Ethics and medical practice: Why psychiatry is unique

Byline: Navneet. Sidhu, Jagannathan. Srinivasraghavan Since ancient times, societies have held physicians to high standards of ethics owing to the caring nature of the medical profession as well as the vulnerability of people in their care. While we are all familiar with the Hippocratic oath, the Formula Comitis Archiatrorum [sup][1] , written in the 5 [sup]th century, is considered by some to be the earliest known code of medical ethics. Modern day medical ethics can be traced to Thomas Percival, an English physician and philosopher who wrote Medical Ethics, or a Code of Institutes and Precepts, Adapted to the Professional Conduct of Physicians and Surgeons in 1803 [sup][2] . His ideas such as conduct of physicians towards patients and inter-professional relationships have been a dominant influence in development of the field. Medical Ethics served as a key source for the American Medical Association (AMA) code, which the association adopted in 1847 [sup][3] . In it's current form, the AMA code of Medical Ethics stresses principles such as professionalism, respect for human dignity and rights, medical knowledge, privacy and access to medical care for all people, and the importance of focusing on patients' best interests [sup][4] . In the United States, organizations such as the American Psychiatric Association (APA) and American Psychological Association have also laid out guidelines that inform psychiatric and psychological practice [sup][5],[6] . Srinivasaraghavan et al . [sup][7] have discussed the unique nature of psychiatry, the presence of stigma in mental illness, the socio-economic disadvantages often present in the mentally ill population and the need for psychiatric ethics to go beyond the ethical standards of General medicine. In this paper, we want to highlight how the everyday practice of psychiatry demands high moral and ethical standards of its' practitioners and is unique in its challenges and ethical dilemmas. I. Privacy and Confidentiality Physicians of all specialties owe complete confidentiality to their patients in most circumstances. The effectiveness of the patient- physician relationship and therapeutic alliance relies heavily on this obligation. It is unethical and illegal to share information discussed within the confines of the medical office, without the explicit and informed permission of the patient. In psychiatry, we often hear our patients' innermost fears, worries, fantasies and desires. To a psychiatrist, patients' often expose their vulnerabilities and discuss concerns that could expose them to the prevalent stigma in society. Were a physician not bound by the promise of confidentiality, the therapeutic relationship would be hindered, and treatment would be impeded. Consider the example of a woman telling her psychiatrist of marital discord in her relationship, or a man talking about sexual dysfunction in treatment. Or the case of an employer calling the psychiatrist about the mental health of employee. It is obvious that if such information were to become known outside the confines of therapy, the consequences could be potentially disastrous. In the United States, the Health Insurance Portability and Accountability Act (HIPAA) [sup][8] of 1996 places civil and criminal penalties on health care providers and entities that disclose protected information to unauthorized individuals or sources. So when can a psychiatrist share information? Organizations like APA have recognized the limits of this confidentiality in the legal setting. For example, if a physician is required by the law to produce medical records, confidentiality is waived. In such situations, the limits of confidentiality should be explained to the patient. Following the landmark United States case [sup][9] involving the killing of a university student, Tatiana Tarasoff by another student in 1969, many U.S states [sup][10] have enacted duty to warn and duty to protect mandates which require a psychiatrist or therapist to reveal information to police or potential victims about dangerous patients in the interest of public safety. …