The ‘complex relationship’ between patient autonomy and safety

Ethical challenges in psychiatry that arise from the vulnerable position of patients and the “very complex relationship between medical ethics and legal standards” featured significantly at the College of Psychiatrists of Ireland (CPsychI) and Royal College of Psychiatrists in Northern Ireland Winter Conference 2025. Topics ranged from complex case studies and challenging decision-making to research data, formal guidance, and recommendations.

Prof Meryam Schouler-Ocak, Professor of Intellectual Psychiatry, Charité – Universitätsmedizin Berlin, Germany, delivered a comprehensive update on the recently revised European Psychiatric Association (EPA) Code of Ethics.

Prof Schouler-Ocak, who is a board member of the EPA, Chair of the committee on ethics of the EPA, and board member of the World Association of Cultural Psychiatry, discussed many of the most complex issues in psychiatry, such as assisted dying, involuntary care, and ethics in digital health.

She began by introducing the current EPA committee on ethics – a diverse group of five female and five male experts “from very different parts of Europe” – that represents the “very different values, cultures, and moral standards” reflected in modern, multicultural societies. The differing ways in which autonomy is exercised in various cultures was a focal point throughout the presentation.

Prof Schouler-Ocak also reflected on some of the darker periods in the history of psychiatry that involved the “misuse of power”, “violations of boundaries and human rights”, and ultimately led to the development of the first code of ethics by the American Psychiatric Association in the 1970s. She also reinforced the importance of the core ethical principles – respect, beneficence, non-maleficence, and justice – describing them as “the cornerstones of modern codes”.

Throughout her talk, Prof Schouler-Ocak highlighted important areas for ethical consideration, ranging from the doctor-patient relationship and informed consent to decision-making, confidentiality, resource allocation, and coercion. She advised against involuntary detention when possible, calling it “a last resort”, and recommended supported, rather than substituted, decision-making unless no other options are viable.

“Use the least restrictive alternative for the shortest duration possible,” she told delegates, and went on to discuss several major challenges that can arise when trying to balance patient autonomy, confidentiality, and safety.

This interplay of ethics, legal considerations, and clinical practice was also demonstrated during a plenary session that used anorexia nervosa, primarily people with the disorder who refuse to consent to feeding, to address dilemmas in practice. Dr Art Malone, Consultant Psychiatrist, St Vincent’s University Hospital, Dublin; Dr Eimear Dunne, Senior Registrar and Vice-Chair, CPsychI Eating Disorder Special Interest Group; and Prof Fiona McNicholas, Consultant Child and Adolescent Psychiatrist, Lucena Clinic and Children’s Health Ireland at Crumlin, Dublin, reflected on compulsory treatment orders and discussed the legal and ethical challenges practitioners often face.

“On both sides of the border we are dealing with relatively new legal frameworks in terms of decision-making capacity. We haven’t really seen how this is going to play out. We know there will be advanced care directives, but we don’t know how exactly they’re going to affect treatment. People who are signing these from a psychiatric point-of-view are probably going to be more vulnerable than those making general medical directives…. Assisted dying is also coming up more and more around Europe,” Dr Malone said.

The session looked at issues like the effects of starvation on brain structure, and subsequently on decision-making capabilities. It also described the effects of involuntary treatment on the therapeutic relationship with patients, as well as the emotional burden on the staff implementing it, and whether current approaches do actually align with the four core ethical principles.

While navigating the complexities of beneficence in anorexia nervosa management, Dr Dunne told the conference that “the research is quite negative” regarding benefits of treatment.

“For some patients, treatment just doesn’t work. Even the most restrictive and coercive measures, like seclusion and NG [nasogastric] feeding under restraint, patients will still resist it. There’s a case mentioned in the literature that only gained 1.1kg…. It’s quite unpredictable; some people will respond over time and others will not.”

Addressing the principle of justice, specifically how equitably healthcare resources are distributed, Dr Dunne described it as a “really significant issue in eating disorder treatment in the Republic of Ireland because we have very unequal access to treatment”.

“There are still some areas that don’t have access to specialist eating disorder teams, and when we are thinking of inpatient care for adults, the situation is even worse. We only have three public inpatient beds in the Republic of Ireland for eating disorder treatment, so, we have to think really carefully about who would benefit most from these inpatient beds, and how we use them in the most equitable manner.”