Diagnostic staging and stratification in psychiatry and oncology: clarifying their conceptual, epistemological and ethical implications.

Staging and stratification are two diagnostic approaches that have introduced a more dynamic outlook on the development of diseases, thus participating in blurring the line between the normal and the pathological. First, diagnostic staging, aiming to capture how diseases evolve in time and/or space through identifiable and gradually more severe stages, may be said to lean on an underlying assumption of "temporal determinism". Stratification, on the other hand, allows for the identification of various prognostic or predictive subgroups based on specific markers, relying on a more "mechanistic" or "statistical" form of determinism. There are two medical fields in which these developments have played a significant role and have given rise to sometimes profound nosological transformations: oncology and psychiatry. Drawing on examples from these two fields, this paper aims to provide much needed conceptual clarifications on both staging and stratification in order to outline how several epistemological and ethical issues may, in turn, arise. We argue that diagnostic staging ought to be detached from the assumption of temporal determinism, though it should still play an essential role in adapting interventions to stage. In doing so, it would help counterbalance stratification's own epistemological and ethical shortcomings. In this sense, the reflections and propositions developed in psychiatry can offer invaluable insights regarding how adopting a more transdiagnostic and cross-cutting perspective on temporality and disease dynamics may help combine both staging and stratification in clinical practice.

Comparing the World Psychiatric Association and European Psychiatric Association Codes of Ethics: Discrepancies and shared grounds.

BACKGROUND: Codes of ethics provide guidance to address ethical challenges encountered in clinical practice. The harmonization of global, regional, and national codes of ethics is important to avoid gaps and discrepancies. METHODS: We compare the European Psychiatric Association (EPA) and the World Psychiatric Association (WPA) Codes of Ethics, addressing main key points, similarities, and divergences. RESULTS: The WPA and EPA codes are inspired by similar fundamental values but do show a few differences. The two codes have a different structure. The WPA code includes 4 sections and lists 5 overarching principles as the basis of psychiatrists' clinical practice; the EPA code is articulated in 8 sections, lists 4 ethical principles, and several fundamental values. The EPA code does not include a section on psychiatrists' education and does not contain specific references to domestic violence and death penalty. Differences can be found in how the two codes address the principle of equity: the EPA code explicitly refers to the principle of universal health care, while the WPA code mentions the principle of equity as reflected in the promotion of distributive justice. CONCLUSIONS: We recommend that both WPA and EPA periodically update their ethical codes to minimize differences, eliminate gaps, and help member societies to develop or revise national codes in line with the principles of the associations they belong to.Minimizing differences between national and international codes and fostering a continuous dialogue on ethical issues will provide guidance for psychiatrists and will raise awareness of the importance of ethics in our profession.

Contribution of ethical reasoning learning sessions on medical training.

INTRODUCTION: Ethical reasoning is an important skill for all physicians who often face complex ethical dilemmas in their daily practice. Therefore, medical training should include methods for learning ethical theories and concepts, as well as how to apply them in practical situations. AIM: Assess the contribution of an Ethical Reasoning Learning session to fifth medical students' training through a comparison of results of the same objective and structured clinical examination (OSCE) in the form of simulated interview before and after sessions. METHODS: Four 45- minutes' sessions of Ethical Reasoning Learning (ERL) were implemented during a psychiatry internship for four groups of 5th-year students of the faculty of medicine of Monastir (Tunisia). Each session was divided into 7 parts: introduction, reading of a clinical vignette, brainstorming concerning the problems posed by this clinical situation, classification of the problems, identification of the principles of medical ethics, construction of the ethical matrix, and a conclusion. RESULTS: Fifty-seven students participated in the study divided into 4 groups. We found a significant difference in the means of the OSCE scores before and after the ERL session and a significant difference between the probability of respecting medical secrecy during pre and post-ethical reasoning learning sessions (p <0.001). We have found an effect of ERL sessions on the acquisition of this ethical competence by medical students. CONCLUSION: We learned that an ERL session has improved medical training in ethics applied to psychiatry. Other sessions dealing with other ethical skills are necessary to confirm these results.

[Advance directives and mental disorders: a practice recommendation of the Commission for Ethics and Law of the German Association for Psychiatry, Psychotherapy and Psychosomatics]. / Patientenverfügungen und psychische Erkrankung ­ eine Praxisempfehlung der Kommission Ethik und Recht der DGPPN.

BACKGROUND: Since the creation of legal requirements for advance directives by the legislator in 2009, special aspects of their application in the treatment of people with mental illnesses have been discussed. GOAL OF THE PAPER: Important questions on dealing with advance directives in everyday life will be answered in a practice-oriented manner. RESULTS: Among other things, this document answers the question of the conditions under which a patient can refuse or consent to hospitalization and treatment in advance, and in particular how to deal with advance directives whose implementation would also affect the rights of third parties. The German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) has addressed these and other questions in the present document and added practical advice on how to formulate advance directives for people with mental illnesses and how to deal with psychiatric advance directives. DISCUSSION: The DGPPN has developed an advance directive for the area of mental health and published it on its website together with detailed explanations. With the help of this advance directive, people can decide on their treatment in phases of incapacity to consent in the context of a mental crisis or illness.

[Historical comments on ethics in psychiatry : Challenges in the 19th century]. / Historische Anmerkungen zur Ethik in der Psychiatrie : Herausforderungen im 19. Jahrhundert.

With the emergence of an early psychiatry around 1800, a number of questions arose on dealing with a group of persons whose "alien", irritating and disruptive behavior was considered to be a phenomenon of being sick. In the context of the growing importance of human rights, the term humanitarianism attained a high relevance as the reference for early psychiatrists. Based on historical sources it is shown that despite a multitude of psychiatric beliefs on humanitarianism the established psychiatric practice was dominated by patriarchal order regimes up to the first decade of the twentieth century, later superimposed by the challenges of somatophysiological and experimental research as well as perceptions of biological racism. The associated new ethical questions were partially addressed within psychiatry but did not prevent an increase in the assessment of the mentally ill as "inferior".

[Historical aspects of ethics in psychiatry : From the end of humanitarianism up to the Human Rights Convention]. / Historisches zur Ethik in der Psychiatrie : Vom Ende der Humanität zur Menschenrechtskonvention.

The establishment of academic psychiatry was completed around 1900. Simultaneously, in view of the societal crisis phenomenon the professional self-concept of the psychiatrist was shifted to a self-image, according to which psychiatry had to place its expertise at the service of the people and the country. This was particularly expressed in World War I in the brutal dealing with the so-called war neurotics. In association with the so-called death by starvation of ca. 70,000 institution inmates, in the post-war period Karl Bonhoeffer debated a transformation of the term humanitarianism. The worst consequence of the rejection of humanitarian thoughts are the murders of invalids under National Socialism; however, legitimization of such crimes by alluding to collective ethics, as attempted by Karl Brandt, seems to be less than convincing. The reform of psychiatry initiated in the 1960s and the United Nations Convention on the Rights of Persons with Disabilities, which came into force in 2008, have achieved prerequisites for a supportive psychiatry with reduced coercion, whereby many questions also in the legal and social systems must still be clarified.

Post-Roe v Wade psychiatry: legal, clinical, and ethical challenges in psychiatry under abortion bans.

In recent history, the world has witnessed a trend towards liberalization of abortion laws driven by an increasing understanding of the negative personal and public health consequences of criminalizing abortion. By contrast, several countries have recently implemented restrictive reproductive laws, joining the 112 countries where access to abortion care is banned completely or with narrow exceptions. On June 24, 2022, the US Supreme Court ruling in Dobbs v Jackson Women's Health Organization overturned its landmark decisions in Roe v Wade that established abortion until the point of viability of the fetus as a constitutional right. After Roe v Wade having been overturned, it is projected that many women in the USA will be prevented from accessing safe abortion care. Importantly, abortion bans not only impose constraints on patient autonomy, they also restrict physicians' ability to practice evidence-based medicine, which will negatively impact psychiatric care. It is therefore crucial for the practicing psychiatrist to be familiar with this new legal landscape. In this Personal View, we aim to provide a topical overview to help clinicians gain a clear understanding of legal, clinical, and ethical responsibilities, focusing on the USA. We also discuss the reality that psychiatrists might be called upon to determine medical necessity for an abortion on psychiatric grounds, which is new for most US psychiatrists. We predict that psychiatrists will be confronted with very difficult situations in which lawful and ethical conduct might be incongruent, and that abortion bans will result in greater numbers of patients needing psychiatric care from a system that is ill-prepared for additional demands.

Navigating merits and limits on the current perspectives and ethical challenges in the utilization of artificial intelligence in psychiatry - An exploratory mixed methods study.

BACKGROUND: The integration of Artificial Intelligence (AI) in psychiatry presents opportunities for enhancing patient care but raises significant ethical concerns and challenges in clinical application. Addressing these challenges necessitates an informed and ethically aware psychiatric workforce capable of integrating AI into practice responsibly. METHODS: A mixed-methods study was conducted to assess the outcomes of the "CONNECT with AI" - (Collaborative Opportunity to Navigate and Negotiate Ethical Challenges and Trials with Artificial Intelligence) workshop, aimed at exploring AI's ethical implications and applications in psychiatry. This workshop featured presentations, discussions, and scenario analyses focusing on AI's role in mental health care. Pre- and post-workshop questionnaires and focus group discussions evaluated participants' perspectives, and ethical understanding regarding AI in psychiatry. RESULTS: Participants exhibited a cautious optimism towards AI, recognizing its potential to augment mental health care while expressing concerns over ethical usage, patient-doctor relationships, and AI's practical application in patient care. The workshop significantly improved participants' ethical understanding, highlighting a substantial knowledge gap and the need for further education in AI among psychiatrists. CONCLUSION: The study underscores the necessity of continuous education and ethical guideline development for psychiatrists in the era of AI, emphasizing collaborative efforts in AI system design to ensure they meet clinical needs ethically and effectively. Future initiatives should aim to broaden psychiatrists' exposure to AI, fostering a deeper understanding and integration of AI technologies in psychiatric practice.

Ethical perspectives regarding Euthanasia, including in the context of adult psychiatry: a qualitative interview study among healthcare workers in Belgium.

INTRODUCTION: Previous research has explored euthanasia's ethical dimensions, primarily focusing on general practice and, to a lesser extent, psychiatry, mainly from the viewpoints of physicians and nurses. However, a gap exists in understanding the comprehensive value-based perspectives of other professionals involved in both somatic and psychiatric euthanasia. This paper aims to analyze the interplay among legal, medical, and ethical factors to clarify how foundational values shape the ethical discourse surrounding euthanasia in both somatic and psychiatric contexts. It seeks to explore these dynamics among all healthcare professionals and volunteers in Belgium. METHODS: Semi-structured interviews were conducted with 30 Dutch-speaking healthcare workers who had encountered patients requesting euthanasia for psychiatric conditions, in Belgium, from August 2019 to August 2020. Qualitative thematic analysis was applied to the interview transcripts. FINDINGS: Participants identified three pivotal values and virtues: religious values, professional values, and fundamental medical values encompassing autonomy, beneficence, and non-maleficence, linked to compassion, quality care, and justice. These values interwove across four tiers: the patient, the patient's inner circle, the medical realm, and society at large. Irrespective of their euthanasia stance, participants generally displayed a blend of ethical values across these tiers. Their euthanasia perspective was primarily shaped by value interpretation, significance allocation to key components, and tier weighting. Explicit mention of varying ethical values, potentially indicating distinct stances in favor of or against euthanasia, was infrequent. CONCLUSION: The study underscores ethical discourse's central role in navigating euthanasia's intricate landscape. Fostering inclusive dialogue, bridging diverse values, supports informed decision-making, nurturing justice, and empathy. Tailored end-of-life healthcare in psychiatry is essential, acknowledging all involved actors' needs. The study calls for interdisciplinary research to comprehensively grasp euthanasia's multifaceted dimensions, and guiding policy evolution. While contextualized in Belgium, the implications extend to the broader euthanasia discourse, suggesting avenues for further inquiry and cross-cultural exploration.

The gender-affirming model of care is incompatible with competent, ethical medical practice.

OBJECTIVE: To examine the compatibility of gender-affirming care with the principles and practices of psychiatry. CONCLUSIONS: The assumption that there is no pathology involved in the development of gender diversity is a necessary precondition for the unquestioning affirmation of self-reported gender identity. Cases where psychosis is the undeniable cause of gender diversity demonstrate this assumption is categorically false. To protect this false assumption, gender-affirming guidelines forbid the application of the core psychiatric competencies of phenomenology and psychopathology to the assessment of gender diversity. They substitute the political goal of expanding personal liberty for the evidence-based medicine processes of clinical reasoning, rendering them incompatible with competent, ethical medical practice.

Crisis y encrucijadas de una psiquiatría en busca de futuro / The crisis and crossroads experienced by a psychiatry in search of the future

Asumiendo la metáfora de la encrucijada, propuesta por Santiago Levín, en la que estaría situada la psiquiatría en la actualidad, el presente artículo pretende reflexionar sobre algunos aspectos de una crisis paradigmática de la medicina mental que ha hecho a algunos temer por su futuro. Se abordan algunas cuestiones epistemológicas de cierto calado, como el régimen de "verdad" en el que supuestamente deben manejarse los expertos, así como los dilemas planteados en los dos elementos clave del encuentro clínico: el diagnóstico y el tratamiento. Finalmente, se insiste en la importancia de lo ético, lo social, y lo político a la hora de replantear saberes y prácticas. (AU)

On the understanding we accept where psychiatry would today be located in the metaphor of the crossroads, as proposed by Santiago Levín, the purpose of this article is to explore certain aspects of a paradigmatic crisis in mental medicine that has raised some concerns as to its future. Certain deep epistemological questions are addressed, such as the schema of "truth", where experts should supposedly manage themselves, and the dilemmas raised from the two key elements of a clinical session: diagnosis and treatment. Finally, the study emphasises the importance of the ethical, social, and political aspects of rethinking knowledge and practices. (AU)

Ethical perspective of covert medication in psychiatry.

Schizophrenic patients deny health care due to lack of insight in many cases. In such situations most of the psychiatrists opt for covert medication in consultation with the families. Covert medication has legal and ethical implications. Moreover, it has certain clinical implications for the patient. In addition, how long the covert medication can be continued and when should it be revealed to the patient are questions that cannot be answered in black and white. This article is a commentary on a real scenario of covert medication in ethical perspective.