An Overview of Psychiatric Ethics

52offered by defendants in the “Doctors’ Trial”, yet it remains difficult to define a core moral failing.As such, the invocation of the Nazi doctors is problematic in contemporary bioethical discourse. 372“The Nuremburg Code”, the declaration of ethical principles which formed the basis of currentCodes of Ethics for research, emphasizes the importance of informed consent to researchparticipation. Informed consent to participate in psychiatric research is amongst the most vexed373, 374of issues in the field.One lingering question is the notion of the universalizability of the Nuremburg Declaration. TheNuremburg Declaration, arguably, sees the global imposition of liberal Anglo-American valuesunder the rubric of the emergent notion of ‘human rights’. 375 Regardless of the apparent validityof such constructs, the question of the universalizability of the concept of informed consent isproblematic. A particular issue is whether data obtained from research participants from settingsother than a researcher’s own institution are subject to the same valid forms of consent as requiredin the researcher’s own country. There is emerging evidence that informed consent to participate inresearch programs is challenging in settings such as China 376 and West Africa, 377 where increasingamounts of psychiatric and neuropsychiatric research are performed, presumably due to costbenefits and the availability of research participants. This then raises the question of what theethical grounds are for publishing such research, if there are credible doubts about the adequacyof informed consent to research into psychiatric treatment.In conducting research in psychiatry, there is an ever-present tension between the duty to protectvulnerable individuals and the duty to advance scientific knowledge. It is argued that concern aboutvulnerability of psychiatric patients has contributed to slow progress in psychiatric research. 378 Theprocess of obtaining informed consent and competence to participate in psychiatric research have374, 379tended to be the main focus of the literature in the area of research ethics in psychiatry.There are four commonly used standards for a person’s competency evidencing a choice in regardto research participation. 380 The first is the patient’s ability to acknowledge they have a choice tonot participate in the research study. The second is the patient’s factual understanding of the issuesinvolved in their participation in the research study. The third is the patient’s capacity for rationalmanipulation of information provided to them about the research, such as the possibility of beingallocated to a placebo or control condition and the risks associated with this. The fourth and finalis the patient’s appreciation of the nature of the situation, in particular the ability to distinguishbetween their access to care being independent of whether or not they choose to participate in theresearch project. These standards move from a basic grasp of the issue through to a more abstractunderstanding of the totality of the situation, a process which is not always the case with severely illpatients. Clearly, the closer the consent to the higher standards, the more comprehensive is the levelof informed consent in the study.Clinical trials involving psychotropic medications are problematic, given the enforced nature of muchpsychiatric treatment, particularly in the chronic mentally ill. 373 Many such patients feel obligated toparticipate in such research, as they may misunderstand the imperative to participate. Moreover, theuse of children as subjects in psychiatric research represents a similar concern of the vulnerability ofsuch patients in the therapeutic relationship. 381-383Ethics and Consultation-Liaison PsychiatryThe Nature of C-L PsychiatryOne of the fundamental features of the role of a C-L psychiatrist is the ambiguous nature of therelationship with the patient. C-L consults are frequently sought by the treating team and not thepatient, which creates a fundamentally “social role” in C-L psychiatry. 384 This social role focuseson the relationship between primary physician or non-medical health professionals and consultantpsychiatrist who works within an institutional setting.The Ethics of Managing the SystemA frequent pretext of the involvement of a C-L psychiatrist in a clinical situation is to provide anintervention at the level of a system, such as where there is a problematic relationship betweena difficult patient and a medical team. In such circumstances, the C-L psychiatrist is expected