Competence and Decision-Making: Ethics and Clinical Psychiatric Practice.
Ethical issues in clinical psychiatry rarely give rise to easy decisions. The application of general ethical issues in psychiatry is more complicated than in other health areas, requiring an assessment of the patient’s clinical presentation, community and cultural circumstances as well as legal principles and patient rights. The practising mental health professional must recognise the extent of this responsibility, not only to the patient but to the community as a whole. Lists of guidelines and standards merely provide advice as to procedures, e.g. the Principles of Medical Ethics of the American Medical Association (1) and the Madrid Declaration of the World Psychiatric Association. (2) Often there are conflicting views, and the clinician is required to make a decision by balancing the principles. This is particularly challenging given the extreme vulnerability of the acutely mentally ill patient. These conflicts relate to overall management, treatments and levels of participation in decision-making. The major influences in the clinical arena are the question of the patient’s competency (partial, specific to the situation, or complete lack). Competence may be considered as the umbrella under which all other issues are dependent. This is closely related to decision-making capacity in broad approach and among other things relates to beneficence, autonomy, informed consent and confidentiality. Clinical applications