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The insight of clinicians regarding the psychiatric health service (legal and ethical aspects).

INTRODUCTION

Mental health is of important concern not only in Romania, but also in the whole world. On a global level the World Health Organization estimates an alarming increase of mental disorders, highlighting that one out of four patients who addresses a health service provider has a mental or a personality disorder.

Mental health legislation is necessary to a society in order to protect the socially vulnerable individuals with mental disorders. In psychiatry, as in other medical fields, ethical problems are encountered both in research and in clinical practice. Within the psychiatric service there are two different ways of admission: with consent (voluntary) and without consent (non-voluntary). In the last 50 years radical changes have arose in many countries. From a psychiatric health service point of view, the changes draw in new ethical problems. At the present day psychiatric patients have the same rights as the patients suffering from other non-psychiatric diseases, including the right to a confidential patient-doctor relationship.

A good understanding and appreciation of the main ethical aspects that appear in the medical practice of a psychiatrist ingrain him with ethical conduct from a professional perspective. A therapeutic relationship built on ethical grounds leads to a better valorisation of the psychiatric patient as a human being with rights and obligations, feelings, failures and accomplishments, without us being guided by protocols.

Apart from the legal and ethical aspects regarding non-voluntary admissions, there are many different opinions regarding the problems concerning voluntary admissions, implicitly the way of obtaining a valid informed consent. Informed consent is a formal act of agreement, free and undamaged, given by a person with judgement.

Discriminated persons and groups of persons are attested in the oldest written documents of humanity (1). Social stigma is a relational and dynamical process (2). The traits of social stigma depend on the society and the time in which they appear. Some forms are obvious (e.g. obesity, skin colour), others are relatively hidden (homosexuality, mentally ill persons) (3). The social stigma process (4) arises when the individual is deviant, process which implies numerous negative stereotypes. Social media bears an important role regarding this process, due to its power to associate mental illness with notions like: incompetence, violence, guilt. Frequently, through stigma, the patient is discriminated against and harmed (5). Mass-media plays an important role in the process of stigmatization of the mentally ill, especially through informational broadcasts, which erroneously highlight criminal behaviour, unpredictability, and dangerousness (6). In our society this category of patients attracts the highest level of social stigma, thus rendering them to social pressure.

According to Crocker, the process of stigmatization is oriented on three dimensional axes within the social relations and interactions: perspective, identity and reaction. Perspective refers to the perception of the society or the mentally ill patients regarding stigmatization. Identity implies affiliation to a group and reaction is the result of stigma (7). Moreover, the characteristics of stigma (visibility, suggestibility and impact) are important aspects in the process of stigmatization (8).

Stigmatization, which is a complex process within society, has multiple ethical implications (9). The stigmatized patient can have difficulties upon employment (10), is discriminated against, and one's access to health services is hindered. Although multiple studies show that mentally ill persons do not have more antisocial acts than non-mentally ill persons, the former are unjustly socially rejected (11). Society's perception about the mentally ill is saturated with fear, rage, disgust and hostility. These negative emotions materialize in social discrimination (9). Stigma and mental illness form together an important barrier in achieving an efficient mental health service (6). The existing preconceptions about the mentally ill contribute to their social withdrawal, henceforth generating discrimination and labelling (12). Mass-media's image about the mentally ill is thus exaggerated, these individuals being portrayed as dangerous and unpredictable (6).

Medical confidentiality is an obligation in medical ethics. Respecting confidentiality is a strong and well kept tradition within medical service. Thus, in the present day, a strong accent is put on the intimacy of information. Medical information can be divulged only with the written consent of the person, thus respecting one's autonomy. In international documents, the confidentiality of the individual is protected by law (13, 14, 15). The term confidentiality appears in most of the codes of ethics. Both a theoretical principle and a practical obligation, medical confidentiality is a stringent requirement in medical care (16). As an ethical ideal of medical care, confidentiality is the cornerstone of the medic-patient relationship (17). By breaking the rules of confidentiality, the integrity of the medical relationship is cleaved, thus leaving the patient vulnerable (13).

Confidentiality, as an old medical tradition, is a practice protected by the law (16), both in medical research and in medical service (18). The medic is frequently subjected to ethical tension and to interferences to violate the medical confidentiality (16). In the medical care, confidentiality (19) is of the utmost importance, and in the psychiatric service it is essential for the development of the medic-patient relationship (20). While in certain medical fields confidentiality is absolute (21), in psychiatry there are some legal regulations that allow, in certain conditions, the disclosure of medical information. In psychiatry, confidentiality can be relative under certain situations, as seen in the non-voluntary admission and the mandatory treatment. These situations imply circumstances that refer to aggression towards others (either verbally or physically), aggression towards oneself (suicide, attempted suicide, or suicidal ideation) or psychotic symptoms. All of these, according to some authors, justify the breaking of confidentiality. In these situations the patient is informed about the possibility of a future broken confidentiality.

MATERIALS AND METHODS

This is a questionnaire-type, prospective study applied to the medical staff involved in the psychiatric aid of the mentally ill. The study was carried out between July 2012 and July 2013 and encompassed an examined population of 50 clinicians involved in the psychiatric aid of the mentally ill from medical centres located in Iasi, Suceava, Botocani and Vaslui. The questionnaires cover questions regarding mental health legislation, stigma, discrimination, confidentiality and informed consent.

The questionnaires covered all the steps ranging from pretesting, reviewing and validation to their application in their final form. The results were statistically processed for every item individually. Afterwards, the correlations between the answers to the questions and the different traits of the studied lots were obtained. The Cronbach alpha value was of 0.730, thus offering an acceptable result in comparison with the 0.70 threshold and also a validation needed for the further usage of the questionnaire on the examined medical population.

The questionnaires were applied in a direct manner, anonymity was preserved and confidentiality was respected, these being important aspects regarding the psychiatric aid of the mentally ill.

RESULTS AND DISCUSSIONS

Statistical analysis

--Two independent groups: [chi square]--it is a nonparametric test that compares two or more frequency repartitions from the same population; it is applied when the events exclude one another

--For more than two independent samples: the Kruskal Wallis test

Demographical characteristics

In the clinicians' lot the analysis of the frequency distribution based on medical specialization shows the predominance of residents (54.0%), followed by primary doctors (24.0%). The use of the Kruskall-Wallis nonparametric intergroup test revealed significant statistical differences between the doctor's specializations (Figure 1).

The distribution of the lots depending on gender reveals the predominance of female doctors with a frequency of 72% (Figure 2).

The distribution based on age

The distribution based on age reveals a greater statistical weight regarding the subjects aged between 30 and 39 years (46.0 %) but a frequency of 32.0% has to be noticed in the less than 30 years old subject group (Figure 3).

Questionnaire

Question 1: The law concerning mental health and the protection of the mentally ill is:

a. Law 487/2002;

b. Law 129/2012;

c. Law 487/2002 and Law 129/2012;

d. I don't know.

Based upon the studied lot, the answer regarding the active legislation concerning the protection of the mentally ill reveals unawareness of the law in 96.0% of cases, this percentage representing the vast majority of the clinical staff involved in aiding of the psychiatric patient (Figure 4).

Question 2: Do you consider that before starting treatment, the mentally ill should be informed regarding the benefits and the adverse effects of the treatment?

a. Yes, the psychiatric patient has the right to an adequate informed consent that must be respected;

b. In the particular case of the psychiatric patient, minimum disclosure is enough;

c. The psychiatric patient must not be informed;

d. I don't know.

[FIGURE 5 OMITTED]

Regarding the answers to question number 2, compared on studied lots, the results show a predominance of affirmative answers.

Question 3: "In your opinion, the social attitude towards the mentally ill is one of":

a. Acceptance and/or tolerance;

b. Discrimination and/or intolerance;

c. Other.

Erving Goffman considers stigmatization to be a form of social disgrace of one's reputation and behaviour (9). The branded patient can come across difficulties on employment (10), can be morally casted out of society and access to health service can be hindered.

The answers to these questions have highlighted significant statistical differences in percentages between the study groups. 48.0% of the clinicians considered that social attitude regarding the psychiatric patient is one of acceptance and/or tolerance. Yet, 46% of clinicians considered that the social attitude is one of discrimination and/or intolerance (Figure 6).

[FIGURE 7 OMITTED]

Question 4: Supposing that the personal information of the psychiatric patient would not be kept confidential and would be therefore disclosed, do you think that the patient would be harmed?

a. The patient would not be harmed;

b. Yes, but without major harm;

c. Yes. Social and professional reinsertion would be compromised;

d. I don't know.

The answers recorded to question number 4 shows a predominance of affirmative answers on all of the studied lots. 70.0% of the clinicians consider that social and professional reinsertion would be compromised if the personal information of the psychiatric patient would be disclosed (Figure 7).

Medical confidentiality is an important principle in health service and the protection of it is a form of respect that should be offered to every person (13).

[FIGURE 8 OMITTED]

Question 5: The personal information of the psychiatric patient can be disclosed in certain situations to the medical team within the health service in conjunction with:

a. Family/legal representative;

b. Police/legal body (e.g., Court);

c. Other alternative;

d. I don't know.

Regarding the answers to question number 5, a percentage of 54.0% of clinicians consider the disclosure of information is to be allowed in conjunction with family and/ or with the police/legal body (Figure 8).

Question 6: Do you consider that the law should force any psychiatric patient to admission to a hospital and to non-voluntary treatment?

a. Yes, because it is desirable to treat the patient and an authoritarian attitude (paternalistic) coming from the psychiatrist is mandatory in this situation;

b. No, the law should force the psychiatric patient to compulsory admission and treatment only in case of psychiatric emergency (e.g., aggression, violence);

c. No, this would defy the patient's right to decide for himself. Hence, non-voluntary admission and compulsory treatment will reduce the patient's demand for psychiatric aid;

d. I don't know.

The answers recorded from question number 6 show the following results:

--with proportions that fluctuate from 64.0%, clinicians implicated in the aid of the mentally ill consider that the law should force the patient to compulsory admission and treatment only in case of psychiatric emergency (e.g., aggression, violence). Yet, a percentage of 26% consider that the law should force any psychiatric patient to compulsory admission (Figure 9).

Question 7: Do you consider that the psychiatric patient is more discriminated compared with other patients?

a. Yes, they are discriminated;

b. No, they are not discriminated;

c. I don't know.

The answers to this question highlighted significant percentage differences from a statistical standpoint between medical residents, specialists and primary doctors.

52% of clinicians consider that the psychiatric patient is discriminated compared to other patients (Figure 10).

CONCLUSIONS

Mental health legislation differs significantly from one country to another. The legal psychiatric system appeared with the purpose to protect the vulnerable mentally ill.

Social stigma and labelling are a violation of human dignity and freedom. The subject of non-discrimination is an ambitious challenge in Romania (an EU country). Within the framework of social services, stigma is an important problem within the modern psychiatric health service.

Although absolute confidentiality is an ethical principle hard to accomplish, the psychiatrist has the obligation to protect it however possible. In mass-media, medical care, and in medical research, the boundaries of medical confidentiality present themselves as an ethical challenge for the 21st century.

ACKNOWLEDGMENET

The authors thank AMPOSDRU for supporting the research for this study, developed in the "Parteneriat interuniversitar pentru crepterea cahtapii pi interdisciplinaritapii cercetarii doctorale medicale prin acordarea de burse doctorale--DocMed.net", POSDRU/107/1.5/ S/78702 project.

REFERENCES

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(2.) Smith M. Anti-stigma campaigns: time to change. Br J Psychiatry Supl 2013; 55: 49-50.

(3.) Corrigan PW. How clinical diagnosis might exacerbate the stigma of mental illness. Social Work 2007; 52(1): 31-39.

(4.) Luchins DJ, Cooper AE, Hanrahan P, Rasinski K. Psychiatrists' attitudes toward involuntary hospitalization. Psychiatr Serv 2004; 55(9): 1058-1060.

(5.) Johnstone MJ. Bioethics: A Nursing Perspective. Elsevier, 5th edition 2009: 184.

(6.) Zalar B, Strbad M, Svab V. Psychiatric education: does it affect stigma? Acad Psychiatry 2007; 31(3): 245-246.

(7.) Crocker J. Major B, Steele C. Social stigma. In: Gilbert D, Fiske ST, Lindzey G, editors. The handbook of social psychology. New York: McGraw-Hill 1998; 2: 504-553.

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(9.) Padurariu M, CiobIrca A, Persson C, $tefanescu C. Self-stigma in psychiatry: ethical and bio-psycho-social perspectives. Romanian Journal of Bioethics 2011; 9(1): 76-82.

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(12.) Smith M. Stigma. APT 2002; 8: 317-323.

(13.) Tirdea TN, Gramma RC. Bioetica medicala In sanatate publica. Suport de curs. Casa Editorial-Poligrafica Bons Offices. Chicinau 2007.

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(15.) Dalla-Vorgia P, Lascaratos J, Skiadas P, Garanis-Papadatos T. Is consent in medicine a concept only of modern times? J Med Ethis 2001; 27(1): 59-61.

(16.) Chirifa V, Chirifa R. Eticapipsihiatrie. Ed Synposion 1994.

(17.) Ferguson AH. The evolution of confidentiality in the United Kingdom and the West. Virtual Mentor 2012; 14(9): 738-742.

(18.) Lysaght T, Capps BJ, Campbell AV. Intervening in clinical research to prevent the onset of psychoses: conflicts and obligations. J Med Ethics 2012; 38(5): 319-321.

(19.) Rogers WA, Draper H. Confidentiality and the ethics of medical ethics. J Med Ethics 2003; 29(4):220-224.

(20.) Bloch S, Chodoff P. Etica psihiatrica. 2t ed. Asociatia Psihiatrilor Liberi, 2000.

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Petronela NECHITA--M. D., Ph. D., Specialist in Psychiatry, "Socola" Institute of Psychiatry, Iasi, Romania

Georgiana CRACIUN--M. D., Ph. D. Student, Assistant Professor, Department of Neurology, "Gr. T. Popa" University of Medicine and Pharmacy Iasi, Resident in Neurology, "Prof. Dr. Nicolae Oblu" Clinical Neurologic Hospital, Iasi, Romania

Razvan AANEI--M. D., Resident in Psychiatry, "Socola" Institute of Psychiatry, Iasi, Romania

Radu ANDREI--M. D., Ph. D., Assistant Professor, Department of Psychology, "Petre Andrei" University Iasi, Senior Psychiatrist, "Socola" Institute of Psychiatry, Iasi, Romania

Correspondence:

GEORGIANA CRACIUN

"Gr. T. Popa" University of Medicine and Pharmacy Iasi, No. 16 Street Universitatii, zip code 700115, Iasi, Romania

Tel.: +40 747 086 940

E-mail: craciungeorgiana@gmail.com

Submission: October, 29th, 2015

Acceptance: January, 7th, 2016
Figure 1. The distribution of clinicians based on specialization

Resident     54,0%
Specialist   22,0%
Primary      24,0%

Note: Table made from pie chart.

Figure 2. Clinicians' repartition based on gender

Female   72
Male     28

Other specialization medical doctor

Note: Table made from bar graph.

Figure 3. The clinicians' distribution based on age

< 30 years              32.0%
60-69 years              2.0%
40-49 years             20.0%
30-39 years             46.0%

Note: Table made from pie chart.

Figure 4. The distribution of the answers of the non-psychiatric
clinicians

I don't know     96,0%
Both              4,0%
Law 487/2002
Law 129/2012

Note: Table made from pie chart.

Figure 6. The clinicians' answer distribution regarding social
attitude towards mentally ill persons

Other                               6
Discrimination and/or intolerance   46
Acceptance and/or intolerance       48

Note: Table made from bar graph.

Figure 7. The non-psychiatric clinicians' answer distribution
regarding the harm brought to the mentally ill in case of lack of
confidentiality

The pacient would not suffer any harm                           4
Yes, but the harm brought wouldn't be of importance             26
Yes, social and professional reinsertion would be compromised   70
Don't know

Note: Table made from bar graph.

Figure 9. The non-psychiatric clinicians' answer distribution
regarding the informing of persons about psychiatric treatment

Yes                                                         28
No, the law should force the patient in case of emergency   64
No, the pacient's right to decide for himself is broken     6
Don't know                                                  2

Note: Table made from bar graph.

Figure 10. The non-psychiatric clinicians' answer distribution
regarding the discrimination of the mentally ill compared with other
patients

Yes          30
No           18
Don't know   52.0

Note: Table made from bar graph.
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Article Details
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Author:Nechita, Petronela; Craciun, Georgiana; Aanei, Razvan; Andrei, Radu
Publication:Bulletin of Integrative Psychiatry
Article Type:Report
Geographic Code:4EXRO
Date:Jun 1, 2016
Words:2957
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