WMA Statement on Ethical Issues Concerning Patients with Mental Illness


Adopted by the 47th WMA General Assembly, Bali, Indonesia, September 1995
and revised by the 57th WMA General Assembly, Pilanesberg, South Africa, October 2006

PREAMBLE

  1. Historically, many societies have regarded patients with mental illness as a threat to those around them rather than as people in need of support and care. Therefore, in the absence of effective treatment, many patients with mental illness were confined to asylums for all or part of their lives. The aim of such confinement in these cases was to prevent behaviour that was self-destructive or aggressive toward others.

  2. At the present time, progress in psychiatric therapy allows for better care of patients with mental illness. Efficacious drugs and other treatments can result in patient outcomes ranging from complete alleviation of symptoms to long remissions for patients whose conditions are more serious.

  3. Patients with mental illness should be viewed, treated and granted the same access to care as any other medical patient. However, this is often not enough since patients with mental illnesses may not know when to seek treatment for somatic problems. Therefore, the physician should actively refer these patients to other physicians when necessary.

  4. A physician has the same obligations toward patients with mental illness as toward any other patient.

  5. The physician's primary role as healer of patients must not be undermined by serving as the agent of the greater society, except in instances of danger to the public.

  6. Recognition must be given to the fact that a large proportion of patients with mental illness are treated by physicians who are not psychiatrists. The same ethical obligations and limitations would apply to these physicians.

ETHICAL PRINCIPLES

  1. The discrimination associated with psychiatry and the mentally ill should be eliminated. This stigma often discourages people in need from seeking psychiatric help, thereby aggravating their situation and placing them at risk of emotional or physical harm.

  2. The physician aspires for a therapeutic relationship founded on mutual trust. He/she should inform the patient of the nature of the patient's condition, standard therapeutic procedures (including possible alternatives and the risk of each), and the expected outcomes for the available therapeutic choices.

  3. In the absence of legally adjudicated incompetence, psychiatric patients must be dealt with as though they are legally competent. The patient's judgment should be respected in areas where he/she is legally capable of making decisions, unless they present a risk of serious harm to themselves or others. A patient with mental illness who is incapable of legally exercising his/her autonomy should be treated like any other patient who is temporarily or permanently legally incompetent. If the patient lacks the capacity to make a decision as to his/her medical care, surrogate consent should be sought from an authorized representative in accordance with applicable law.

  4. Involuntary hospitalization of psychiatric patients evokes ethical controversy. While laws regarding involuntary hospitalization and treatment vary worldwide, it is generally acknowledged that this treatment decision requires the following: (a) a severe mental disorder that prevents the individual from making his/her own treatment decisions; and/or (b) the likelihood that the patient may harm him/her self or others. Physicians should consider compulsory hospitalization to be exceptional and should utilize it only when it is medically necessary and for the shortest duration feasible under the circumstances.

  5. Every physician should offer the patient the best available therapy to his/her knowledge, and should treat the patient with the solicitude and respect due all human beings. The physician practising in a psychiatric institution, the military or a prison can be faced with a conflict between his/her responsibilities to society and the responsibilities to the patient. The physician's primary loyalty and duty must be to the patient's best interest. The physician should ensure that the patient is made aware of the conflict in order to minimize feelings of betrayal, and should offer the patient the opportunity to understand measures mandated by legal authority.

  6. The confidentiality and privacy of all patients should be safeguarded. When required by law, the physician should disclose only the required relevant material and should disclose such material only to the entity having legal authority to make such a request or demand. Data banks that allow access to or transfer of information from one authority to another may be used provided that medical confidentiality is respected and such access or transfer is fully compliant with applicable law.

  7. A physician must never use his/her professional position to violate the dignity or human rights of any individual or group and should never allow his/her personal desires, needs, feelings, prejudices or beliefs to interfere with the treatment. Neither should a physician take advantage of his/her professional position or the vulnerability of a patient to abuse his/her authority.

RECOMMENDATION

  1. National Medical Associations should publicize this Statement and use it as a basis for affirming the ethical foundations for treatment of patients with mental illness.