Patients should know from the start that information will be shared as necessary
with other members of the care team, and these team members must follow the
principles of confidentiality. If a patient refuses the disclosure of information
despite clear information about the likely consequences of non-disclosure, their
wishes must be respected unless this would put others at serious risk.
• Group therapy
Group therapy presents special problems of confidentiality because patients
reveal personal information not only to the therapist but also to other members
of the group. Before treatment begins, the therapist should explain the
requirement to treat as confidential.
• Therapy with couples
Often couples’ therapy is preceded by an interview with each partner separately.
Information obtained in this way should not be revealed without an agreement.
 Exceptions to the rule of confidentiality
• Exceptions in the patient’s interest
In exceptional circumstances, doctors may disclose information to a third party
without the patient’s consent, when this disclosure is in the patient’s best interest.
• Exceptions in the public interest
There are special circumstances in which doctors are obligated to disclose
information. There are statutory obligations to do so in relation, for example, to
communicable disease, the use of certain controlled drugs, unfitness to drive, and
suspected child abuse. There is also an obligation to disclose relevant information in
response to a Court Order, and when there is evidence of serious crime, usually a
crime that will put some person at risk of death or serious harm.
• Exceptions for legal representatives
A patient’s legal representative, like the patient, may read their clinical notes and
letters, although there may be restrictions in relation to the possibility of harm to
others and for information given in confidence by informants.
 Privilege
• Privilege is the right to maintain secrecy or confidentiality in the face of a
subpoena (A subpoena is an order to appear as a witness in court or at a
deposition).
• Privileged communications are statements made by certain persons within a
relationship—such as husband–wife, priest–penitent, or doctor–patient—that
the law protects from forced disclosure on the witness stand.
• The right of privilege belongs to the patient, not to the physician, so the
patient can waive the right.
• Psychiatrists, who are licensed to practice medicine, may claim medical
privilege, but privilege has some qualifications. For example, privilege does not
exist at all in military courts, regardless of whether the physician is military or
civilian and whether the privilege is recognized in the state in which the court
martial takes place
 Consent to treatment

• Obtaining consent
The patient should:
1. Have a clear and full understanding of the nature of the condition to be treated,
the procedures available, and their probable side effects.
2. Agree freely to receive the treatment.
3. Be competent to take decisions.
• When explicit consent is not required??
1. Implied consent—for example, when a patient holds out his arm to have his
blood pressure measured.
2. Necessity —that is, a circumstance in which grave harm or death is likely to
occur without intervention, and there is doubt about the patient’s competence.
3. Emergency —to prevent immediate serious harm to the patient or to others, or
to prevent a crime.
• When consent to medical treatment is refused , the doctor needs to make
two judgements before accepting that the patient has the right to refuse.
1. Does the patient lack competence, i.e. the legal capacity to consent to or
refuse treatment, by reason of mental illness?
2. Has the patient been influenced by others to the extent that a refusal has
been coerced or is not voluntary?
Refusal by competent patients
Clinicians should set aside the time needed to understand the patient’s
concerns and understanding of their condition before explaining the medical
issues once more. With such an approach, agreement can usually be reached
on a treatment plan that is both medically appropriate and acceptable to the
patient. Nevertheless, some competent adult patients continue to refuse
treatment even after a full discussion, and it is their right to do so.
• Refusal by incompetent patients
In the UK and most other countries the doctor has the right to act in the patient’s best interests
and give immediate treatment in life-threatening emergencies when the patient lacks capacity
to consent, as when they are unconscious or delirious.
• Refusal by mentally disordered patients
If a patient who refuses medical treatment has an accompanying mental
disorder that appears to impair their ability to give informed consent, the
mental disorder should be treated, if necessary and appropriate, under
compulsory legal powers.

In English law, if an adult patient does not have the capacity to consent to treatment, proxy
consent on behalf of that patient can only be given if there is a written advance statement. In
some other jurisdictions there is provision for a form of proxy consent such as, in Scottish law,
the appointment of a guardian. When there is no legal provision for proxy consent and the
patient has not made an advance directive, and a decision as to whether to give treatment
must be made, this is done on the basis of the patient’s best interests. Best interest is judged
by the responsible clinician in accordance with general medical opinion.
 Legal aspects of consent

• The legal concept of capacity to consent relates to a patient’s ability to

comprehend and retain information about the treatment, to believe this
information, and to use it to make an informed choice.
• Patients may lack the capacity to give informed consent by reason of the
following:
1. Young age—parents give consent for children and adolescents below the
age at which, in law, they are able to consent.
2. Learning disability.
3. Mental disorder. Psychiatrists may be asked to assess patients who are
thought to be in this third group
Compulsory treatment for mental
disorders
• The conditions for detention are worded differently for treatment and
assessment, but there are essentially four of them:
1. You consider that the patient is likely to be suffering from a mental
disorder (detention may sometimes be necessary to establish this).
2. Detention is necessary for the health or safety of the patient or of
others.
3. The patient refuses voluntary admission.
4. Appropriate treatment is available (for treatment orders).
 Ethics of research
• Informed consent is crucial to the ethical conduct of research.
1. Patients must be made specifically aware that the research is not being
conducted for their individual benefit.
2. Patients must be free from any coercion or inducement.
3. Patients have the right to withdraw from the study at any time without any
kind of penalty or impact on their broader treatment.
4. In addition to the investigator, a family member or other suitable person
should be encouraged to monitor the patient’s condition and report to the
investigator if there are concerns.
5. In placebo-controlled trials, patients must understand clearly the
probability of receiving placebo, the lack of improvement that might result,
and the possibility of symptomatic worsening.
Research involving people who
cannot give informed consent
The decision as to whether to include such patients is made after
considering the following:
1. any potential benefit of the research to the person who is being
asked to consent;
2. any possible discomfort or risk to this person;
3. the potential benefit to others who have a similar problem and
incapacity;
4. any signs or other indications that suggest unspoken objection.
 Testamentary capacity
• This term refers to the capacity to make a valid will.
• Psychiatrists may be asked to report in relation to two issues:
1. Testamentary capacity.
2. The possibility that the testator was subjected to undue influence.
To decide whether or not a testator is of sound disposing mind, the doctor
should decide whether the person making the will:
● Understands what a will is and its consequences.
● Knows the nature and extent of his property (not necessarily in detail).
● Knows the names of close relatives and can assess their claims to his property.
● Is free from an abnormal state of mind that might distort feelings or
judgements relevant to making the will. A deluded person may legitimately make
a will, provided that the delusions are unlikely to influence it.
 Fitness to drive
• Questions of fitness to drive arise in relation to many psychiatric disorders.
• Dangerous driving may result from suicidal inclinations or manic disinhibition
• panicky or aggressive driving may result from persecutory delusions, and
indecisive or inaccurate driving may be due to dementia.
• Concentration on driving may be impaired in severe anxiety or depressive
disorders.
• The question of fitness to drive also arises in relation to the sedative and
other side effects of some psychiatric drugs, such as some anxiolytic or
antipsychotic drugs in high dosage.
Doctors should be aware of and follow the legal criteria for fitness to drive in
the places in which they are working
Thank You For
Listening