Ethical challenges in contemporary psychiatry: an overview and an appraisal of possible strategies and research needs
- PMID: 39279422
- PMCID: PMC11403198
- DOI: 10.1002/wps.21230
Ethical challenges in contemporary psychiatry: an overview and an appraisal of possible strategies and research needs
Abstract
Psychiatry shares most ethical issues with other branches of medicine, but also faces special challenges. The Code of Ethics of the World Psychiatric Association offers guidance, but many mental health care professionals are unaware of it and the principles it supports. Furthermore, following codes of ethics is not always sufficient to address ethical dilemmas arising from possible clashes among their principles, and from continuing changes in knowledge, culture, attitudes, and socio-economic context. In this paper, we identify topics that pose difficult ethical challenges in contemporary psychiatry; that may have a significant impact on clinical practice, education and research activities; and that may require revision of the profession's codes of ethics. These include: the relationships between human rights and mental health care, research and training; human rights and mental health legislation; digital psychiatry; early intervention in psychiatry; end-of-life decisions by people with mental health conditions; conflicts of interests in clinical practice, training and research; and the role of people with lived experience and family/informal supporters in shaping the agenda of mental health care, policy, research and training. For each topic, we highlight the ethical concerns, suggest strategies to address them, call attention to the risks that these strategies entail, and highlight the gaps to be narrowed by further research. We conclude that, in order to effectively address current ethical challenges in psychiatry, we need to rethink policies, services, training, attitudes, research methods and codes of ethics, with the concurrent input of a range of stakeholders, open minded discussions, new models of care, and an adequate organizational capacity to roll-out the implementation across routine clinical care contexts, training and research.
Keywords: Ethics of psychiatry; coercive practices; conflicts of interests; digital psychiatry; early intervention; end‐of‐life decisions; experts by experience; family supporters; human rights; mental health legislation; shared decision‐making.
© 2024 World Psychiatric Association.
Conflict of interest statement
Conflicts of interests (CoIs) are defined as a set of circumstances that may unduly interfere with physicians’ professional obligations and primary interests in providing care, advancing research and scientific knowledge, and promoting public health. They can be financial, or related to professional achievements, or arising from allegiance to political/cultural beliefs or schools of thought, . The term CoI does not refer to ethical dilemmas arising from tensions between two physicians’ primary interests (e.g., a conflict between the respect for a person's autonomy and the principle of non‐maleficence).
CoIs can lead to misconduct and illegal or unprofessional behavior, but far more often can influence judgment in subtle ways, and most clinicians and researchers may be unaware of an existing bias in their decision‐making. CoIs may threaten the quality of clinical care as well as the integrity of research and education, and may jeopardize public trust in science and medicine, including psychiatry, . The issue of public trust may be particularly relevant for psychiatry, which, more often than other medical specialties, has to face a poor public image as both a profession and a scientific discipline, , , , , .
Health care professionals, including psychiatrists, may benefit from relationships with pharmaceutical and biomedical manufacturers in ways that are consistent with their primary interests, as they can acquire information on new therapeutic options, have the opportunity to give their feedback to facilitate further development of industry products, and access resources to update their knowledge and continue their education. However, while both pharmaceutical companies and professionals share the goal of improving health care, important differences cannot be ignored, as companies remain profit‐driven and have their primary interest in the promotion of their brand and products. In all countries, pharmaceutical companies target health care professionals through a series of marketing strategies, which may involve gifts, free meals and travels, and provision of drug samples, .
Interactions between industry and professionals have raised concerns, as they can potentially influence physicians’ clinical decision‐making. Several studies have addressed the relationship between financial interactions and prescription patterns, and systematic reviews, have reported a correlation between the two, also suggesting a temporal and dose‐dependent association. A study conducted in the US found that physicians were from 39% to 83% less likely to prescribe a new medication if they practiced in states with regulations against using pharmaceutical representatives to market products, in comparison with colleagues practicing in non‐regulated states.
In the light of these concerns, attempts have been made to regulate the interactions of physicians with pharmaceutical company representatives. These have included specific restrictions on interactions or the disclosure of these interactions (either self‐regulated or mandatory), especially when benefits are received by the physician. However, relevant policies and legislations show substantial heterogeneity across countries, , , .
Both the WPA and the European Psychiatric Association (EPA) have developed sets of recommendations for psychiatrists in their relationships with the industry and in situations presenting potential CoIs, . The WPA warns psychiatrists to take with caution and critical review the information provided by industry representatives, and suggests that psychiatrists and health care organizations limit meetings and interactions with pharmaceutical company representatives, and forbid their access to patient care areas. Both the WPA and the EPA currently discourage psychiatrists from accepting meals and gifts, and the WPA additionally recommends accepting drug samples only to provide them to people who are otherwise unable to afford medications. In addition, both associations discourage psychiatrists from exposing items bearing companies’ logos in the presence of service users, because these may influence the users’ perceptions of the relationship between the industry and their doctors.
CoI concerns have led to the development of disclosure policies mandating transparent reporting of financial interactions, such as the Physician Payments Sunshine Act in the US, and the Disclosure Code of the European Federation of Pharmaceutical Industries and Associations (EFPIA) in Europe. Disclosure may motivate clinicians to avoid circumstances and behaviors representing potential CoIs, , and aims to improve public trust in the health system through transparency. However, CoI disclosure may actually decrease trust, as it may make patients more aware of the relationships between their physicians and pharmaceutical companies, .
By significantly increasing public access to data on the financial ties of the pharmaceutical and biomedical industries with health care systems, disclosure policies have allowed systematic tracking and better understanding of this complex phenomenon. In particular, recent data shed light on the existence of a complex network involving not only prescribers and industry representatives, but multiple other parties, such as regulators, supply chains, patient advocacy groups and foundations. For instance, patient advocacy groups have been the subject of increasing reports of funding from pharmaceutical companies, , , and may participate in drug advisory committees, drug reviews and public reimbursement decisions, thus indirectly influencing prescription patterns. Hence, a narrow focus on individual relationships, such as the direct ties between health care professionals and industry representatives, may overlook the role of the multiple pathways through which clinical decision‐making may be indirectly influenced. These pathways, which may have cumulative effects, are far less documented, and may not be detected by policy makers.
CoI restriction policies have been implemented to reduce the probability of prescribing a newly marketed drug as a result of marketing activities, , but their prevalence and strictness vary greatly, with North American medical schools having more frequent and stricter CoI policies as compared to European institutions, .
Non‐financial CoIs are also relevant to psychiatric practice, and clinical decision‐making may be influenced in case of intellectual allegiance to a school of thought or to political ideas, or in relation to defensive practices. In the case of the latter, the pursuit of the primary interest of the PWLE's well‐being and autonomy may be attenuated by the physician's personal interest in preventing a perceived or actual risk of litigation or legal responsibility. For instance, the clinician may opt for overly cautious interventions – such as overmedication, hospitalization, delayed discharge from the hospital, and even coercive measures such as involuntary hospitalization – instead of less invasive ones. Although psychiatry is at low risk of malpractice claims in comparison to other specialties, surveys in different countries report that the majority of interviewed psychiatrists acknowledged having resorted to defensive practices, which, in their opinion, compromised the quality of the provided care, , .
CoIs may also be relevant to research activities, in which the pharmaceutical and medical device industries are often important partners. Financial interactions may create secondary interests interfering with the primary goal, i.e., contributing to scientific progress through rigorous research. Several studies indicate that industry funding can lead to bias in clinical trials, systematic reviews and clinical guidelines, , , .
CoIs in research activities are currently regulated by a set of norms, policies and guidelines for researchers participating in scientific investigations, clinical trials, peer‐review and publication processes, and guideline development, , , . However, financial CoIs do not only affect individual researchers, but also academic institutions and institutional leaders, , , , and current policies tend to regulate even small benefits to individual researchers (e.g., free meals), while often failing to address appropriately the effects of large amount of funding for institutions, . In addition, while current policies identify different magnitudes and types of CoIs, the lack of a shared standardized taxonomy of CoIs and the dearth of studies testing the influence of different CoIs on research and publication activities limit the efficiency of restrictions.
Non‐financial CoIs are less often acknowledged, although they may impact research as much as, or even more than, financial ones. Indeed, it has been stated that “the prospect of fame may be even more seductive than fortune”. According to this perspective, non‐financial CoIs should be disclosed, or even regulated, using similar policy frameworks as for financial CoIs. In psychotherapy, for instance, an allegiance to a particular approach, due to personal training or involvement in previous research efforts, may significantly influence reported outcomes of results, , , . A systematic review of 30 meta‐analyses found that researchers’ allegiance to the tested psychotherapy inflated the reported effect sizes by almost 30%.
Concerns about non‐financial CoI disclosure have included privacy violation (e.g., in the case of political or religious beliefs) and irrelevance, insofar as it duplicates publicly available information, such as intellectual positions and education, training, institutional and academic affiliations. It has been argued that these CoIs may be better addressed through other approaches, such as ensuring a balance of opposing perspectives, and diversity of professional backgrounds in the involved researchers.
Psychiatrists often have roles as teachers, mentors and public speakers, and participate in the education of students and residents. As such, they have a professional obligation to share up‐to‐date, evidence‐based and ethically informed knowledge. In these roles, CoIs may arise when either financial or non‐financial secondary interests influence the content, quality and objectivity of the teaching and training. For instance, as pharmaceutical companies aim to promote their brands, as well as new therapeutic options, they have an interest in sponsoring educational initiatives, materials and events. Education providers may receive promotional speaking fees, which may bias – or be perceived to bias – the information they provide. Additionally, participants may receive gifts, reimbursements to participate in sponsored conferences, or scholarships, , and the possibility that these marketing activities influence their prescription patterns cannot be ruled out. The WPA Code of Ethics indicates that psychiatrists should be presenting in sponsored educational activities only when they have control over the educational content.
Several regulators, , , , have developed accreditation criteria limiting direct industry funding, as well as codes of conduct requiring management and transparent disclosure of CoIs. As noted, however, these regulations have limitations and may fail to address indirect financial ties and influences, .
Recent research and policy efforts have improved transparency and thus increased our understanding of the complexity of the issue of CoIs, as well as of the relevant health care and scientific ecosystem. In this ecosystem, not only clinicians and researchers, but each individual player may have multiple financial and non‐financial interactions with multiple entities, often in ways that are consistent with the primary interests of benefitting PWLE and society. However, all these interactions carry risks of undue influences, and growing evidence shows that commercial sponsors can influence these networks both at individual and institutional levels. Future policy and legislative efforts should not only aim to cut down such potential influences, but also promote a confluence of primary and secondary interests and foster public trust through transparency and accountability.
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