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Royal Australian & New Zealand College of Psychiatrists Code of Ethics
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13 November 2009
Dr Nick Judson
Committee for Professional Practice
Royal Australian New Zealand College of Psychiatrists
Dear Dr Judson
Re: Code of Ethics ─
Thank you for giving HDC the opportunity to comment on the
revised Royal Australian and New Zealand College of Psychiatrists
(RANZCP) Code of Ethics (Code of Ethics), which RANZCP intends to
publish early in 2010.
I strongly support the RANZCP's goal of achieving "the best
attainable quality of psychiatric care and mental health". I agree
that cultivating and maintaining the highest ethical standards is
vital to realising this vision, and retaining community trust in
In general, I found the Code of Ethics to be very good. However,
there were some minor matters that in my view need clarification,
in particular the language surrounding consent, and who may provide
this in the case of a consumer who lacks competence.
While I appreciate that the Code of Ethics is also for
Australian psychiatrists, references to "substitute consent",
"valid consent" and "authorised substitute decision-makers" do not
align well with terms used in the HDC Code, or to usage in New
Zealand. I suggest replacing references to "valid consent"
with "informed consent".
In relation to the usage of "substitute consent" and "authorised
substitute decision-makers", the HDC Code states that where a
consumer is not competent to make an informed choice and give
informed consent, consent may be sought from a "person entitled to
consent on behalf of the consumer". It may be useful to amend the
Code of Ethics to reflect this difference.
For example, sub-principle 4.4 currently states that "[w]here
the patient is unable to understand the concept of confidentiality
and its limits, substitute consent may be required". I suggest
amending this statement to read that "[w]here the patient is unable
to understand the concept of confidentiality and its limits,
consent may be sought from a person entitled to consent on behalf
of the patient". References to "authorised substitute
decision-makers" should also be amended accordingly. For example,
sub-principle 5.7 could be modified to state that "[w]here a
patient does not have the capacity to provide consent,
psychiatrists shall seek consent from a person entitled to consent
on behalf of the patient".
I have made some specific comments and suggestions below for
your consideration. I have also included valuable comments made by
Judi Strid, Director of Advocacy.
Co-operation with other providers
In the period between 2004 and 2009, HDC received approximately
150 complaints involving psychiatrists. A significant number of
complainants were concerned that psychiatrists had not co-operated
with other providers to ensure continuity of care for patients, and
had breached Right 4(5) of the Code, which provides that "every
consumer has the right to co-operation among provides to ensure
quality and continuity of services".
For example, Complaint 07/06672 involved Ms C, a young mental
health consumer who complained about a change in diagnosis when she
was admitted to a mental health unit. Ms C had a long history of
mental health problems, and had previously been diagnosed as having
a major depressive disorder. Dr C, a locum consultant psychiatrist,
reviewed Ms C when she was admitted to the mental health unit, and
concluded that she was not suffering from depression, but from a
factitious disorder. The psychiatrist did not consult with the
patient's clinicians prior to making the new diagnosis, and did not
keep clear documentation outlining the reasons for his new
diagnosis. While I made no finding in relation to whether Dr C's
diagnosis was correct, I was concerned that he had not consulted
his colleagues prior to making a diagnosis that was very different
to the previous diagnosis, and resulted in a change in treatment.
In these circumstances, I found that Dr C had breached Right 4(5)
of the Code.
Complaints such as Ms C's highlight the need for co-operation
and clear communication between members of multi-disciplinary teams
in the mental health setting. To emphasise the importance of this,
I suggest that the Code of Ethics include a principle stating that
psychiatrists shall co-operate with other providers to ensure
quality and continuity of services.
It is good to see that the Code of Ethics contains a reference
to relieving the "suffering of those whose autonomy is impaired
through loss of capacity from mental illness".
I note that the Code of Ethics states that sexual relationships
between psychiatrists and their current and former patients are
"always unethical". I applaud the unambiguous language.
I also note the statement in principle 2.4 that "any behaviour
that might be reasonably interpreted by a patient as demeaning, or
as a sexual advance, is unethical. Such behaviour may include
physical contact, or conduct, comments or innuendo of sexual nature
… that is not necessary for clinical purposes." Complaints to
HDC have highlighted the risk of treatment provided by
psychiatrists being misinterpreted or misconstrued, particularly
where consumers have presented with a history of sexual abuse.
Complaint 04/02840 involved a complaint from Ms A about the
services provided to her by Dr A, a psychiatrist. Ms A, a consumer
with a history of sexual abuse, had been undergoing psychotherapy
sessions with Dr A. She complained that in the course of her
psychotherapy sessions with Dr A, he had sexualised their
relationship" by making inappropriate comments and divulging
personal details about himself to her. I found that the
techniques used by Dr A were based on well-established therapeutic
principles and that Dr A had not breached the Code. However, it
became apparent during my investigation that Dr A had communicated
personal information about himself to Ms A, which she interpreted
as a sexual advance. I accepted that Dr A had disclosed personal
information about himself in the context of psychotherapy for
sexual abuse and exploration of transference issues. However, I
advised him that "the degree of disclosure of personal information
… during the counselling sessions seem[ed] inappropriate".
Principle three states that "psychiatrists shall provide the
best attainable psychiatric care for their patients". I have three
comments in relation to this principle.
First, I query whether this is a realistic expectation, without
some qualification such as clause 3 of the HDC Code, which states
that a "provider is not in breach of the Code if the provider has
taken reasonable actions in the circumstances to give effect to the
right, and comply with the duties, in this Code".
My second comment relates to the sub-principle that
"psychiatrists may decline to accept the referral of patients when
appropriate and justifiable". I consider that this statement
requires clarification, such as:
"Psychiatrists may decline to accept the referral of patients
when appropriate and justifiable so long as they ensure safe
arrangements have been put in place that do not the patient at
My third comment is about the statement in sub-principle 3.11
that "psychiatrists shall use evidence-based interventions wherever
possible but appreciate that novel procedures and treatments may be
indicated in certain clinical circumstances". In my view, any
innovative procedures and treatments which psychiatrists propose to
use should be subject to appropriate ethics committee approval.
I also suggest that this sub-principle be amended to
emphasise the need for active effort to be made to "reduce the use
of restraint and seclusion … and that ECT should only be used as a
last resort, and should not be used if the patient has made a valid
advance directive stating ECT is not to be used".
Principle four states that "psychiatrists shall strive to
maintain confidentiality of patients and their families". This goal
is qualified by sub-principle 4.3, which states that a
"breach of confidentiality may be justified on rare occasions in
order to promote the best interests and safety of the patient or of
other people. Psychiatrists may have a duty to inform the intended
victim/s and/or relevant authorities."
I accept that this qualification is necessary.
The issue of family involvement in the face of objections from a
mental health consumer is example one. Complaint 07/06607
involved a complaint about the care provided to Mr B at a public
hospital in 2003-2004. Mr B had been receiving mental health
services since 1990, for a range of psychiatric disorders. He had a
number of acute admissions during this period, and in January 2004,
he was once again admitted to the inpatient unit at the public
hospital. At this time, he was assessed as being acutely
psychotic, with a low risk of suicide and medium risk of violence
and aggression. While he was initially admitted into the open ward
of the public hospital, he was transferred to a secure unit a short
time later, because of increased aggression towards hospital staff.
Shortly after his transfer, Mr B committed suicide.
I investigated the complaint, and assessed the care provided to
Mr B between 2001 and 2004. One of the questions that arose
during the course of the investigation was whether the hospital
staff should have involved Mr B's family in his care, despite his
express request to the contrary. I conclude
"Mr [B] had made it clear that he did not want his family
involved in his care. I acknowledge the importance of maintaining
patient privacy. However … due consideration should be given to the
part the illness may play in the attitude of the consumer when
refusing family involvement."
In this case, the public hospital had a policy which emphasised
the "involvement of family in providing quality treatment and
support services" to mental health consumers. There was scant
evidence that involvement of Mr B's family and friends was ever
thoroughly explored, a fact which suggested that the hospital's
policy was not well known to staff. I considered that there "would
certainly have been value in involving the family at the time of Mr
[B's] discharge [and] staff should have explored involving the
family, particularly in relation to the provision of ongoing
support and crisis management".
Sub-principle 5.1 states that "psychiatrists shall inform, and
make sure that, the patient understands the purposes, nature,
benefits, side-effects, risks and costs of a proposed procedure and
treatment". Right 6 of the HDC Code entitles a consumer to the
information that a reasonable consumer, in that consumer's
circumstances, would expect to receive, including the purposes,
nature, benefits, side-effects, risks and costs of a proposed
procedure and treatment. Right 5 of the HDC Code also requires that
this information be communicated to the consumer in a form,
language, and manner that enables the consumer to understand the
I consider that sub-principle 5.1 is too strictly worded and
does not accurately reflect the legal obligations incumbent upon
providers. I suggest rewording sub-principle 5.1 to read
"psychiatrists shall inform, and seek to ensure that, the
patient understands the purposes, nature, benefits, side-effects,
risks and costs of a proposed procedure and treatment."
It may also be useful to add that psychiatrists should
"encourage their patients to develop advance directives when they
are well so their wishes will be known when they are unable to make
decisions". This is consistent with Right 7(5) of the HDC
Code, which provides for consumers to "use an advance directive in
accordance with the common law". However, I acknowledge that
advance directives may not apply in a situation where a consumer
has been placed under a Compulsory Treatment Order.
In summary, the principles set out in the Code of Ethics appear
sound and will contribute positively to the delivery of psychiatric
services to consumers. I trust my comments are of assistance, and
would appreciate receiving a copy of the final version of Code of
Ethics, when it is published in early 2010.
Health and Disability Commissioner
cc: Judi Strid,
Director of Advocacy