DECLARATION OF MADRID

In 1977, the World Psychiatric Association approved the Declaration of Hawaii which set out ethical guidelines for the practice of psychiatry. The Declaration was updated in Vienna in 1983. To reflect the impact of changing social attitudes and new medical developments on the psychiatric profession, the World Psychiatric Association has once again undertaken a review of ethical standards that should be abided to by all its members and all persons practicing psychiatry.

Medicine is both a healing art and a science. The dynamics of this combination are best reflected in psychiatry, the branch of medicine that specializes in the care and protection of those who are ill or infirm, because of a mental disorder or impairment. Although there may be cultural, social and national differences, the need for ethical conduct and continual review of ethical standards is universal.

As practitioners of medicine, psychiatrists must be aware of the ethical implications of being a physician, and of the specific ethical demands of the specialty of psychiatry. As members of society, psychiatrists must advocate for fair and equal treatment of the mentally ill, for social justice and equity for all.

Ethical practice is based on the psychiatrist’s individual sense of responsibility to the patient and judgment in determining what is correct and appropriate conduct. External standards and influences such as professional codes of conduct, the study of ethics, or the rule of law by themselves will not guarantee the ethical practice of medicine.

Psychiatrists should keep in mind at all times the boundaries of the psychiatrist-patient relationship, and be guided primarily by the respect for patients and concern for their welfare and integrity.

It is in this spirit that the World Psychiatric Association approved at the General Assembly on August 25th, 1996, amended on August 8th 1999 and on August 26th 2002 the following ethical standards that should govern the practice of psychiatrists universally.

1. Psychiatry is a medical discipline concerned with the prevention of mental disorders in the population, the provision of the best possible treatment for mental disorders, the rehabilitation of individuals suffering from mental illness and the promotion of mental health. Psychiatrists serve patients by providing the best therapy available consistent with accepted scientific knowledge and ethical principles. Psychiatrists should devise therapeutic interventions that are least restrictive to the freedom of the patient and seek advice in areas of their work about which they do not have primary expertise. While doing so, psychiatrists should be aware of and concerned with the equitable allocation of health resources.

2. It is the duty of psychiatrists to keep abreast of scientific developments of the specialty and to convey updated knowledge to others. Psychiatrists trained in research should seek to advance the scientific frontiers of psychiatry.

3. The patient should be accepted as a partner by right in the therapeutic process. The psychiatrist-patient relationship must be based on mutual trust and respect to allow the patient to make free and informed decisions. It is the duty of psychiatrists to provide the patient with all relevant information so as to empower the patient to come to a rational decision according to personal values and preferences.

4. When the patient is gravely disabled, incapacitated and/or incompetent to exercise proper judgment because of a mental disorder, the psychiatrists should consult with the family and, if appropriate, seek legal counsel, to safeguard the human dignity and the legal rights of the patient. No treatment should be provided against the patient’s will, unless withholding treatment would endanger the life of the patient and/or the life of others. Treatment must always be in the best interest of the patient.

5. When psychiatrists are requested to assess a person, it is their duty first to inform and advise the person being assessed about the purpose of the intervention, the use of the findings, and the possible repercussions of the assessment. This is particularly important when psychiatrists are involved in third party situations.

6. Information obtained in the therapeutic relationship is private to the patient and should be kept in confidence and used, only and exclusively, for the purpose of improving the mental health of the patient. Psychiatrists are prohibited from making use of such information for personal reasons, or personal benefit. Breach of confidentiality may only be appropriate when required by law (as in obligatory reporting of child abuse) or when serious physical or mental harm to the patient or to a third person would ensue if confidentiality were maintained; whenever possible, psychiatrists should first advise the patient about the action to be taken.

7. Research that is not conducted in accordance with the canons of science and that is not scientifically valid is unethical. Research activities should be approved by an appropriately constituted ethics committee. Psychiatrists should follow national and international rules for the conduct of research. Only individuals properly trained for research should undertake or direct it. Because psychiatric patients constitute a particularly vulnerable research population, extra caution should be taken to assess their competence to participate as research subjects and to safeguard their autonomy and their mental and physical integrity. Ethical standards should also be applied in the selection of population groups, in all types of research including epidemiological and sociological studies and in collaborative research involving other disciplines or several investigating centres.

GUIDELINES CONCERNING SPECIFIC SITUATIONS

The World Psychiatric Association Ethics Committee recognizes the need to develop a number of specific guidelines on a number of specific situations. The first five were approved by the General Assembly in Madrid, Spain, on August 25, 1996, the 6 through 8 by the General Assembly in Hamburg, Germany, on August 8, 1999, the 9 through 12 by the General Assembly in Yokohama, Japan, on August 26, 2002, the 13 through 15 at the General Assembly in Cairo, Egypt, on September 12, 2005, and the 16 at the General Assembly in Buenos Aires, Argentina, on September 21, 2011.

1. Euthanasia:

A physician’s duty, first and foremost, is the promotion of health, the reduction of suffering, and the protection of life. The psychiatrist, among whose patients are some who are severely incapacitated and incompetent to reach an informed decision, should be particularly careful of actions that could lead to the death of those who cannot protect themselves because of their disability. The psychiatrist should be aware that the views of a patient may be distorted by mental illness such as depression. In such situations, the psychiatrist’s role is to treat the illness.

2. Torture:

Psychiatrists shall not take part in any process of mental or physical torture, even when authorities attempt to force their involvement in such acts.

3. Death Penalty:

Under no circumstances should psychiatrists participate in legally authorized executions nor participate in assessments of competency to be executed.

4. Selection of Sex:

Under no circumstances should a psychiatrist participate in decisions to terminate pregnancy for the purpose of sex selection.

5. Organ Transplantation:

The role of the psychiatrist is to clarify the issues surrounding organ donations and to advise on religious, cultural, social and family factors to ensure that informed and proper decisions be made by all concerned. The psychiatrists should not act as a proxy decision maker for patients nor use psychotherapeutic skills to influence the decision of a patient in these matters. Psychiatrists should seek to protect their patients and help them exercise self-determination to the fullest extent possible in situations of organ transplantation.

6. Psychiatrists addressing the media:

In all contacts with the media psychiatrists shall ensure that people with mental illness are presented in a manner which preserves their dignity and pride, and which reduces stigma and discrimination against them.

An important role of psychiatrists is to advocate for those people who suffer from mental disorders. As the public perception of psychiatrists and psychiatry reflects on patients, psychiatrists shall ensure that in their contact with the media they represent the profession of psychiatry with dignity.

Psychiatrists shall not make announcements to the media about presumed psychopathology on any individuals.

In presenting research findings to the media, psychiatrists shall ensure the scientific integrity of the information given and be mindful of the potential impact of their statements on the public perception of mental illness and on the welfare of people with mental disorders.

7. Psychiatrists and discrimination on ethnic or cultural grounds:

Discrimination by psychiatrists on the basis of ethnicity or culture, whether directly or by aiding others is unethical. Psychiatrists shall never be involved or endorse, directly or indirectly, any activity related to ethnic cleansing.

8. Psychiatrists and genetic research and counseling:

Research on the genetic bases of mental disorders is rapidly increasing and more people suffering from mental illness are participating in such research.

Psychiatrists involved in genetic research or counseling shall be mindful of the fact that the implication of genetic information are not limited to the individual from whom it was obtained and that its disclosure can have negative and disruptive effects on the families and communities of the individuals concerned.

Psychiatrist shall therefore ensure that:

– People and families who participate in genetic research do so with a fully informed consent;

– Any genetic information in their possession is adequately protected against unauthorized access, misinterpretation or misuse;

– Care is taken in communication with patients and families to make clear that current genetic knowledge is incomplete and may be altered by future findings. Psychiatrists shall only refer people to facilities for diagnostic genetic testing if that facility has:

– Demonstrated satisfactory quality assurance, procedures for such testing;

– Adequate and easily accessible resources for genetic counseling.

Genetic counseling with regard to family planning or abortion shall be respectful of the patients’ value system, while providing sufficient medical and psychiatric information to aid patients make decisions they consider best for them.

9. Ethics of Psychotherapy in Medicine:

Medical treatments of any nature should be administered under the provisions of good practice guidelines regarding their indications, effectiveness, safety, and quality control. Psychotherapy, in its broadest sense, is an accepted component of many medical interactions. In a more specific and restricted sense, psychotherapy utilizes techniques involving verbal and non-verbal communication and interaction to achieve specified treatment goals in the care of specific disorders. Psychiatrists providing specific forms of psychotherapy must have appropriate training in such techniques. The general guidelines that apply to any medical treatment also apply to specific forms of psychotherapy in regard to its indications and outcomes, positive or negative. The effectiveness of psychotherapy and its place in a treatment plan are important subjects for both researchers and clinicians.

Psychotherapy by psychiatrists is a form of treatment for mental and other illnesses and emotional problems. The treatment approach utilized is determined in concert by the doctor and patient and/or the patient's family and/or guardians following a careful history and examination employing all relevant clinical and laboratory studies. The approach employed should be specific to the disease and patient's needs and sensitive to personal, familial, religious and cultural factors. It should be based on sound research and clinical wisdom and have the purpose of removing, modifying or retarding symptoms or disturbed patterns of behavior. It should promote positive adaptations including personal growth and development.

Psychiatrists and other clinicians responsible for a patient have to ensure that these guidelines are fully applied. Therefore, the psychiatrist or other delegated qualified clinician should determine the indications for psychotherapy and follow its development. In this context the essential notion is that the treatment is the consequence of a diagnosis and both are medical acts performed to take care of an ill person. These two levels of decisions, interventions and responsibilities are similar to other situations in clinical medicine; however, this does not exclude other interventions such as rehabilitation, which can be administered by non-medical personnel.

1. Like any other treatment in medicine, the prescription of psychotherapy should follow accepted guidelines for obtaining informed consent prior to the initiation of treatment as well as updating it in the course of treatment if goals and objectives of treatment are modified in a significant way.

2. If clinical wisdom, long standing and well-established practice patterns (this takes into consideration cultural and religious issues) and scientific evidence suggest potential clinical benefits to combining medication treatment with psychotherapy this should be brought to the patient’s attention and fully discussed.

3. Psychotherapy explores intimate thoughts, emotions and fantasies, and as such may engender intense transference and counter-transference. In a psychotherapy relationship the power is unequally shared between the therapist and patient, and under no circumstances shall the psychotherapist use this relationship to personal advantage or transgress the boundaries established by the professional relationship.

4. At the initiation of psychotherapy, the patient shall be advised that information shared and health records will be kept in confidence except where the patient gives specific informed consent for release of information to third parties, or where a court order may require the production of records. The other exception is where there is a legal requirement to report certain information as in the case of child abuse.

10. Conflict of Interest in Relationship with Industry:

Although most organizations and institutions, including the WPA, have rules and regulations governing their relationship with industry and donors, individual physicians are often involved in interactions with the pharmaceutical industry, or other granting agencies that could lead to ethical conflict In these situations psychiatrists should be mindful of and apply the following guidelines.

1. The practitioner must diligently guard against accepting gifts that could have an undue influence on professional work.

2. Psychiatrists conducting clinical trials are under an obligation to disclose to the Ethics Review Board and their research subjects their financial and contractual obligations and benefits related to the sponsor of the study. Every effort should be made to set up review boards composed of researchers, ethicists and community representatives to assure the rights of research subjects are protected.

3. Psychiatrists conducting clinical trials have to ensure that their patients have understood all aspects of the informed consent. The level of education or sophistication of the patient is no excuse for bypassing this commitment. If the patient is deemed incompetent the same rules would apply in obtaining informed consent from the substitute decision maker. Psychiatrists must be cognizant that covert commercial influence on the trial design, promotion of drugs trials without scientific value, breach of confidentiality, and restrictive contractual clauses regarding publication of results may each in different ways encroach upon the freedom of science and scientific information.

11. Conflicts Arising with Third Party Players:

The obligations of organizations toward shareholders or the administrator regarding maximization of profits and minimization of costs can be in conflict with the principles of good practice Psychiatrists working in such potentially conflicting environments, should uphold the rights of the patients to receive the best treatment possible.

1. In agreement with the UN Resolution 46/119 of the “Principles for the Protection of Persons with Mental Illness, psychiatrists should oppose discriminatory practices which limit their benefits and entitlements, deny parity curb the scope of treatment, or limit their access to proper medications for patients with a mental disorder.

2. Professional independence to apply best practice guidelines and clinical wisdom in upholding the welfare of the patient should be the primary considerations for the psychiatrist. It is also the duty of the psychiatrist to protect the patient privacy and confidentiality as part of preserving the sanctity and healing potential of the doctor-patient relationship.

12. Violating the Clinical Boundaries and Trust between Psychiatrists and Patients:

The psychiatrist-patient relationship may be the only relationship that permits an exploration of the deeply personal and emotional space, as granted by the patient. Within this relationship, the psychiatrist’s respect for the humanity and dignity of the patient builds a foundation of trust that is essential for a comprehensive treatment plan. The relationship encourages the patient to explore deeply held strengths, weaknesses, fears, and desires, and many of these might be related to sexuality. Knowledge of these characteristics of the patient places the psychiatrist in a position of advantage that the patient allows on the expectation of trust and respect. Taking advantage of that knowledge by manipulating the patient’s sexual fears and desires in order to obtain sexual access is a breach of the trust, regardless of consent. In the therapeutic relationship, consent on the part of the patient is considered vitiated by the knowledge the psychiatrists possesses about the patient and by the power differential that vests the psychiatrist with special authority over the patient. Consent under these circumstances will be tantamount to exploitation of the patient.

The latent sexual dynamics inherent in all relationships can become manifest in the course of the therapeutic relationship and if they are not properly handled by the therapist can produce anguish to the patient. This anguish is likely to become more pronounced if seductive statements and inappropriate non-verbal behavior are used by the therapist. Under no circumstances, therefore, should a psychiatrist get involved with a patient in any form of sexual behavior, irrespective of whether this behavior is initiated by the patient or the therapist.

13. Protection of the Rights of Psychiatrists:

1. Psychiatrists need to protect their right to live up to the obligations of their profession and to the expectations the public has of them to treat and to advocate for the welfare of their patients.

2. Psychiatrists ought to have the right to practice their specialty at the highest level of excellence by providing independent assessments of a persons’ mental condition and by instituting effective treatment and management protocols in accordance to best practices and evidence-based medicine.

3. There are aspects in the history of psychiatry and in present working expectations in some totalitarian political regimes and profit driven economical systems that increase psychiatrists’ vulnerabilities to be abused in the sense of having to acquiesce to inappropriate demands to provide inaccurate psychiatric reports that help the system, but damage the interests of the person being assessed.

4. Psychiatrists also share the stigma of their patients and, similarly, can become victims of discriminatory practices. It should be the right and the obligation of psychiatrists to practice their profession and to advocate for the medical needs and the social and political rights of their patients without suffering being outcast by the profession, being ridiculed in the media or persecuted.

14. Disclosing the Diagnosis of Alzheimer’s Disease (AD) and Other Dementias:

AD patient’s right to know is now a well-established priority, recognised by healthcare professionals. Most patients want all information available and to be actively involved in making decision about treatments. At the same time, patients have the right also not to know if that is their wish. All must be given the opportunity to learn as much or as little as they want to know.

The alteration of patient’s cognition makes the ability to make judgements and insight more difficult. Patients with dementia are also often brought by family members which introduces into the doctor-patient relationship a third partner.

Doctors, patients and families who share the responsibilities for fighting and coping with Alzheimer’s disease for years all require access to information on the disease, including the diagnosis.

In addition to the “patient’s right to know”, telling the patient has many benefits. Patients and/or families should be told the diagnosis as early as possible in the disease process. Having family (or informal carer) involved in the discussion of the disclosure process is highly beneficial.

The physician should give accurate and reliable information, using simple language. He also should assess the patient’s and the family’s understanding of the situation. As usual, the bad news should be accompanied by information on a treatment and management plan. Information on physical or speech therapy, support groups, day care centres, and other interventions should be provided. It should also be emphasised that a reorganised family network can alleviate the carer’s burden and maintain quality of life as far as possible.

There are some exceptions, some of them transitory, to the disclosure of the diagnosis to a patient with dementia: (1) severe dementia where understanding the diagnosis is unlikely; (2) when a phobia about the condition is likely, or (3) when a patient is severely depressed;

15. Dual Responsibilities of Psychiatrists:

These situations may arise as part of legal proceedings (i.e. fitness to stand trial, criminal responsibility, dangerousness, testamentary capacity) or other competency related needs, such as for insurance purposes when evaluating claims for benefits, or for employment purposes when evaluating fitness to work or suitability for a particular employment or specific task.

During therapeutic interactions conflicting situations may arise if the physician’s knowledge of the patient’s condition cannot be kept private or when clinical notes or medical records are part of a larger employment dossier, hence not confidential to the clinical personnel in charge of the case (i.e. the military, correctional systems, medical services for employees of large corporations, treatment protocols paid by third parties).

It is the duty of a psychiatrist confronted with dual obligations and responsibilities at assessment time to disclose to the person being assessed the nature of the triangular relationship and the absence of a therapeutic doctor-patient relationship, besides the obligation to report to a third party even if the findings are negative and potentially damaging to the interests of the person under assessment. Under these circumstances, the person may choose not to proceed with the assessment.

Additionally, psychiatrists should advocate for separation of records and for limits to exposure of information such that only elements of information that are essential for purposes of the agency can be revealed.

16. Working with patients and carers

1. Legislation, policy and clinical practice relevant to the lives and care of people living with mental disorders, whenever possible, should be developed in collaboration with patients and carers.

2. The international psychiatric community should promote and support the development of patients’ organizations and carers’ organizations.

3. International and local psychiatric organizations, including WPA through its programs and member societies, are expected to seek the involvement of patients and carers in their activities where appropriate.

4. The best clinical care of any person in acute or rehabilitation situations is done in collaboration between the patient, the carers and the clinicians.

5. WPA member societies and other psychiatric organizations should collaborate with patients’ organizations, carers’ organizations and other community organizations to lobby governments for political will and action for better funding of services, community education and fighting stigma.

6. Each country needs specific guidelines in order to apply these recommendations.

NOTA STORICA  SUL LAVORO DELLA WPA NEL CAMPO DELL'ETICA
The Declaration of Hawaii issued by the World Psychiatric Association in 1977 and updated in 1983 in Vienna was initiated because of political abuse of psychiatry in some countries in the seventies. This led to a long process of investigation and concern within the domain of professional ethics and paved the ground for the Declaration of Madrid which was endorsed by the General Assembly of the World Psychiatric Association in Madrid in 1996. In its final form, the Declaration of Madrid [Espanol] includes seven general guidelines that focus on the aims of psychiatry namely to treat mentally ill patients, prevent mental illness, promote mental health and provide care and rehabilitation for mentally ill patients.

The Declaration prohibits abuse and that treatment be provided against a patient's will unless such treatment is necessary for the welfare and safety of the patient and others. Emphasis is placed on advising the patient or caregiver of all details of management, and informing him or her about confidentiality and the ethics of research. An appendix to the declaration includes guidelines on specific ethical issues in psychiatry (i.e., euthanasia, torture, the death penalty, sex selection and organ transplantation), as well as a summary of the 1991 United Nations resolutions on the rights of patients with mental illness. Issues of patient consent and autonomy are addressed in the Declaration of Madrid, and absolute commitment to patient welfare and condemnation of abuse by political institutions or other parties are evident in the declaration and its appendices.

In 1999 three other guidelines were endorsed addressing ethnic discrimiantion, genetic counselling and addressing the mass media. Further issues that are pending for discussion by the WPA Ethics Committee are the ethics of psychotherapy, the ethics of the conflict of interest in relationship with industry and the ethics of conflicts arising with third party payers. We believe that implementation of codes of ethics is frequently difficult because of the cultural and social setups in which the attempts at implementation are being made. These difficulties stem not only from interactions among individuals, families, and the community but also from the social position of the medical doctor and the hierarchical structure of the medical profession vis-à-vis the rest of the community. Religion and other beliefs also have an effect on the lives and behavior of people.

The development and implementation of ethical guidelines require attention to cultural sensitivity. For example, in Eastern cultures, social integration is emphasized more than autonomy; that is, the family, not the individual, is the unit of society. Dependence is more natural and infirmity is less alien in these cultures. When affiliation is more important than achievement, how one appears to others becomes vital and shame, rather than guilt, becomes a driving force. In the same manner, physical illness and somatic manifestations of psychological distress become more understood and acceptable and evoke a caring response. In some traditional cultures the collectivity of the community is valued rather than the individuality of its members. Decisions are made not at an individual level but on a familial, tribal or communal level, in the best perceived collective interest.

How can we adhere to our ethical guidelines and at the same time not disregard the local values and norms of our target population? How can we practice without showing disrespect or disregard for local values? On the other hand, how can we ensure that respect for the local culture does not become a pretext for bypassing ethical guidelines, to the detriment of the patients' rights?

The Declaration of Madrid and its specific guidelines are dynamic that it can address any challenges that may face psychiatrists from the ethical point of view. The WPA Ethics Committee welcome suggestions from Member Societies or individual Members to study any specific ethical issues facing the progressive development and changes in Medicine related to psychiatry.

A book published by American Psychiatric Press 2000, edited by Okasha et al "Ethics, Culture, and Psychiatry: International Perspectives" discusses the similarity and diversity of cultures in implementing the Declaration of Madrid and other ethical issues.

A forum on the Declaration of Madrid and Current Psychiatric Practice was published in Current Opinion in Psychiatry Vol. 12 No. Jan. 1999 where users and advocates views were addressed with the Ethics Committee of the WPA.