Ethics in Psychiatry and Medical Training

VOICEOVER
Welcome to Melbourne University Up Close, a fortnightly podcast of research, personalities, and cultural offerings of the University of Melbourne, Australia. Up Close is available on the web at upclose.unimelb.edu.au. That’s upclose.u-n-i-m-e-l-b.edu.au.

JACKY ANGUS
Hello and welcome to another episode of Up Close, from the University of Melbourne, Australia. I’m Jacky Angus. Our subject today is the practice of psychiatry with a particular focus on psychiatric ethics. That is, a focus on the moral dimension, underlining the relationship between doctor and patient. What is entailed in a code of ethics for psychiatrists? And how is it to be achieved? To discuss this subject, I turn to Sidney Bloch, Professor of Psychiatry in the Medical School at the University of Melbourne, Australia. Here at the University of Melbourne, Prof Sidney Bloch is probably best known for his imaginative approach to medicine as a whole. The practice of which he regards as an art, as well as a science. Understanding and empathy are clearly central to the practice of psychiatry, but so too is the personal integrity of the psychiatrist. What if this is lacking or flawed in some way? And what happens to the patient when morality and ethics are abandoned by the psychiatrist? Welcome to Up Close, Prof Bloch.

SIDNEY BLOCH
Hello, thank you.

JACKY ANGUS
Well, Prof Bloch, why are ethics so important in the field of psychiatry?

SIDNEY BLOCH
Unfortunately psychiatry is being bedeviled, by I guess, what we could call, scandals, but, really by perversion. In other words, psychiatrists, have been derailed from the job of helping those who are mentally ill and I stumbled upon this quite accidentally and in fact couldn’t believe it because I was naïve when I was a young trainee, but I came across, by accident a particular perversion and that was how the Soviet Union was then using psychiatry as a means to label people as mentally ill, that is, dissenters, people who were interested in human rights and freedom of religious expression. Placing those people in mental hospitals, sometimes for years.

JACKY ANGUS
When was this professor?

SIDNEY BLOCH
This was back in 1971 and it changed my life, I’ll have to say. Because from then on, psychiatry and ethics became indivisible to me and I got very steeped into the particular story of Soviet psychiatric abuse, as it became known. And did my best to bring it to the attention of my fellow psychiatrists who were equally incredulous, because they couldn’t understand how this could be the case. And eventually we – together with a colleague who was an expert in Russian political science – we wrote a book called Russia’s Political Hospitals. Also known as ‘psychiatric terror’ because it was a sort of terrorism of ordinary human beings – dissidents, dissenters – but ordinary human beings without any mental illness, being placed in mental illness institutions.

JACKY ANGUS
And what sorts of abuses are we actually talking about? What sort of things were happening in the Soviet Union?

SIDNEY BLOCH
Well, there was repression. This was a totalitarian state, as we know. The Party and the KGB, in power – and at that time, this was post-Stalin – Stalin had simply disposed of his enemies by sending them to the gulag, or shooting them. When he went and Khrushchev came into power, there was a wish to make the Soviet Union appear to be more ‘civilised’, to have a legal system. And so, it was quite convenient to take people who were, in the terms of the Soviet system, ‘mad’ or ‘confused’; ‘how could they come up with ideas of reforming society when everyone knows that communist society is an ideal society?’ So, it was that rather curious paradox, labelling them as ‘mad’ because of their ideas and then as a result of their label, placing them in mental hospitals. The KGB, the secret police would come up to psychiatrists, who had no choice, out of fear, conformism, to go along with the authorities. A very widespread practice. Probably thousands. The number will never be known. But, several thousand were detained in this way.   

JACKY ANGUS
And I suppose in Nazi Germany, there was abuse, medical abuse, perhaps not of the exact same sort, but similar -

SIDNEY BLOCH
Well, we know about the experiments done in Auschwitz and the other concentration camps, much less is known about psychiatry and the way it was abused in the most shocking way. There is an excellent book on this that has been recently published by Michael Burleigh, the English historian, called Death and Deliverance. And essentially psychiatrists paved the way for the extermination of Jews and other undesireables in the concentration camps, in Auschwitz. For this reason, Hitler decided, very soon after the beginning of the war, that the mentally ill should be exterminated and the problem of them being burdens on the state and the like would be dealt with in one blow. It was then applied by the foremost professors of psychiatry and the idea was to do a census of all patients throughout Germany in mental hospitals. So this was quite an extensive operation. But all done in top secret. And by the end of August 1941, some 70,000 patients had been gassed to death. They were herded into six special hospitals, remotely placed in the countryside, and there, psychiatrists and psychiatric nurses actually did the gassing. So, it is appalling to think that one’s colleagues actually participated in such a ghastly perversion in some ways worse than the Soviet. After this was uncovered, by a bishop actually, a member of the church, it was suspended. Thereafter, nobody was actually gassed to death. But through sheer neglect, another 70,000, it is estimated, also died in the mental hospitals.

JACKY ANGUS
And presumably the medical profession was complicit in this because they felt they had to be.

SIDNEY BLOCH
Well, it is a rather curious thing that eminent professors of psychiatry lent themselves to this murder, mass murder, and – take an example of Prof.Carl Schneider, who was the most eminent professor of rehabilitation psychiatry; he held the chair in Heidelberg. A very esteemed university. So, was he forced to do this? No, not necessarily. He was convinced that euthanasia of what was called in German,  ‘lebensunswertes leben’, (life not worthy of life in German). People, who are not worthy of living, should not live.  They should be killed.  

JACKY ANGUS
Well, fortunately ideas have changed. I understand you were part of this in the 70s, in association with the World Psychiatric Association, or congress, that met. Can you tell us a little about the background of that and how ethics evolved from that?

SIDNEY BLOCH
Yes. A fateful congress took place in Honolulu in 1977 when the Russian saga was prominent. People now began to hear about it, they couldn’t deny it anymore. Our book came out in the very same month as the congress and was widely cited. So the debate was intense. But the vote was – should they be expelled or not, was put and was won by 90 votes to 88. Anyway, as a result of that they resigned and withdrew and remained out of the association for many years. And at that point onwards, the WPA and other psychiatric associations, national ones, took hold of the matter and began, in concert with Amnesty International and other human rights organisations to try and eliminate this ghastly practice. And by 85, the advent of Gorbachev, and the loosening up of communism, allowed a change to take place. So, by 1990, it had more or less gone.

JACKY ANGUS
You’re listening to Up Close, coming to you from the University of Melbourne. I’m Jacky Angus and I’m talking about ethics and psychiatry with Prof Sidney Bloch. So, what does all of this mean for the practice of psychiatry today?

SIDNEY BLOCH
Well, I think we have to be vigilant always, because psychiatry is a field of medicine, where the boundaries are very blurred. Who is mad and who is not, mad versus bad? They are all sorts of debates that go on that have been going on throughout my entire career and not been fully resolved. And the other problem I’d say is awesome in that we have the power to detain people against their will by law. I’ve done this many times. Because people have been disturbed, or they have disturbed their environment and they’re suspected of being mentally ill and the power of that, coupled with the blurred boundaries makes our job tough. So vigilance to be absolutely sure about we are not putting people in a psychiatric category, when they don’t warrant it.

JACKY ANGUS
What about the psychiatrists themselves? How does one train them to operate in a way that is benevolent, that is caring?

SIDNEY BLOCH
Well, by teaching them the ethics of our profession. But that is more difficult than it seems. And when I trained in the field and long after, there was absolutely no training in this area whatsoever. In fact, when the Soviet abuse became prominent, as we’ve said in 77, that was the beginnings of psychiatric ethics. And over those last 30 years or so, it has gradually evolved to the point where we now can say, it is a regular part of the curriculum. People have accepted in our profession that ethics is extraordinarily important and fortunately, medical ethics in general, is flourishing. It flourishes because we have stem cell problems and all the other high-tech stuff, but also because people are much more conscious of things like informed consent, confidentiality. And fortunately the patients, the families that we work with are now better informed.

JACKY ANGUS
Well, the world has changed. Everyone is informed. There is Google there.  You can ask questions of your doctor that perhaps you wouldn’t have dared 50 years ago. And that probably includes psychiatric patients and their families.  

SIDNEY BLOCH
Very much better informed. And what a good thing it is too. So, we are much more partnership-like than ever before. And the paternalism that dominated medicine from the time of Hippocrates, 2,400 years ago, is evaporating. We are in an amazing social transformation in how medicine is seen by the community and also by the practitioners.

JACKY ANGUS
What about professional bodies, do they provide ongoing monitoring in regard to psychiatrists observing a sort of code of ethics or an understanding of ethics and psychiatry?

SIDNEY BLOCH
Well, in Australasia, we’ve had a code of ethics since 94 and we are now finalising the third edition. So, it keeps moving. Things change. People are mindful of this code. It raises their consciousness in a moral sense. The code is very detailed: it tells you what is acceptable and what is not. It points out the difficulties. A simple example is, say, confidentiality. You should always keep your patients’ secrets and not broadcast them beyond the clinical encounter. But it then expresses a number of annotations, which indicate that sometimes you have to breach confidentiality. So, if someone is that disturbed that they cannot retain contact with reality, one has to go to their relatives or to friends or neighbours -

JACKY ANGUS
Or to a policeman, I suppose.

SIDNEY BLOCH
Or to the police. The courts, indeed. And breach confidentiality.

JACKY ANGUS
Well, what other ethical issues in the practice of psychiatry, spring to mind?

SIDNEY BLOCH
Just to give you some examples, one key one is, the boundary within which we work. If you cross that boundary, you violate it. And a good example of that, unfortunately still occurring, is developing a sexual relation with the patient. It used to happen, used to be thought it was okay to marry a patient, but nowadays it is regarded as totally unacceptable, even with a former patient, that you meet ten years later. Not possible.

JACKY ANGUS
What other boundaries?

SIDNEY BLOCH
Well, there is another boundary, where it is not ‘violation’, but is referred to as a crossing. So, you’ve got a patient that you spot through your windows waiting out in the pelting rain for a bus and you know that the bus service is crashed that day and you’re just about to leave your clinic, she was your last patient of the day, you know she has got to go to the station, the railway station to get a train home, the bus isn’t there to take her, and you are going to pass by as she stands there at the bus stop. Do you say, ‘June, I’ve just seen you as a patient, but now I want to offer you a ride to the train station.’ Is that ethically okay or is it dubious?’

JACKY ANGUS
Surely that’s alright.

SIDNEY BLOCH
Well, most people would regard that as a crossing. In other words, you have crossed the boundary – because you shouldn’t see her in any other situation beside the professional one, i.e. in your clinic – but it is not a violation because any sensible, civilised person would take somebody out of the rain, if you vaguely knew them, and say, ‘do you need a lift to the station?’ So, that is an example of the professional boundary. Another common, common one is informed consent. And we go into great detail in our codes – you should inform your patient about the range of possible treatments. Let’s just talk about electro-convulsive therapy. Otherwise known as ‘shock therapy’. It sounds awful, but it is life saving. So, instead of saying, ‘we are going to do this, we are going to give you shocks.’ You know, the brutal fashion. You say, ‘the treatment possibilities are as follows, and they include ECT (Electro Convulsive Therapy). Let me tell you about ECT because a lot of people have great confusion and prejudice.’

JACKY ANGUS
And anxiety.

SIDNEY BLOCH
Anxiety, of course. ‘So, it is a treatment which is eminently safe. You get put to sleep. You get a muscle relaxant. There is no harm. A bit of memory impairment.’ So, that is something that people are taught via the code of ethics. Confidentiality, we have mentioned in another context. We also have another one, which is about not harassing one’s trainees. So, if you have trainees, you shouldn’t harass them. Be it sexually. You shouldn’t humiliate them. Just one final example, we have a principle, which says we should remain abreast of contemporary knowledge. If in 20 years time, I am still practicing how I practiced when I qualified two decades earlier and I know nothing about the new, wonderful anti-depressant medications, that is unethical. So, lots of requirements within a good code of ethics that we have to abide by.   

JACKY ANGUS
So, I suppose this varies across different countries, doesn’t it? In certain parts of the world this would be more likely to be observed, this kind of code, than in others.

SIDNEY BLOCH
Yes, well, some countries don’t have codes whatsoever and who knows what is going on there. But, world medicine and world psychiatry, I think, are making headway to ensure that human rights are respected in a general sense and that would incorporate the idea that medicine not be exploited for the wrong reasons.

JACKY ANGUS
You’re listening to Up Close from the University of Melbourne, Australia. I’m Jacky Angus and I’m speaking to Prof. Sidney Bloch about ethics and psychiatry and the training of young doctors. So, how can ethics be hardwired into students and practitioners?

SIDNEY BLOCH
I don’t have a clue. More or less. But in terms of empathy, which is another aspect that I believe is very central to good medicine; I have been fascinated by the possibility of drawing on imaginative artists – i.e. writers, painters, photographers, musicians, composers. Their imagination can help us understand what the experience is of suffering, for example. So, if a young student is trying to work out what it is like to face impending death. How does one do it? You talk to the patient; you talk to your relatives who have experienced somebody who has died in the family. How do you do this? And the medical students, a youngish person who has not experienced much in the way of loss and death himself or herself, so, I thought, let’s go to the great artists. And a good example, I seem to be known for, is using Tolstoy, his short story called The Death of Ivan Illich. And getting students to read that very carefully and taking notes about what they see in Ivan’s experience of dying. Because he is a young narcissistic lawyer, who suddenly is ill and before long he is dying. And the doctors around him are extraordinarily unhelpful, unempathic, his family don’t want to know him because he has been so narcissistic, he is not a great character. But the reader can detect a lot about the nature of his suffering. His loneliness. Beautifully spelt out. Tolstoy, like Shakespeare and like Chekhov, like so many writers, are great psychologists. They know how to, I think, penetrate the human psyche in a way that we ordinary mortals can’t do.  

JACKY ANGUS
Well, Prof Bloch, as a medical educator, what are the new developments on the scene, in terms of teaching ethics, to students as a whole?

SIDNEY BLOCH
Well, I have just come back from a sabbatical at Columbia University in New York, and came across a lot of new developments and also a lot of confusion about how to teach ethics, about the art of medicine, the question of empathising with patients, all these related challenges. And the confusion is really, how do you best do this? I came to the conclusion that one can do it in a range of ways, but primarily, through the new student who comes into the hospital setting, still quite young, just put on his white coat, just got his stethoscope, going in and interviewing patients to make a lot of that experience – those early experiences of working with patients and families – and also using the humanities, so, getting them to read short stories, poetry, and so on and so forth. But there you are in the ward, and somebody is suffering with shocking pain and crying out for medication. A situation that makes one, as a bystander or as a carer, feel very, very sad and distressed about. How do you deal with yourself, with your own needs? So, there we have a young student who is going to be a doctor within two and half, three years, facing distress and suffering day in day out, what is the usual thing? They become very thick skinned. Hard nosed. It is difficult to take on these burdens, day in day out. It is wearisome. Emotionally it is very draining. So, what we want to do is, say, ‘face this patient, read accounts that we are going to give you, poems and the like, and see whether it can help you empathise with what this patient is experiencing.’ And, I feel, together with some colleagues is that empathy – that is, putting oneself in the shoes of the patient – not getting burdened by that, but just experiencing what they are experiencing, is the way for them to be more understanding of the patient, the needs of the patient, and also to survive. Because, 40 years later, they’ve still got to be doing the same thing. There is an estimate that there are 200,000 clinical encounters in an average medical lifetime. And a lot of them are of this distressing variety. So, over these 40 years, 200,000 encounters, don’t become routinised, don’t become stereotyped, don’t pigeonhole yourself, allow yourself to reflect constantly on what you are doing, on what impact somebody’s suffering is having on you. To remain always curious, and interested. Find out about your patients beyond their symptoms; learn about them as human beings, some sort of empathic resonance. So, that combination of getting really into the experience of the patient in a structured way, not just wild and woolly and also using the arts, it has got a tremendous potential, to win over the student to be this interested, empathic, lively, curious individual.

JACKY ANGUS
Sounds like you’re doing a very good job, professor. Thank you very much for coming on Up Close.

SIDNEY BLOCH
Pleasure. Thank you.

JACKY ANGUS
Relevant links, a full transcript and more information on this episode can be found on our website at upclose.unimelb.edu.au. We also invite you to leave your comments or feedback on this or any other episode of Up Close. Simply click on the ‘add comment’ link at the bottom of the episode page. Melbourne University Up Close is brought to you by the Marketing and Communications Division in association with Asia Institute of the University of Melbourne, Australia. Our producers for this episode were Kelvin Param, Eric van Bemmel and myself, Jacky Angus. Audio recording by Craig McArthur. Theme music provided by Sergio Ercole. Melbourne University Up Close is created by Eric van Bemmel and Kelvin Param. I’m Jacky Angus, until next time, thank you for joining us on Up Close.  Goodbye.

VOICEOVER
You’ve been listening to Melbourne University Up Close, a fortnightly podcast of research, personalities and cultural offerings of the University of Melbourne, Australia. Up Close is available on the web at upclose.unimelb.edu.au, that’s upclose.u-n-i-m-e-l-b.edu.au. Copyright 2008 University of Melbourne.