World Medical Association, Statement on Ethical Issues Concerning Patients with Mental Illness (1995)

Adopted by the 47th General Assembly
Bali, Indonesia, September 1995



PREAMBLE
Historically, society has regarded patients with mental illness as a threat to those around them rather than a sick person in need of support and care. Therefore, in the absence of efficient treatment many patients with mental illness were confined to asylums for all or part of their lives. The aim of such treatment in these cases was to prevent self-destructive behaviour and aggressive behaviour toward others.

At the present time, progress in psychiatric therapy allows better care of patients with mental illness. Efficient drugs and other treatments are capable of curing mild cases and bringing about long remissions for patients whose conditions are more serious.

Patients with mental illness should be viewed, treated and have the same access to care as any other patient.

The psychiatrist is a physician with the same obligations towards his/her patient as any other specialist.

Thus, the role, sometimes imposed upon the psychiatrist, as society's agent, should not be allowed to undermine or erode their primary role as healers.

ETHICAL PRINCIPLES
1. The WMA believes that the discrimination associated with psychiatry and the mentally ill should be eradicated. This stigma often discourages people in need from seeking psychiatric help, therefore aggravating their situation.
2. The psychiatrist aspires for a therapeutic relationship founded on mutual trust. He/she should inform the patient of the nature of the condition, therapeutic procedures (including possible alternatives and the risk of each), and the expected outcome.

The condition of a patient with mental illness incapable of exercizing his/her autonomy does not differ from that of any other legally incompetent patient. He/she should be treated like any other patient who is temporarily or permanently incompetent. A patient with mental illness, including psychosis, should not automatically be considered to be legally incompetent. His/her judgement should be respected in areas where he/she is capable of making decisions. If the patient lacks the capacity to make a decision as to his/her medical care, surrogate consent should be sought from an authorized representative in accordance with applicable law.
3. Involuntary treatments should be used in the treatment of a patient with mental illness only when he/she is in an acute state and may pose a threat to himself/herself or others. Physicians should consider compulsory hospitalization to be exceptional and, therefore, should utilize it only when and as long it is medically necessary.
4. Every psychiatrist should offer to the patient the best available therapy to his/her knowledge, and should treat him/her with the solicitude and respect due the dignity of all human beings. The psychiatrist practicing in an institution, the military, or prison, can be faced with a conflict between his/her responsibilities to society and his/her obligation to the patient. His/her primary loyalty must be to the patient. When the psychiatrist is required to act as an agent for society instead of in the patient's best interest, the patient should be made aware of the conflict so that he/she does not feel betrayed by or blame the doctor for measures mandated by legal authorities.
5. The confidentiality and privacy of all patients should be safeguarded. When required by law, the psychiatrist should disclose only the relevant material and only to the relevant authority. Data banks which allow automatic transfer of information from one authority to another may be used provided that medical confidentiality is respected.
6. A psychiatrist must never use his/her professional position to violate the dignity or human rights of any individual or group and should never allow his/her personal desires, needs, feelings, prejudices or beliefs to interfere with the treatment. Nor should a psychiatrist take advantage of his/her professional position or the vulnerability of a patient to abuse his/her authority, such as by using a patient's labor for personal purposes or by having ***ual relations with a patient.

RECOMMENDATION
National Medical Associations should publicize this Statement and use it as a basis for affirming the ethical foundations of psychiatric practice.