Patients – WMA – The World Medical Association

Adopted by the 73^rd WMA General Assembly, Berlin, Germany, October 2022

PREAMBLE

The interaction between the physicians and their relatives seeking medical care can be complex. Moreover, this possibility is highly conditioned by cultural aspects. Interaction can start with asking for simple advice, consultation for minor ailments, and general questions about healthcare and health promotion. This can escalate to seeking medical care and even surgery. Physicians are often their relatives’ first point of call for medical and emotional support. Physicians may be able to offer immediate care in cases of emergency and contribute to well-informed, evidence-based self-care. Other than in emergencies, offering general health information or for minor health problems, physicians should avoid treating those close to them.

The ethical principles governing the work of physicians are equally important and valid when treating relatives. Respect for autonomy may be compromised by lack of privacy, unintentional breaches of confidentiality, and failure to seek informed consent. The relationship with the physician might compromise the patient’s ability to make independent decisions.

Treating relatives may pose challenges in the following circumstances:

When objectivity is compromised and decisively affected by emotional factors, there could be a risk of either under- or over-treating relatives or of encountering problems that are beyond the physician’s expertise or abilities, which could cause serious harms.
When there are potential barriers to considering sensitive medical history and/or conducting an appropriate physical examination, which may result in incorrect medical diagnosis and treatment.
When the physician fails to fulfil requirements concerning patient clinical records, which may result in difficulties if the related patient needs follow-up treatment or when liability issues arise.
When a negative medical outcome could compromise the relationship between the physician and the related patient.
When the treatment is not in the best interest or against the will of the related patient.
When the physician risks providing relatives, perhaps unintentionally and unconsciously, with undue advantages.

RECOMMENDATIONS

1.Physicians should avoid routinely acting as a relative’s primary care physician or serving as the attending physician when treating a potentially life-threatening condition. Physicians may provide care to a relative in emergencies, for minor health problems or when there is no other qualified physician available.

2. Related patients may ask for a second opinion about another physician’s care. If a second opinion is shared, it should be consistent with these recommendations and fulfil the duties of physicians to colleagues. Care should be taken to only discuss the treatment, which is most appropriate and recommended, rather than any judgements about the other treating physician’s care and advice.

3. If a physician treats a relative, the physician should be mindful of the following:

Strict respect for medical ethics, the patient’s autonomy and consent, with special consideration for minors.
The physician has the duty to respect a patient’s right to confidentiality and should not share information with anyone else without a lawful basis, including other family members, with the exception of necessary clinical documentation when referring to other health care personnel.
If a relative indicates an intention to seek a second opinion about another physician’s care, that intention must be respected.
Consent for treatment must be given by the patient, including competent minors, and for that consent to be valid, it must be fully informed.
Depending on the nature of the relationship, taking a sensitive history and performing a physical examination may be emotionally difficult or uncomfortable for the patient or the physician. In such situations the physician and the patient should consider consulting another physician.
Clear and concise patient records must be maintained at all times.

4. If the physician cannot accommodate the recommendations above, the physician should avoid treating relatives.

5. While physicians are encouraged not to treat relatives except in certain circumstances, it is acknowledged that physicians are often approached by their relatives for medical advice or treatment, and their help is frequently beneficial and appreciated.

6. In all circumstances, physicians shall maintain the highest professional and ethical standards, in accordance with the Declaration of Geneva, the WMA International Code of Medical Ethics, and the WMA Declaration of Lisbon on the Rights of the Patient.

Adopted by the 47^th WMA General Assembly, Bali, Indonesia, September 1995
and revised by the 57^th WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 66^th WMA General Assembly, Moscow, Russia, October 2015

PREAMBLE

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. In the absence of effective treatment, to prevent self-destructive behaviour or harm to others, many persons with mental illness were confined to asylums for all or part of their lives.

Today, progress in psychiatric treatment allows for better care of patients with mental illness. Efficacious drugs and psychosocial interventions offer outcomes ranging from complete recovery to remission for varying lengths of time.

The adoption in 2006 of the United Nations Convention on the Rights of Persons with Disabilities constituted a major step towards viewing them as full members of society with the same rights as everyone else. It is the first comprehensive human rights treaty of the 21^st century. It aims to promote, protect and reinforce the human rights and dignity of all persons with disabilities, including those with mental impairments.

Persons with major mental illnesses and those with learning disability have the same right to preventive services and interventions to promote health as others members of the community, for which they often have greater need because they are more likely to live unhealthy lifestyles.

Patients with psychiatric morbidity may also experience non- psychiatric illness. Persons with mental illness have the same right to health care as any other patient. Psychiatrists and health care professionals who provide mental health services should refer patients to other appropriate professionals when patients need medical care. Health care professionals should never decline to provide needed medical care solely because the patient has a mental illness.

Physicians have the same obligations to all patients, including patients with mental illness. Psychiatrists or other physicians who treat patients with mental illness must adhere to the same ethical standards as any physician.

The physician’s primary obligation is to the patient and not to serve as agents of society, except in circumstances when a patient presents clear danger to himself/ herself or others due to mental illness.

PHYSICIANS’ ETHICAL RESPONSIBILITIES

The stigma and discrimination associated with psychiatry and the mentally ill should be eliminated. Stigma and discrimination may discourage people in need from seeking medical care, thereby aggravating their situation and placing them at risk of emotional or physical harm.

Physicians have a responsibility to respect the autonomy of all patients. When patients who are being treated for mental illness have decision-making capacity, they have the same right to make decisions about their care as any other patient. Because decision-making capacity is specific to the decision to be made and can vary over time, including as a result of treatment, physicians must continually evaluate the patient’s capacity. When a patient lacks decision-making capacity, physicians should seek consent from an appropriate surrogate in accordance with applicable law.

The therapeutic relationship between physician and patient is founded on mutual trust, and physicians have a responsibility to seek patients’ informed consent to treatment, including patients who are being treated for mental illness. Physicians should inform all patients of the nature of the psychiatric or other medical condition, and the expected benefits, outcomes and risks of treatment alternatives.

Physicians should always base treatment recommendations on their best professional judgment and treat all patients with solicitude and respect, regardless of the setting of care. Physicians who practice in mental health facilities, the military, or correctional institutions may have concurrent responsibilities to society that create conflicts with the physician’s primary obligation to the patient. In such situations, physicians should disclose the conflict of interest to minimize possible feelings of betrayal on the patient’s part.

Involuntary treatment or hospitalization of persons with mental illness is ethically controversial. While laws regarding involuntary hospitalization and treatment vary worldwide, it is generally acknowledged that this treatment decision without the patient’s informed consent or against the patient’s will is ethically justifiable only when: (a) a severe mental disorder prevents the individual from making autonomous treatment decisions; and/or (b) There is significant likelihood that the patient may harm him/her self or others. Involuntary treatment or hospitalization should be exceptional and physicians should utilize it only when there is good evidence that it is medically appropriate and necessary and should ensure that the individual is hospitalized for the shortest duration feasible under the circumstances. Wherever possible and in accordance with local laws, physicians should include an advocate for the rights of that patient in the decision process.

Physicians must protect the confidentiality and privacy of all patients.. When legally required to disclose patient information, the physician should disclose only the minimum relevant information necessary and only to an entity legally authorized to request or require the information. When databanks allow access to or transfer of information from one authority to another confidentiality must be respected and such access or transfer must comply fully with applicable law.

The participation of individuals with psychiatric illness in research needs to be in full accordance with the Declaration of Helsinki’s recommendations.

Physicians must never use their professional position to violate the dignity or human rights of any individual or group, and should never allow their personal desires, needs, feelings, prejudices or beliefs to interfere with a patient’s treatment. Physicians must never abuse their authority or take advantage of a patient’s vulnerability.

RECOMMENDATIONS

The World Medical Association and National Medical Associations are encouraged to:

Publicize this Statement and affirm the ethical foundations for treatment of patients with mental illness;
While doing so, call for full respect – at all times – of the dignity and human rights of patients with mental illness;
Raise awareness of physicians’ responsibilities to support the well-being and rights of patients with mental illness;
Promote recognition of the privileged relationship between patient and physician based on trust, professionalism and confidentiality;
Advocate for appropriate resources to meet the needs of persons with mental illness.