Ethical dangers of facial phenotyping through photography in psychiatric genomics studies.

Psychiatric genomics research protocols are increasingly incorporating tools of deep phenotyping to observe and examine phenotypic abnormalities among individuals with neurodevelopmental disorders. In particular, photography and the use of two-dimensional and three-dimensional facial analysis is thought to shed further light on the phenotypic expression of the genes underlying neurodevelopmental disorders, as well as provide potential diagnostic tools for clinicians. In this paper, I argue that the research use of photography to aid facial phenotyping raises deeply fraught issues from an ethical point of view. First, the process of objectification through photographic imagery and facial analysis could potentially worsen the stigmatisation of persons with neurodevelopmental disorders. Second, the use of photography for facial phenotyping has worrying parallels with the historical misuse of photography to advance positive and negative eugenics around race, ethnicity and intellectual disability. The paper recommends ethical caution in the use of photography and facial phenotyping in psychiatric genomics studies exploring neurodevelopmental disorders, outlining certain necessary safeguards, such as a critical awareness of the history of anthropometric photography use among scientists, as well as the exploration of photographic methodologies that could potentially empower individuals with disabilities.

Agency, embodiment and enactment in psychosomatic theory and practice.

In this paper, we examine some of the conceptual, pragmatic and moral dilemmas intrinsic to psychosomatic explanation in medicine, psychiatry and psychology. Psychosomatic explanation invokes a social grey zone in which ambiguities and conflicts about agency, causality and moral responsibility abound. This conflict reflects the deep-seated dualism in Western ontology and concepts of personhood that plays out in psychosomatic research, theory and practice. Illnesses that are seen as psychologically mediated tend also to be viewed as less real or legitimate. New forms of this dualism are evident in philosophical attacks on Engel's biopsychosocial approach, which was a mainstay of earlier psychosomatic theory, and in the recent Research Domain Criteria research programme of the US National institute of Mental Health which opts for exclusively biological modes of explanation of illness. We use the example of resignation syndrome among refugee children in Sweden to show how efforts to account for such medically unexplained symptoms raise problems of the ascription of agency. We argue for an integrative multilevel approach that builds on recent work in embodied and enactive cognitive science. On this view, agency can have many fine gradations that emerge through looping effects that link neurophenomenology, narrative practices and cultural affordances in particular social contexts. This multilevel ecosocial view points the way towards a renewed biopsychosocial approach in training and clinical practice that can advance person-centred medicine and psychiatry.

[Psychiatric treatment--legal aspects]. / Rechtliche Aspekte einer Behandlung in der Psychiatrie.

Doctors want to save lives and promote health. But their patients have the right to decide for themselves about what doctors do with them, and they are free to refuse treatment, even if it is unreasonable from a medical perspective. The law acknowledges this freedom even if a patient is incapable of responsible self-determination as a result of (mental) illness. Treatment contrary to the patient's declared intention will be allowed only under specific, narrow circumstances. These requirements must be legally established in a clear and precise manner.

[Involuntary treatment in psychiatry]. / Zwangsunterbringung und Zwangsbehandlung in der Psychiatrie.

Involuntary treatment in psychiatry should be reflected under the German constitutional right of self-determination und the ethical principles of autonomy and beneficience. Forced treatment in psychiatry should be applied only as a last resort. A narrative perspective reconstructs the case of Gustl Mollath who was hospitalized in forensic-psychiatric institutions because of an alleged delusion. Psychiatric experts should be aware of the potential of misuse when defining what is real and what seems to be a delusion.

Placebos in clinical practice: comparing attitudes, beliefs, and patterns of use between academic psychiatrists and nonpsychiatrists.

Controversial and ethically tenuous, the use of placebos is central to medicine but even more pivotal to psychosocial therapies. Scholars, researchers, and practitioners largely disagree about the conceptualization of placebos. While different professionals often confound the meanings of placebo effects with placebo responses, physicians continue to prescribe placebos as part of clinical practice. Our study aims to review attitudes and beliefs concerning placebos outside of clinical research. Herein we compare patterns of placebo use reported by academic psychiatrists with those reported by physicians from different specialties across Canadian medical schools. Using a web-based tool, we circulated an online survey to all 17 Canadian medical schools, with a special emphasis on psychiatry departments therein and in university-affiliated teaching hospitals. A variation on earlier efforts, our 5-minute, 21-question survey was anonymous. Among the 606 respondents who completed our online survey, 257 were psychiatrists. Our analysis revealed that psychiatrists prescribed significantly more subtherapeutic doses of medication than physicians in other specialties, although about 20% of both psychiatrists and nonpsychiatrists prescribed placebos regularly as part of routine clinical practice. However, compared with 6% of nonpsychiatrists, only 2% of psychiatrists deemed placebos of no clinical benefit. In addition, more than 60% of psychiatrists either agreed or strongly agreed that placebos had therapeutic effects relative to fewer than 45% of other practitioners. Findings from this pan-Canadian survey suggest that, compared with other physicians, psychiatrists seem to better value the influence placebos wield on the mind and body and maintain more favourable beliefs and attitudes toward placebo phenomena.

'What would you do if you were me, doctor?': randomised trial of psychiatrists' personal v. professional perspectives on treatment recommendations.

BACKGROUND: If patients are unsure whether a specific treatment is really good for them, they often pose the question, 'What would you do if you were me, doctor?' Patients want their psychiatrists to put themselves in their shoes and not to give a 'standard recommendation'. AIMS: To study whether this question really leads psychiatrists to reveal their personal preferences. METHOD: Randomised experimental study with 515 psychiatrists incorporating two decision scenarios (depression scenario: antidepressant v. watchful waiting; schizophrenia scenario: depot v. oral antipsychotic) and three experimental conditions (giving a recommendation to a patient asking, 'What would you do if you were me, doctor?'; giving a regular recommendation to a patient without being asked this question; and imagining being ill and deciding for yourself). Main outcome measures were the treatments chosen or recommended by physicians. RESULTS: Psychiatrists choosing treatment for themselves predominantly selected other treatments (mostly watchful waiting and oral antipsychotics respectively) than what psychiatrists recommended to patients when asked in the 'regular recommendation role' (i.e. antidepressant and depot respectively). Psychiatrists in the 'what-would-you-do role' gave recommendations similar to the 'regular recommendation role' (depression scenario: χ(2) = 0.12, P = 0.73; schizophrenia scenario: χ(2) = 2.60, P = 0.11) but distinctly different from the 'self role'. CONCLUSIONS: The question 'What would you do if you were me, doctor?' does not motivate psychiatrists to leave their professional recommendation role and to take a more personal perspective. Psychiatrists should try to find out why individuals are asking this question and, together with the individual, identify the most appropriate treatment option.

End-of-life care education for psychiatric residents: attitudes, preparedness, and conceptualizations of dignity.

OBJECTIVE: The authors examined psychiatric residents' attitudes, perceived preparedness, experiences, and needs in end-of-life care education. They also examined how residents conceptualized good end-of-life care and dignity. METHODS: The authors conducted an electronic survey of 116 psychiatric residents at the University of Toronto. The survey had a mix of qualitative and quantitative questions. RESULTS: Eighty-two of 116 invited psychiatric residents participated for a response rate of 71%. With favorable attitudes, residents felt least prepared in existential, spiritual, cultural, and some psychological aspects of caring for dying patients. Trainees conceptualized dignity at the end of life in a way very similar to that of patients, including concerns of the mind, body, soul, relationships, and autonomy. Residents desired more longitudinal, contextualized training, particularly in the psychosocial, existential, and spiritual aspects of care. CONCLUSION: This is the first study to examine the end-of-life educational experience of psychiatric residents. Despite conceptualizing quality care and the construct of dignity similarly to dying patients, psychiatric residents feel poorly prepared to deliver such care, particularly the nonphysical aspects of caring for the dying. These results will inform curriculum development in end-of-life care for psychiatric residents, a complex area now considered a core competency.

Psychiatry for the person.

PURPOSE OF REVIEW: This review considers much recent work focused around the Psychiatry for the Person Programme of the World Psychiatric Association. Yet we have also considered the wider medical context, based on recent publications familiar to us in the fields of ethics, religion, spirituality and person-centred medicine as well as 'medicine of the person' as developed by Tournier. RECENT FINDINGS: There is an urgent need for evaluative outcome studies of person-centred care, including the narratives of service users, rigorous scientific methods and new conceptual models; and for a reformulation of the bio-psychosocial model to incorporate new knowledge in the neurosciences, philosophy, anthropology, ethics and theology. SUMMARY: We suggest that a biosocial/psychospiritual (BSPS) approach to relationship-based healthcare should be more actively considered.

A basic decision-making approach to common ethical issues in consultation-liaison psychiatry.

Ethical dilemmas are found throughout the daily work of C-L psychiatrists. Unfortunately, most psychiatrists have no more training in ethics than their nonpsychiatric colleagues. Psychiatric consults spurred by ethical dilemmas can provoke anxiety in psychiatrists and leave anxious colleagues without the clear recommendations they seek. C-L psychiatrists, and probably all psychiatrists, need more training in clinical ethics. C-L psychiatrists do not need to become clinical ethicists, but competence in handling the ethical issues most commonly seen in C-L work is needed. The 2008 ABPN guidelines for specialists in psychosomatic medicine mention specific ethics topics important in C-L work, and ways of attaining competence in these areas have been discussed in the C-L literature. The four cases discussed here illustrate the high level of complexity often seen in situations in which ethical dilemmas arise in C-L psychiatry. Given the sometimes furious pace of hospital work, it can be easy for C-L psychiatrists to be seduced by the idea of the quick, focused consult that simply responds to a simple question with a simple answer. Because cases involving ethical dilemmas often involve multiple stakeholders, each with his or her own set of concerns, a brief consult focused only on the patient often leads to errors of omission. A wider approach, such as that suggested by the Four Topics Method, is needed to successfully negotiate ethical dilemmas. Busy C-L psychiatry services may struggle at first to find the time to do the type of global evaluations discussed here, but increasing familiarity with approaches such as the Four Topics Method should lead to quicker ways of gathering and processing the needed information.

Ethical and cultural considerations in delivering psychiatric diagnosis: reconciling the gap using MDD diagnosis delivery in less-acculturated Chinese patients.

Talking to patients from diverse cultural backgrounds about their psychiatric disorders requires knowledge of one's own culture, the patients' cultures, and the ways in which they might interact, both in positive and unexpectedly negative ways. In this paper, we discuss the issues raised by discussing psychiatric diagnoses with Chinese-Americans who hold traditional illness beliefs and are not familiar with Western conceptions of psychiatric disorders. We explore how cultural values influence this aspect of medical practice, and suggest practical approaches to communicating the diagnosis of major depressive disorder in a culturally sensitive manner. Our clinical approach is to develop co-constructed illness narratives with patients, and to aid this process by reframing different elements of the clinical process into more culturally resonant forms. The following steps are suggested: 1) elicit patient's illness beliefs; 2) understand and acknowledge multiple explanatory models; 3) contextualize depressive symptoms into patient's physical health and social system; 4) introduce Western psychiatric theories in ways that reflect assumptions shared by Traditional Chinese Medicine (TCM); 5) involve patients' families whenever possible; and 6) use terminology that avoids unintended stigma.

Towards an evidence-based 'Medicine of the Person': the contribution of psychiatry to health care provision.

The purpose of this essay is to outline how the conceptual and clinical approaches of psychiatry contribute to increased understanding about the nature of evidence, and the art and science of medicine. It is based on the author's search for a more integrative medicine, the influence of Paul Tournier's 'Medicine de la Personne' and the Institutional Programme on Psychiatry for the Person led by the World Psychiatric Association. Evidence to support this approach from palliative care and general practice is cited, but new educational and research initiatives from other international organizations, such as the World Medical Association, the World Federation for Medical Education and the World Association of Family Practice and the medical Royal Colleges, are proposed.

Psychiatric education and simulation: a review of the literature.

OBJECTIVES: Simulation methodologies are integral to health professional education at all levels of training and across all disciplines. This article reviews the literature on simulation in psychiatric education and explores recent innovations and emerging ethical considerations related to teaching and evaluation. METHOD: The authors searched the MEDLINE, ERIC, and PsycINFO databases from 1986 to 2006 using multiple search terms. A detailed manual search was conducted of Academic Psychiatry, Academic Medicine, and Medical Education. Literature indirectly relevant to the search parameter was also included. RESULTS: Of the more than 5000 articles retrieved from the literature on simulation and health professional education, 72 articles and books used the terms simulation and standardized patients or role play and psychiatry education. Of the more than 900 articles on objective structured clinical examinations (OSCE), 24 articles related specifically to psychiatry OSCEs. CONCLUSIONS: Live simulation is used in teaching, assessment, and research at all levels of training in psychiatric education. Simulated and standardized patients are useful and appropriate for teaching and assessment and are well accepted at both undergraduate and post-graduate level. There is also an important place for role play. Further research is needed regarding the implications of different simulation technologies in psychiatry.

DNR versus DNT: clinical implications of a conceptual ambiguity: a case analysis.

Psychiatrists who practice psychosomatic medicine are routinely called upon to help resolve ethical dilemmas that arise in the care of patients near the end of their lives. Psychosomatic-medicine psychiatrists may be of unique value in these situations because of the clinical insights that we bring to the care of the dying patient. In particular, our subspecialty brings expertise related to the evaluation of decisional capacity of patients who are faced with accepting or declining end-of-life clinical interventions, such as resuscitation and intubation. In this first entry in a new bioethics case series in Psychosomatics, we will lay the groundwork for examining a complex patient case and provide an illustrative analysis of the end-of-life care issues that may be addressed by psychiatrists who practice psychosomatic medicine.

Consultation-liaison psychiatrists on bioethics committees: opportunities for academic leadership.

OBJECTIVE: This article briefly reviews the history of the relationship between psychiatry and the leadership of ethics committees as a background for examining appropriate educational initiatives to adequately prepare residents and early career psychiatrists to serve as leaders of ethics committees. METHOD: A Medline review of literature on psychiatry and ethics committees and consultation as well as recent survey data from the Academy of Psychosomatic Medicine indicate that psychosomatic medicine psychiatrists are particularly qualified and interested in serving as chairs of ethics committees. The authors compare knowledge and skills obtained in psychiatric training with the Society for Heath and Human Values and the Society for Bioethics Consultation Task Force on standards for ethics consultation proposed as core competencies for ethics committee leadership. RESULTS: Psychiatric residency and fellowship training in psychosomatic medicine can provide the knowledge and skill sets to meet the standards for ethics consultation. Further professional development through pursuit of formal ethics training, advance degrees in bioethics, mentoring, and residency and felloships focus on ethics and enhance competency, confidence, and the skills required for ethics committee leadership. CONCLUSIONS: Academic psychiatrists, particularly those in psychosomatic medicine, have historically made a significant contribution as chairs of ethics committees. Continuation and expansion of this leadership may require interested psychiatrists to obtain additional training in bioethics.

Ethical considerations in the integration of religion and psychotherapy: three perspectives.

The authors maintain that the integration of religion in psychotherapy is, at best, problematic and requires a respect for boundaries, but that the integration of a nonreligious but spiritual psychotherapy consisting of the three elements identified above (attention to the person, not the disease, considering one's work as vocation, and the pursuit of empathic understanding) is a therapeutic necessity and an ethical duty. The authors speak with distinct voices in the three major sections of the article but come to remarkably similar conclusions: (1) the ability to inquire into the religious and spiritual life of patients is an important element of psychotherapeutic competency; (2) information about the religious and spiritual lives of patients often reveals extremely important information; (3) the inquiry process must communicate respect and curiosity for this dimension of the patient's life even (and perhaps especially) when the content is at variance from that of the therapist; and (4) there is significant potential for therapeutic abuse when the therapist communicates in a manner reflecting a personal agenda that abandons the principle of psychotherapeutic neutrality. One area of potential disagreement came as the authors considered the possibility of different combinations of faith disciplines and therapy in designated religious settings that all parties recognize as such. One author (G.P.M.) believes that such combinations in these settings may be ethically permissible. The other two authors are concerned about such combinations because of the powerful but covert factor of transference in healing relationships. The authors eventually decided that this question was beyond the scope of the article and limited themselves to discussions about psychotherapy in secular settings. They each advocate the systematic inclusion of spiritual assessment as a core competency for psychotherapy education. In a way similar to the exploration of any deeply personal dimension of human experience, integrating spiritual and religious dimensions of our patients' lives into their treatment requires consummate professionalism, the highest quality of knowledge, skills, and attitudes, and thorough grounding in a sophisticated biopsychosocial model.