AUDIO-DIGEST PSYCHIATRY 40:24
THE APPLICATION OF MEDICAL ETHICS IN PSYCHIATRY
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To submit a test form by mail or fax, complete Pretest section before listening and Posttest section after listening.
1. The _______ was the first set of guidelines primarily concerned with research ethics.
(A) Nuremberg Code
(B) Declaration of Helsinki
(C) Belmont Report
(D) Council for International Organizations of Medical Sciences Ethical Guidelines
2. Which of the following statements about the Hippocratic Oath is not true?
(A) It includes the concept of maintenance of confidentiality
(B) It includes admonitions against the administration of lethal drugs and abortion
(C) It is the source of the phrase “primum non nocere”
(D) It is strongly religious
3. The American Medical Association’s (AMA) Principles of Medical Ethics includes:
(A) The obligation to report fellow physicians deficient in character or competence
(B) The obligation to respect established laws
(C) The obligation to seek change in laws contrary to patient interests
(D) All the above
4. Which of the following is not included as a fundamental provision of the Physician Charter of Professionalism?
(A) Primacy of patient welfare
(C) Patient autonomy
(B) Respect for life
(D) Social justice
5. Which of the following oaths includes a clear and definite statement covering beneficence and nonmaleficence?
(A) Hippocratic Oath
(C) AMA Principles of Medical Ethics
(B) Declaration of Geneva
(D) Physician Charter of Professionalism
6. Which of the following concepts is included in every medical oath and code discussed by the speaker?
(A) Justice and fairness
(C) Patient confidentiality
(B) Concern for public health
(D) Lifelong learning
7. According to the AMA Principles of Medical Ethics, physicians must make the health of patients paramount:
(A) At all times
(B) When they have been identified to others as a physician
(C) Only in emergency situations
(D) While providing care
8. Which of the following oaths does not specifically address conflicts of interest?
(A) Hippocratic Oath
(C) AMA Principles of Medical Ethics
(B) Declaration of Geneva
(D) Physician's Charter of Professionalism
9. Primum non nocere (or modern interpretations thereof) applies equally to all areas of medicine.
(A) True
(B) False
10. Ethical concerns in medicine remain essentially consistent over time.
(A) True
(B) False
Answers to Audio-Digest Psychiatry Volume 40, Issue 23: 1-B, 2-A, 3-C, 4-B, 5-C, 6-D, 7-A, 8-C, 9-A, 10-D
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Volume 40, Issue 24
December 21, 2011
THE APPLICATION OF MEDICAL ETHICS IN PSYCHIATRY
From Drugs, Psychosis, and Ethical Dilemmas in the Treatment of Children, Adolescents, and Young Adults,
presented by the Indiana Psychiatric Society
Albert J. Allen, MD, PhD, Senior Medical Fellow, Bioethics & Pediatric Capabilities,
Eli Lilly and Company, Indianapolis, IN
Medical oaths: Hippocratic Oath (Greek); Oath of Maimonides (named for Jewish scholar); Oath of Hindu Physician; Absolute Sincerity of Great Physicians (Chinese form
of physician’s oath); nearly all cultures and societies place
high value on medical ethics
Principles, codes, and books of medical ethics: Adab alTabib (“Practical Ethics of the Physician”; first known
book on medical ethics); Thomas Percival's Code of Medical Ethics; American Medical Association (AMA) code of
medical ethics (1847; similar to and released shortly after
Percival’s code); AMA Principles of Medical Ethics (extremely long, with annotations); Physician’s Charter of
Professionalism
Codes, declarations, and reports on research ethics: primarily begins with Nuremberg Code (response to discoveries of World War II atrocities conducted under pretext of
medical research); Declaration of Helsinki (follows on
Nuremberg Code); Belmont Report (created in United
States after revelation of unethical Tuskegee Institute experiments with syphilis); International Committee on Harmonization's Good Clinical Practice guidelines; Council
for International Organizations of Medical Sciences’ ethical guidelines
Hippocratic Oath (original version): exists in 3 forms
(original version from Byzantine texts, classic version used
during 17th and 18th centuries, and current version [updated for modern world]); original oath — strong religious
oath; begins with emphasizing respect for teachers; includes statements related to avoiding harm (with controversial language forbidding administration of lethal drugs and
abortion), acting only in patient’s best interest, and maintenance of confidentiality; not typically used by modern
medical schools (due to cultural specificities associated
with ancient Greece)
Declaration of Geneva (1948): originally developed by World
Medical Association; eligible for and subjected to multiple
amendments and revisions; updated to address controversies
related to “respect for life” (eg, abortion, euthanasia); emphasizes “service to humanity,” respect and gratitude for teachers,
practicing with conscience and dignity, prioritization of patient
concerns, maintenance of confidentiality, protection of medical profession, nondiscriminatory practices, and respect for
human life; internationally relevant; contains clause forbidding physicians from using medical knowledge “to violate human rights and civil liberties” (supports physicians in resisting
pressure to commit atrocities [as seen during World War II]);
secular oath (unlike Hippocratic Oath)
AMA Principles of Medical Ethics: standards of conduct
defining essentials of honorable behavior among physicians; emphasizes dedication to competent medical care
with compassion and respect for human dignity and
rights, upholding standards of professionalism, honesty
in all professional interactions, and reporting of physicians deficit in character or competence (or engaging in
fraud or deception) to appropriate entities
Reporting of fellow physicians: does not necessarily imply
legal involvement, but mandates review process or action
of some sort (eg, treatment in impaired physicians programs in cases of substance abuse)
Legal obligations: physicians required to respect established laws, but also to seek changes in legal requirements contrary to patient’s best interest; laws may forbid
asking about information critical to assessment of safety
of patient (eg, presence of firearms in home); physicians
must personally decide how to handle situations in which
laws conflict with patient’s best interest; AMA code emphasizes working within constraints of law (with regard
to, eg, privacy)
Other principles: lifelong learning; consulting colleagues to
address concerns outside personal expertise; freedom to
choose patients and associates during nonemergencies
(which suggests that physicians have obligation to help
in true emergencies); participation in activities contributing to improvement of community and public health;
making patient first priority while providing care; supporting universal access to medical care
Physician Charter (2002): authored by American Board of
Internal Medicine, in partnership with American College
Educational Objectives
Faculty Disclosure
The goal of this program is to review a physician's ethical obligations and to improve understanding of the applicability of
ethical considerations to the practice of psychiatry. After hearing and assimilating this program, the clinician will be better
able to:
1. Discuss the history and origin of physician oaths and
codified medical ethics.
2. Differentiate ethical standpoints associated with varying oaths, codes, and principles.
3. Recognize unique ethical considerations inherent to the
field of psychiatry.
4. Identify common obligations found in most ethical
oaths and codes.
5. Address conflicts of interest arising from multiple
sources or in multiple forms.
In adherence to ACCME Standards for Commercial Support,
Audio-Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within
the past 12 months that might create any personal conflicts of
interest. Any identified conflicts were resolved to ensure that
this educational activity promotes quality in health care and
not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Allen is an employee of and owns stock in Eli Lilly and Company. The
planning committee reported nothing to disclose.
AUDIO-DIGEST PSYCHIATRY 40:24
of Physicians and European Federation of Internet Medicine; endorsed by >100 medical groups (eg, AMA,
American Psychiatric Association, American Academy
of Pediatrics, American Association of Family Practitioners, American College of Surgeons, American Board of
Medical Specialties, Accreditation Counsel for Greater
Medical Education, Association of American Medical
Colleges, Chinese Medical Doctors Association, Federation of Royal College of Physicians, Turkish Medical Society, Medical Counsel of Canada)
Preamble: “professionalism is the basis of medicine's contract with society”
Fundamental provisions: patient autonomy; primacy of patient welfare; (social) justice; all 3 similar to provisions
of Belmont Report
Commitments: professional competence; honesty with patients; patient confidentiality; maintaining appropriate
relations with patients; improving quality of care; improving access to care; just distribution of finite resources; scientific knowledge; maintaining trust by
managing conflicts of interest (subject of increased focus
after late 1990s); professional responsibilities
Concepts common to most medical oaths and codes: responsibility to patients; beneficence and nonmaleficence;
respect for persons (eg, patients, peers, colleagues, teachers); justice and fairness; concern for public health; high
moral character; professional responsibilities; lifelong
learning
Distinctions: codes and oaths vary due to differences in societies (eg, religious countries or organizations may place
added emphasis on respect for life), politics, and eras;
contemporary oaths attempt to address modern concerns
(eg, public health)
Responsibility to physician's patients: implied in Hippocratic Oath; clearly stated in Declaration of Geneva (eg,
“the health of my patients will be my first consideration”) and AMA Principles of Medical Ethics (eg, “physician shall, while caring for a patient, regard
responsibility of patient as paramount,” and "physician
shall respect the law and also recognize a responsibility
to seek changes")
Physician Charter: includes primacy of patient welfare as
fundamental principle, and commitment to maintaining
trust by managing conflicts of interest (ie, patients must
view physician as putting their interests first)
Beneficence and nonmaleficence: included in Hippocratic
Oath (“I will prescribe regiments for the good of my patients according to my ability and my judgment, and well
never do harm to anyone”); not clearly stated in Declaration of Geneva, AMA Principles of Medical Ethics, and
Physician Charter
Primum non nocere: “first, do no harm”; concept fails to
address benefits (only risks); not directly stated in any
oath or codes; modern interpretations emphasize maximizing benefits while minimizing risk and harm (balancing of benefits and risks must occur before any
treatment)
Applications to psychiatry: cognitive behavioral therapy
for treatment of obsessive compulsive disorder; prescribing medication to child with attention-deficit disorder; transference and countertransference (must be
cognizant of potential for negatively affecting patient’s
well-being); treating mentally ill patients with goal of
competency to stand trial, or be executed (“benefit” to
patient questionable)
Confidentiality of patient information: specifically addressed in Hippocratic oath, Declaration of Geneva
(“even after the patient has died”), AMA Principles of
Medical Ethics (“within the constraints of the law”),
and Physician Charter (included as commitment)
Applications to psychiatry: release and publication of information from medical records has occurred after patient’s death (eg, therapist authoring biography based
on patient records, without consent); child psychiatrists sharing information confided by preteen patients
(eg, issues with substance abuse, pregnancy) with parents; in cases of knowledge pertaining to child abuse,
AMA principles obligate psychiatrists to comply with
laws mandating reporting of abuse (confidentiality no
longer applies; not true of other types of confidential
information, so appropriate course of action often unclear; violating confidentiality may be in child's best
interest)
Conflicts between patient interests and public health interests: specifically addressed in Declaration of Geneva
(as “service to humanity”), AMA Principles of Medical Ethics (“improvement of the community and the
betterment of public health”), and Physician Charter
(preamble speaks of “contract with society”; social
justice included as fundamental principle; several
commitments discuss public health activities); some
codes imply primacy of patient's interest over public
health interest (eg, “health of patient is paramount”),
but do not offer explicit prioritization
Implications: in mass casualty situations, physicians may
be obligated to offer limited care or comfort to less severely injured patients so that more serious cases can
be addressed; AMA Principles of Medical Ethics gives
primary interest to patients only during provision of
care (raises question of whether physicians may consider giving greater consideration to public health
when not directly providing care; important consideration when committing patients to psychiatric facilities
[intended to benefit patient, but may also involve public health issues such as danger of harm to others]; also
has potential to affect confidentiality issues [ie, findings may be entered into public court records])
Addressing conflicts of interest: speaker argues all individuals face conflicts of interest; groups with policies
about conflict of interest invariably have interests subject to conflict; specifically addressed in Hippocratic
Oath (“for the good of my patients, keeping myself far
from”), Declaration of Geneva (“will not permit considerations of age...or any other factor to intervene between my duty and my patient”) and Physician Charter
(“commitment to maintaining trust by managing conflicts of interest”); AMA Principles of Medical Ethics
do not specifically address conflicts of interest, but
state “physician shall, while caring for a patient, regard
responsibility to the patient as paramount”; often implied or explicitly stated in oaths, codes, and principles
associated with medical and nonmedical specialties;
multiple conflicts commonly occur from different
sources (eg, role as investigator, employment by hospital, ownership of company stock, financial stake in
particular theory) or in multiple forms (eg, financial,
professional)
Examples: implications of different sources of funding
given to investigators in clinical studies; department
chair requesting donation from grateful parents of suc-
AUDIO-DIGEST PSYCHIATRY 40:24
cessfully treated patient; journal reviewer assigned to
manuscript authored by competitor (disclosure of conflicting interests may be demanded)
Speaker’s view on corporate interests: argues that biopharmaceutical companies “exist to invent, develop, market,
and sell new drugs that have value to patients and customers, in return for sufficient money to pay expenses and
make enough profit to incentivize future innovation” (ie,
companies exist to provide new treatments that benefit
consumers, and produce profit only as byproduct); therefore, if corporate employees view providing quality medications as primary priority, corporate interests need not
conflict with ethical oaths
Interface between psychiatry and rest of medicine: primum non nocere (or maximizing benefit and minimizing
harm) applies to all areas of medicine equally; failures in
maintaining confidentiality of patient information led to
creation of Health Insurance Portability and Accountabil-
ity Act, and often result in leaking of medical information
about celebrities to public press; conflicts of interest occur
across all specialties
Closing thoughts: concerns about medical ethics appear universal (eg, found in all traditions); medical ethics continually evolve and change in context of time period, and as
result of new concerns (eg, recent bioethical concerns
about “synthetic life”); oaths and principles often fail to
cover important ethical concepts (eg, beneficence and nonmaleficence, primum non nocere [not included in oaths
and principles, and often oversimplified or misconstrued]);
conflicts of interest — important to medical ethics; occur in
multiple forms; focusing on one form of conflict can be
misleading and may cause loss of important information or
dangerous situations; although medical applications have
some special applications in psychiatry, most show overwhelming similarities to other areas of medicine
Acknowledgements
Dr. Allen spoke at Drugs, Psychosis, and Ethical Dilemmas in the Treatment of Children, Adolescents, and Young Adults, held September 17, 2011, in Indianapolis, IN, and presented by the Indiana Psychiatric Society. For further information about CME programs
sponsored by the Indiana Psychiatric Society, call (888) 477-9119, or visit IndianaPsychiatricSociety.org. The Audio-Digest Foundation thanks Dr. Allen and the Indiana Psychiatric Society for their cooperation in the production of this program.
Suggested Reading
Fulford KW: The value of evidence and evidence of values:
bringing together values-based and evidence-based practice in
policy and service development in mental health. J Eval Clin
Pract 17:976, 2011; Jotterand F: Human dignity and transhumanism: do anthro-technological devices have moral status? Am
J Bioeth 10:45, 2010; Konrad N: Ethical issues in forensic psychiatry in penal and other correctional facilities. Curr Opin Psychiatry 23:467, 2010; Nelson G et al: Evidence-based and
values-based policy, management and practice in child and adolescent mental health services. Am J Community Psychol 42:192,
2008; Ngui EM et al: Mental disorders, health inequalities and
ethics: A global perspective. Int Rev Psychiatry 22:235, 2010;
Accreditation: The Audio-Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing
medical education for physicians.
Designation: The Audio-Digest Foundation designates this enduring material for a maximum of 2 AMA PRA Category 1 CreditsTM. Physicians should
claim only the credit commensurate with the extent of their participation in
the activity.
Audio-Digest Foundation is approved by the American Psychological Association to sponsor continuing education for psychologists. Audio-Digest Foundation maintains responsibility for this program and its content. Each Audio-Digest
Psychiatry home study activity is offered for 2 CE credits for psychologists.
The American Academy of Physician Assistants (AAPA) accepts certificates of
participation for educational activities designated for AMA PRA Category 1 Credit
from organizations accredited by ACCME or a recognized state medical society.
Physician assistants may receive a maximum of 2 AMA PRA Category 1 Credits
for each Audio-Digest activity completed successfully.
Audio-Digest Foundation is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center’s (ANCC’s) Commission on Accreditation. Audio-Digest designates each activity for 2.0 CE
contact hours.
Rabins PV, Black BS: Ethical issues in geriatric psychiatry. Int
Rev Psychiatry 22:267, 2010; Rothstein M: Currents in contemporary bioethics. Constitutional right to informational health privacy in critical condition. J Law Med Ethics 39:280, 2011;
Rothstein MA: Is deidentification sufficient to protect health
privacy in research? Am J Bioeth 10:3, 2010; Seeman MV, Seeman B: Bioethics in a clinic for women with psychosis. J Med
Etics 37:518, 2011; von Cranach M: Ethics in psychiatry: the
lessons we learn from Nazi psychiatry. Eur Arch Psychiatry Clin
Neurosci 260:S152; Williams R, Fulford KW: Evidence-based
and values-based policy, management and practice in child and
adolescent mental health services. Clin Child Psychol Psychiatry
12:223, 2007.
Audio-Digest Foundation is approved as a provider of nurse practitioner continuing education by the American Academy of Nurse Practitioners (AANP
Approved Provider number 030904). Audio-Digest designates each activity
for 2.0 CE contact hours, including 0.5 pharmacology CE contact hours.
The California State Board of Registered Nursing (CA BRN) accepts
courses provided for AMA PRA Category 1 Credit as meeting the continuing
education requirements for license renewal.
Expiration: This CME activity qualifies for AMA PRA Category 1 Credit for
3 years from the date of publication.
Cultural and linguistic resources: In compliance with California Assembly Bill 1195, Audio-Digest Foundation offers selected cultural and linguistic resources on its website. Please visit this site: www.audiodigest.org/
CLCresources.
Estimated time to complete the educational process:
Review Educational Objectives on page 1
5 minutes
Take pretest
10 minutes
Listen to audio program
60 minutes
Review written summary and suggested readings
35 minutes
Take posttest
10 minutes
AUDIO-DIGEST PSYCHIATRY 40:24
of Physicians and European Federation of Internet Medicine; endorsed by >100 medical groups (eg, AMA,
American Psychiatric Association, American Academy
of Pediatrics, American Association of Family Practitioners, American College of Surgeons, American Board of
Medical Specialties, Accreditation Counsel for Greater
Medical Education, Association of American Medical
Colleges, Chinese Medical Doctors Association, Federation of Royal College of Physicians, Turkish Medical Society, Medical Counsel of Canada)
Preamble: “professionalism is the basis of medicine's contract with society”
Fundamental provisions: patient autonomy; primacy of patient welfare; (social) justice; all 3 similar to provisions
of Belmont Report
Commitments: professional competence; honesty with patients; patient confidentiality; maintaining appropriate
relations with patients; improving quality of care; improving access to care; just distribution of finite resources; scientific knowledge; maintaining trust by
managing conflicts of interest (subject of increased focus
after late 1990s); professional responsibilities
Concepts common to most medical oaths and codes: responsibility to patients; beneficence and nonmaleficence;
respect for persons (eg, patients, peers, colleagues, teachers); justice and fairness; concern for public health; high
moral character; professional responsibilities; lifelong
learning
Distinctions: codes and oaths vary due to differences in societies (eg, religious countries or organizations may place
added emphasis on respect for life), politics, and eras;
contemporary oaths attempt to address modern concerns
(eg, public health)
Responsibility to physician's patients: implied in Hippocratic Oath; clearly stated in Declaration of Geneva (eg,
“the health of my patients will be my first consideration”) and AMA Principles of Medical Ethics (eg, “physician shall, while caring for a patient, regard
responsibility of patient as paramount,” and "physician
shall respect the law and also recognize a responsibility
to seek changes")
Physician Charter: includes primacy of patient welfare as
fundamental principle, and commitment to maintaining
trust by managing conflicts of interest (ie, patients must
view physician as putting their interests first)
Beneficence and nonmaleficence: included in Hippocratic
Oath (“I will prescribe regiments for the good of my patients according to my ability and my judgment, and well
never do harm to anyone”); not clearly stated in Declaration of Geneva, AMA Principles of Medical Ethics, and
Physician Charter
Primum non nocere: “first, do no harm”; concept fails to
address benefits (only risks); not directly stated in any
oath or codes; modern interpretations emphasize maximizing benefits while minimizing risk and harm (balancing of benefits and risks must occur before any
treatment)
Applications to psychiatry: cognitive behavioral therapy
for treatment of obsessive compulsive disorder; prescribing medication to child with attention-deficit disorder; transference and countertransference (must be
cognizant of potential for negatively affecting patient’s
well-being); treating mentally ill patients with goal of
competency to stand trial, or be executed (“benefit” to
patient questionable)
Confidentiality of patient information: specifically addressed in Hippocratic oath, Declaration of Geneva
(“even after the patient has died”), AMA Principles of
Medical Ethics (“within the constraints of the law”),
and Physician Charter (included as commitment)
Applications to psychiatry: release and publication of information from medical records has occurred after patient’s death (eg, therapist authoring biography based
on patient records, without consent); child psychiatrists sharing information confided by preteen patients
(eg, issues with substance abuse, pregnancy) with parents; in cases of knowledge pertaining to child abuse,
AMA principles obligate psychiatrists to comply with
laws mandating reporting of abuse (confidentiality no
longer applies; not true of other types of confidential
information, so appropriate course of action often unclear; violating confidentiality may be in child's best
interest)
Conflicts between patient interests and public health interests: specifically addressed in Declaration of Geneva
(as “service to humanity”), AMA Principles of Medical Ethics (“improvement of the community and the
betterment of public health”), and Physician Charter
(preamble speaks of “contract with society”; social
justice included as fundamental principle; several
commitments discuss public health activities); some
codes imply primacy of patient's interest over public
health interest (eg, “health of patient is paramount”),
but do not offer explicit prioritization
Implications: in mass casualty situations, physicians may
be obligated to offer limited care or comfort to less severely injured patients so that more serious cases can
be addressed; AMA Principles of Medical Ethics gives
primary interest to patients only during provision of
care (raises question of whether physicians may consider giving greater consideration to public health
when not directly providing care; important consideration when committing patients to psychiatric facilities
[intended to benefit patient, but may also involve public health issues such as danger of harm to others]; also
has potential to affect confidentiality issues [ie, findings may be entered into public court records])
Addressing conflicts of interest: speaker argues all individuals face conflicts of interest; groups with policies
about conflict of interest invariably have interests subject to conflict; specifically addressed in Hippocratic
Oath (“for the good of my patients, keeping myself far
from”), Declaration of Geneva (“will not permit considerations of age...or any other factor to intervene between my duty and my patient”) and Physician Charter
(“commitment to maintaining trust by managing conflicts of interest”); AMA Principles of Medical Ethics
do not specifically address conflicts of interest, but
state “physician shall, while caring for a patient, regard
responsibility to the patient as paramount”; often implied or explicitly stated in oaths, codes, and principles
associated with medical and nonmedical specialties;
multiple conflicts commonly occur from different
sources (eg, role as investigator, employment by hospital, ownership of company stock, financial stake in
particular theory) or in multiple forms (eg, financial,
professional)
Examples: implications of different sources of funding
given to investigators in clinical studies; department
chair requesting donation from grateful parents of suc-
AUDIO-DIGEST PSYCHIATRY 40:24
cessfully treated patient; journal reviewer assigned to
manuscript authored by competitor (disclosure of conflicting interests may be demanded)
Speaker’s view on corporate interests: argues that biopharmaceutical companies “exist to invent, develop, market,
and sell new drugs that have value to patients and customers, in return for sufficient money to pay expenses and
make enough profit to incentivize future innovation” (ie,
companies exist to provide new treatments that benefit
consumers, and produce profit only as byproduct); therefore, if corporate employees view providing quality medications as primary priority, corporate interests need not
conflict with ethical oaths
Interface between psychiatry and rest of medicine: primum non nocere (or maximizing benefit and minimizing
harm) applies to all areas of medicine equally; failures in
maintaining confidentiality of patient information led to
creation of Health Insurance Portability and Accountabil-
ity Act, and often result in leaking of medical information
about celebrities to public press; conflicts of interest occur
across all specialties
Closing thoughts: concerns about medical ethics appear universal (eg, found in all traditions); medical ethics continually evolve and change in context of time period, and as
result of new concerns (eg, recent bioethical concerns
about “synthetic life”); oaths and principles often fail to
cover important ethical concepts (eg, beneficence and nonmaleficence, primum non nocere [not included in oaths
and principles, and often oversimplified or misconstrued]);
conflicts of interest — important to medical ethics; occur in
multiple forms; focusing on one form of conflict can be
misleading and may cause loss of important information or
dangerous situations; although medical applications have
some special applications in psychiatry, most show overwhelming similarities to other areas of medicine
Acknowledgements
Dr. Allen spoke at Drugs, Psychosis, and Ethical Dilemmas in the Treatment of Children, Adolescents, and Young Adults, held September 17, 2011, in Indianapolis, IN, and presented by the Indiana Psychiatric Society. For further information about CME programs
sponsored by the Indiana Psychiatric Society, call (888) 477-9119, or visit IndianaPsychiatricSociety.org. The Audio-Digest Foundation thanks Dr. Allen and the Indiana Psychiatric Society for their cooperation in the production of this program.
Suggested Reading
Fulford KW: The value of evidence and evidence of values:
bringing together values-based and evidence-based practice in
policy and service development in mental health. J Eval Clin
Pract 17:976, 2011; Jotterand F: Human dignity and transhumanism: do anthro-technological devices have moral status? Am
J Bioeth 10:45, 2010; Konrad N: Ethical issues in forensic psychiatry in penal and other correctional facilities. Curr Opin Psychiatry 23:467, 2010; Nelson G et al: Evidence-based and
values-based policy, management and practice in child and adolescent mental health services. Am J Community Psychol 42:192,
2008; Ngui EM et al: Mental disorders, health inequalities and
ethics: A global perspective. Int Rev Psychiatry 22:235, 2010;
Accreditation: The Audio-Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing
medical education for physicians.
Designation: The Audio-Digest Foundation designates this enduring material for a maximum of 2 AMA PRA Category 1 CreditsTM. Physicians should
claim only the credit commensurate with the extent of their participation in
the activity.
Audio-Digest Foundation is approved by the American Psychological Association to sponsor continuing education for psychologists. Audio-Digest Foundation maintains responsibility for this program and its content. Each Audio-Digest
Psychiatry home study activity is offered for 2 CE credits for psychologists.
The American Academy of Physician Assistants (AAPA) accepts certificates of
participation for educational activities designated for AMA PRA Category 1 Credit
from organizations accredited by ACCME or a recognized state medical society.
Physician assistants may receive a maximum of 2 AMA PRA Category 1 Credits
for each Audio-Digest activity completed successfully.
Audio-Digest Foundation is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center’s (ANCC’s) Commission on Accreditation. Audio-Digest designates each activity for 2.0 CE
contact hours.
Rabins PV, Black BS: Ethical issues in geriatric psychiatry. Int
Rev Psychiatry 22:267, 2010; Rothstein M: Currents in contemporary bioethics. Constitutional right to informational health privacy in critical condition. J Law Med Ethics 39:280, 2011;
Rothstein MA: Is deidentification sufficient to protect health
privacy in research? Am J Bioeth 10:3, 2010; Seeman MV, Seeman B: Bioethics in a clinic for women with psychosis. J Med
Etics 37:518, 2011; von Cranach M: Ethics in psychiatry: the
lessons we learn from Nazi psychiatry. Eur Arch Psychiatry Clin
Neurosci 260:S152; Williams R, Fulford KW: Evidence-based
and values-based policy, management and practice in child and
adolescent mental health services. Clin Child Psychol Psychiatry
12:223, 2007.
Audio-Digest Foundation is approved as a provider of nurse practitioner continuing education by the American Academy of Nurse Practitioners (AANP
Approved Provider number 030904). Audio-Digest designates each activity
for 2.0 CE contact hours, including 0.5 pharmacology CE contact hours.
The California State Board of Registered Nursing (CA BRN) accepts
courses provided for AMA PRA Category 1 Credit as meeting the continuing
education requirements for license renewal.
Expiration: This CME activity qualifies for AMA PRA Category 1 Credit for
3 years from the date of publication.
Cultural and linguistic resources: In compliance with California Assembly Bill 1195, Audio-Digest Foundation offers selected cultural and linguistic resources on its website. Please visit this site: www.audiodigest.org/
CLCresources.
Estimated time to complete the educational process:
Review Educational Objectives on page 1
5 minutes
Take pretest
10 minutes
Listen to audio program
60 minutes
Review written summary and suggested readings
35 minutes
Take posttest
10 minutes
AUDIO-DIGEST PSYCHIATRY 40:24
THE APPLICATION OF MEDICAL ETHICS IN PSYCHIATRY
To test online, go to www.audiodigest.org and sign in to online services.
To submit a test form by mail or fax, complete Pretest section before listening and Posttest section after listening.
1. The _______ was the first set of guidelines primarily concerned with research ethics.
(A) Nuremberg Code
(B) Declaration of Helsinki
(C) Belmont Report
(D) Council for International Organizations of Medical Sciences Ethical Guidelines
2. Which of the following statements about the Hippocratic Oath is not true?
(A) It includes the concept of maintenance of confidentiality
(B) It includes admonitions against the administration of lethal drugs and abortion
(C) It is the source of the phrase “primum non nocere”
(D) It is strongly religious
3. The American Medical Association’s (AMA) Principles of Medical Ethics includes:
(A) The obligation to report fellow physicians deficient in character or competence
(B) The obligation to respect established laws
(C) The obligation to seek change in laws contrary to patient interests
(D) All the above
4. Which of the following is not included as a fundamental provision of the Physician Charter of Professionalism?
(A) Primacy of patient welfare
(C) Patient autonomy
(B) Respect for life
(D) Social justice
5. Which of the following oaths includes a clear and definite statement covering beneficence and nonmaleficence?
(A) Hippocratic Oath
(C) AMA Principles of Medical Ethics
(B) Declaration of Geneva
(D) Physician Charter of Professionalism
6. Which of the following concepts is included in every medical oath and code discussed by the speaker?
(A) Justice and fairness
(C) Patient confidentiality
(B) Concern for public health
(D) Lifelong learning
7. According to the AMA Principles of Medical Ethics, physicians must make the health of patients paramount:
(A) At all times
(B) When they have been identified to others as a physician
(C) Only in emergency situations
(D) While providing care
8. Which of the following oaths does not specifically address conflicts of interest?
(A) Hippocratic Oath
(C) AMA Principles of Medical Ethics
(B) Declaration of Geneva
(D) Physician's Charter of Professionalism
9. Primum non nocere (or modern interpretations thereof) applies equally to all areas of medicine.
(A) True
(B) False
10. Ethical concerns in medicine remain essentially consistent over time.
(A) True
(B) False
Answers to Audio-Digest Psychiatry Volume 40, Issue 23: 1-B, 2-A, 3-C, 4-B, 5-C, 6-D, 7-A, 8-C, 9-A, 10-D
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Volume 40, Issue 24
December 21, 2011
THE APPLICATION OF MEDICAL ETHICS IN PSYCHIATRY
From Drugs, Psychosis, and Ethical Dilemmas in the Treatment of Children, Adolescents, and Young Adults,
presented by the Indiana Psychiatric Society
Albert J. Allen, MD, PhD, Senior Medical Fellow, Bioethics & Pediatric Capabilities,
Eli Lilly and Company, Indianapolis, IN
Medical oaths: Hippocratic Oath (Greek); Oath of Maimonides (named for Jewish scholar); Oath of Hindu Physician; Absolute Sincerity of Great Physicians (Chinese form
of physician’s oath); nearly all cultures and societies place
high value on medical ethics
Principles, codes, and books of medical ethics: Adab alTabib (“Practical Ethics of the Physician”; first known
book on medical ethics); Thomas Percival's Code of Medical Ethics; American Medical Association (AMA) code of
medical ethics (1847; similar to and released shortly after
Percival’s code); AMA Principles of Medical Ethics (extremely long, with annotations); Physician’s Charter of
Professionalism
Codes, declarations, and reports on research ethics: primarily begins with Nuremberg Code (response to discoveries of World War II atrocities conducted under pretext of
medical research); Declaration of Helsinki (follows on
Nuremberg Code); Belmont Report (created in United
States after revelation of unethical Tuskegee Institute experiments with syphilis); International Committee on Harmonization's Good Clinical Practice guidelines; Council
for International Organizations of Medical Sciences’ ethical guidelines
Hippocratic Oath (original version): exists in 3 forms
(original version from Byzantine texts, classic version used
during 17th and 18th centuries, and current version [updated for modern world]); original oath — strong religious
oath; begins with emphasizing respect for teachers; includes statements related to avoiding harm (with controversial language forbidding administration of lethal drugs and
abortion), acting only in patient’s best interest, and maintenance of confidentiality; not typically used by modern
medical schools (due to cultural specificities associated
with ancient Greece)
Declaration of Geneva (1948): originally developed by World
Medical Association; eligible for and subjected to multiple
amendments and revisions; updated to address controversies
related to “respect for life” (eg, abortion, euthanasia); emphasizes “service to humanity,” respect and gratitude for teachers,
practicing with conscience and dignity, prioritization of patient
concerns, maintenance of confidentiality, protection of medical profession, nondiscriminatory practices, and respect for
human life; internationally relevant; contains clause forbidding physicians from using medical knowledge “to violate human rights and civil liberties” (supports physicians in resisting
pressure to commit atrocities [as seen during World War II]);
secular oath (unlike Hippocratic Oath)
AMA Principles of Medical Ethics: standards of conduct
defining essentials of honorable behavior among physicians; emphasizes dedication to competent medical care
with compassion and respect for human dignity and
rights, upholding standards of professionalism, honesty
in all professional interactions, and reporting of physicians deficit in character or competence (or engaging in
fraud or deception) to appropriate entities
Reporting of fellow physicians: does not necessarily imply
legal involvement, but mandates review process or action
of some sort (eg, treatment in impaired physicians programs in cases of substance abuse)
Legal obligations: physicians required to respect established laws, but also to seek changes in legal requirements contrary to patient’s best interest; laws may forbid
asking about information critical to assessment of safety
of patient (eg, presence of firearms in home); physicians
must personally decide how to handle situations in which
laws conflict with patient’s best interest; AMA code emphasizes working within constraints of law (with regard
to, eg, privacy)
Other principles: lifelong learning; consulting colleagues to
address concerns outside personal expertise; freedom to
choose patients and associates during nonemergencies
(which suggests that physicians have obligation to help
in true emergencies); participation in activities contributing to improvement of community and public health;
making patient first priority while providing care; supporting universal access to medical care
Physician Charter (2002): authored by American Board of
Internal Medicine, in partnership with American College
Educational Objectives
Faculty Disclosure
The goal of this program is to review a physician's ethical obligations and to improve understanding of the applicability of
ethical considerations to the practice of psychiatry. After hearing and assimilating this program, the clinician will be better
able to:
1. Discuss the history and origin of physician oaths and
codified medical ethics.
2. Differentiate ethical standpoints associated with varying oaths, codes, and principles.
3. Recognize unique ethical considerations inherent to the
field of psychiatry.
4. Identify common obligations found in most ethical
oaths and codes.
5. Address conflicts of interest arising from multiple
sources or in multiple forms.
In adherence to ACCME Standards for Commercial Support,
Audio-Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within
the past 12 months that might create any personal conflicts of
interest. Any identified conflicts were resolved to ensure that
this educational activity promotes quality in health care and
not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Allen is an employee of and owns stock in Eli Lilly and Company. The
planning committee reported nothing to disclose.