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
and by the 66th 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 21st 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.