Psychiatry for the person and its ethical perspectives

Volume 13 No. 3 August 2007 SAJP Every medical (and psychiatric) act is or should be an ethical act. This is consistent with the fundamental aspirations of the medical and health field, from Hippocratic and similar ancient philosophical perspectives to recent developments in public and clinical policies. Ethical concerns have been priority institutional commitments since the beginnings of the World Psychiatric Association (WPA). In line with the above, the WPA established in 2005 an Institutional Program on Psychiatry for the Person. This editorial summarises the precedents, goals, structure and activities of this WPA initiative and outlines some of its ethical perspectives.


The WPA Institutional Program on Psychiatry for the Person
The need for holism in medicine was strongly advocated by Ancient Greek philosophers and physicians, the ethicists of those times.Socrates and Plato taught that 'if the whole is not well it is impossible for the part to be well', and such was also the position of Aristotle. 1 These ideas are re-emerging today, not only within the Western medical tradition but also in a number of other rich traditions around the world.For example, Ayurvedic and Chinese medical traditions, ancient and still practised, with sound philosophical, experiential and experimental bases, focus on the patient's total health rather than only on disease.Both of them articulate a comprehensive and harmonious framework of health and life and promote a highly personalised approach for the treatment of specific diseases and the enhancement of quality of life. 2 Concern for the centrality of the person is also being adopted by influential international health organisations through recent major statements by the US Presidential Commission on Mental Health and the WHO European Ministerial Conference on Mental Health. 3,4other trend towards personalised medicine has emerged with the introduction of the concepts of recovery and resilience and of values-based medicine. 5 8These concepts support the involvement, active participation and responsibility of the person in protecting him-or herself from illness, promoting and maintaining health, and recovering from illness. .This initiative affirms the whole person of the patient in context as the centre and goal of clinical care and health promotion, at both individual and community levels.This involves the articulation of science and humanism to optimise attention to the ill and positive health aspects of the person.As care is basically a partnership experience, the programme involves the integration of all relevant health and social services.Furthermore it involves advancing propitious public health policies.

Psychiatry for the person and its ethical perspectives
The programme goals can be summarised as the promotion of a psychiatry of the person (of the totality of the person's health, both ill and positive), by the person (with clinicians adopting humanistic and ethical attitudes and extending themselves as full human beings), for the person (assisting the fulfilment of the person's life project), and with the person (in respectful collaboration with the person who consults).Operationally, the programme has four components, i.e. conceptual bases, clinical diagnosis, clinical care, and public health. 9Some of its ethical perspectives are outlined below.

Ethical perspectives from a psychiatry for the person
The context of each person is closely linked to identity.Nobody lives in a vacuum.This is exemplified by the philosopher Ortega y Gasset's dictum, 'I am I and my circumstance'.1][12][13][14] Additionally, a more person-centred approach on the part of the physician is strongly encouraged. 15,16This touches on ethics of the medical profession.Indeed, consideration of the patient as a person and not as a carrier of illness is a fundamental ethical obligation of the physician.This is consistent with the 'respect for autonomy' in principle-based ethics, 17 and with each of the wide range of other ethical theories that support health care practice.
Consistent with a fundamental institutional concern present since its inception, the WPA approved in 1977 the Declaration of Hawaii, which set out ethical guidelines for the practice of psychiatry.This Declaration was updated in Vienna in 1983, Madrid in 1996, Hamburg in 1999, Yohohama in 2002 and Cairo in 2005, to reflect the impact of changing social attitudes and new medical developments on the psychiatric profession.
In its preamble, the Madrid Declaration (www.wpanet.org/aboutus/manual of procedures/appendix D) points out that medicine is both a healing art and a science, consistent with the IPPP emphasis on articulating science and humanism.The Declaration also indicates that ethical practice is based on the psychiatrist's individual sense of responsibility and that it should be guided primarily by the respect for patients and concern for their welfare and integrity.
Among its core guidelines, the Declaration points out that psychiatrists should devise therapeutic interventions that are least restrictive to the freedom of the patient, and that the patient should be accepted as a partner by right in the therapeutic process.The Declaration's additional guidelines include that the treatment approach should be determined in concert by the doctor and patient and/or the patient's family, that professional independence to apply best practice guidelines and clinical wisdom in upholding the welfare of the patient should be the primary considerations of the psychiatrist, and that the psychiatrist's respect for the humanity and dignity of the patient builds a foundation of trust that is essential for a comprehensive treatment plan.
Another important medical code of ethics is that issued by the World Medical Association (WMA) since 1964 and amended periodically as its Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects (www.wma.net).Tellingly, among other things it proclaims that in medical research on human subjects, considerations related to the well-being of the human subject should take precedence over the interests of science and society.The WPA has been invited this year by the WMA for the first time to participate formally in the review of the Helsinki Declaration, which opens opportunities for extending to the medical field at large WPA's ethical aspirations, including those that are particularly person-centred.
It is also worth noting that one of the major objectives of the IPPP is to promote a psychiatry with the person.It involves engaging the patient as a whole person and the commitment to work in a respectful and collaborative way with him or her.This includes firstly work with individuals, which highlights the ethical underpinnings of this effort.It also encompasses work with patient groups including those critical of psychiatry.These considerations speak clearly of the dialogal bases of our profession. 18A renewed commitment to the clinician-patient relationship appears crucial, as well as building an effective dialogue with patient and user groups (as well as trialogues including families) respecting the diversity of their perspectives.It should be noted that evolving evidence-and experience-based information in our field should also frame our professional work and interactions with patients.

editorials Volume 13 No. 3
August 2007 -SAJP The above considerations indicate the high relevance of a comprehensive understanding of health and the centrality of the person in such understanding and for the planning of health actions.In line with this, the 2005 General Assembly of the WPA established the Institutional Program on Psychiatry for the Person: from Clinical Care to Public Health (IPPP)