SRI LANKA COLLEGE OF PSYCHIATRISTS

The guideline addresses the following topics pertaining to the role of a Psychiatrist.

1. Psychiatrists shall respect the dignity and autonomy of all patients
2. Psychiatrists shall never exploit patients physically, emotionally, sexually or financially
3. Psychiatrists shall provide the best possible psychiatric care for the patients
4. Psychiatrists shall uphold the confidentiality of their patients
5. Psychiatrists shall always obtain valid consent before undertaking any procedure or treatment
6. Psychiatrists shall not misuse professional knowledge or skill to degrade human rights
7. Psychiatrists shall endeavor to maintain and develop their professional knowledge and skills and share the knowledge and skills appropriately with their colleagues, trainees, patients and care givers
8. Psychiatrists shall adhere to national and international guidelines in carrying out research
9. Psychiatrists shall strive to uphold the integrity of the profession
10. Psychiatrists shall work to improve mental health services in the country, to reduce stigma and discrimination against patients with mental illness and treat and prevent mental illness
11. Psychiatrists shall interact and work in an ethical and transparent manner with industries and other entities

1. Psychiatrists shall respect the dignity and autonomy of all patients

   1. The Psychiatrist shall maintain a relationship with patients that is based on openness, trust, honesty and good communication
   2. The Psychiatrist shall always protect and respect the dignity and human rights of their patients and strive to protect them from exploitation, abuse and neglect, including from professionals.
   3. The Psychiatrist shall take action to prevent further abuse of patients whenever any form of abuse perpetrated on a patient is brought to their attention.
   4. The Psychiatrist shall never discriminate against patients based on their ethnicity, religion, age, social status, caste, political opinion, disability, gender, occupation or sexual orientation.
   5. The Psychiatrist shall never impose their political, religious or moral belief on patients.
   6. The Psychiatrist shall always respect and promote the autonomy of patients by adopting the least restrictive treatment option and by reserving any compulsory treatment intervention only to restore the autonomy and welfare of the patient.

2. Psychiatrists shall never exploit patients physically, emotionally, sexually or financially

   1. The Psychiatrist shall always be aware of the vulnerability of their patients because of the nature of their illness and of the impact of the conduct by the Psychiatrist on the therapeutic relationship, which is private, sensitive and emotional and generally more intense than other relationships.
   2. The Psychiatrist shall never have sexual relationships with their patients.
   3. The Psychiatrist shall refrain from financially exploiting their patient especially in the private sector by abiding to the following ethical recommendations.
      1. Where fees are levied for professional services it shall be reasonable and appropriate and proportionate for service rendered .
      2. Adequate time shall be allocated to each patient according to their need
      3. Abstain from imposing unnecessary investigations or treatments on patients.
      4. Maintain punctuality towards patient appointments.
      5. Refrain from engaging in private practice during normal government duty hours.
      6. Desist from receiving, soliciting or offering commissions, gifts, bonuses or gratuities for referring, recommending or obtaining any investigations or treatments that includes prescribing branded medications to any patients.

3. Psychiatrists shall provide the best possible psychiatric care for the patient

   1. The Psychiatrist shall provide the best treatment option which is evidence based and in line with accepted scientific and clinical practice.
   2. The Psychiatrist shall consider not only the illness aspect but also the physical, social, cultural and spiritual aspects when providing care.
   3. The Psychiatrist shall not seek treatment options based on financial and other gains to themselves.
   4. The Psychiatrist shall adhere to the best available treatment guidelines and shall seek second opinion at the earliest possible, when it is deemed necessary.
   5. When choosing certain treatment options like electro convulsive therapy the Psychiatrist shall adhere to the best available treatment guidelines. If in doubt they shall seek a second opinion at the earliest possible opportunity.
   6. The Psychiatrist shall ensure the follow up care of all patients who areunder their care including those discharged from the institutions.
   7. The Psychiatrist shall keep a comprehensive and legible treatment record of all patients.
   8. The Psychiatrist shall discuss with patients and their care givers the treatment options in a clear and honest manner and ensure their participation in the decision making as much as possible.
   9. The Psychiatrist shall endeavor not to treat their close relatives, colleagues or friends.

4. Psychiatrists shall uphold the confidentiality of their patient

   1. The Psychiatrist shall not directly or indirectly reveal information of a patient learned during the professional relationship to a third party.
   2. The Psychiatrist shall take adequate measures to protect clinical records or computerized databases of patients from those not involved in the care of the patient.
   3. The Psychiatrist shall make every effort to protect the identity of the patient used in teaching as clinical material by keeping the personal information to a minimum and disguised as far as possible.
   4. The Psychiatrist shall explain the purpose of the interview and the potential for breach of confidentiality whenever the interview is done for medicolegal purposes.
   5. The Psychiatrist shall disclose only the necessary information at events of disclosure to a third party for legal, safety or clinical purposes.

5. Psychiatrists shall always take valid consent before undertaking any procedure or treatment

   1. The Psychiatrist shall take consent from patients whenever possible before imparting any treatment or procedure unless the capacity to consent of the patient is impaired.
   2. The Psychiatrist shall provide all relevant information regarding the treatment, side effects, consequence of non-treatment and risks of treatment that is limited to the content which a reasonable person in the patient’s position would be likely to attach significance, before taking consent, thus making the process of consent voluntary, free and following complete understanding of the nature and implications of proposed treatment.
   3. The Psychiatrist shall ensure validity of consent from a minor by taking a consent from a child who has the capacity to give consent and taking consent from a guardian or parent when the child does not have capacity to give consent.
   4. The Psychiatrist shall get the consent of next of kin if feasible and shall undertake any necessary treatment without formal consent in case of genuine emergencies, or in unconscious patients after seeking a second opinion from one or more colleagues if there is any element of doubt, with a view of saving the life of the patient or to prevent deterioration.
   5. The Psychiatrist shall act according to the prevailing law of the country especially regarding mental health and obtain consent for specific treatments as per a normal patient from patients having capacity. In the case of patients who lack capacity due to unsound mind, they shall act in the best interests of the patient by obtaining approval from a guardian, treatment team or relatives and shall not hesitate to get the second opinion of a colleague if necessary.
   6. The Psychiatrist shall be aware that a judicial order at forensic examination does not preclude the psychiatrist of his ethical obligation to bypass a valid consent, though he may be legally relieved for not obtaining the consent. Therefore, they shall explain to the patient the legal implications and if the patient refuses consent, the psychiatrist shall inform the courts about the unwillingness of the patient and provide any objective (external) findings to the courts.
   7. The Psychiatrist shall undertake assessment for insurance purposes, fitness to work or immigration purposes only when the patient has given written consent for examination and disclosure of information

6. The Psychiatrist shall not misuse professional knowledge or skill for personal gain or to cause harm to others

   1. The Psychiatrist shall not diagnose or be biased in diagnosing a patient as mentally ill based on a patient’s political, religious, ideological, philosophical or moral beliefs or according to their age, sex, ethnicity, race, language, religion, social status, sexual orientation, political affliction, disability or language.
   2. The Psychiatrist shall not participate in any form of punishment, torture, degrading interrogation or facilitation of executions and shall report whenever those are brought to their attention.
   3. The Psychiatrist shall understand their dual allegiance when working for armed forces, intelligence services or prison services and act in the best interest of the patient and seek advice from experts when confronted with an ethical dilemma or seek second opinion of a psychiatrist free from such conflict of interest.
   4. The Psychiatrist shall adhere to ethical guidelines even when involved in clinical care during times of conflict and war.
   5. The psychiatrists shall not violate human rights misusing their professional knowledge or skill

7. Psychiatrists shall endeavor to maintain and develop their professional knowledge and skills and share knowledge and skills appropriately with their colleagues, trainees, patients and their care givers.

   1. The Psychiatrist shall develop and update their professional knowledge and skills by actively pursuing continuous professional development and including validation processes where available
   2. The Psychiatrist shall contribute to develop and maintain knowledge, skills and standards of practice of their colleagues, trainees and other health professionals.
   3. The Psychiatrist shall educate their patients, caregivers and the community at large in order to improve their wellbeing.
   4. The Psychiatrist shall take measures to educate the general public about professional ethics
   5. The Psychiatrist shall ensure and have confidence that the third party has the skills, training, ethical standards and capacity to meet the needs of a patient before referring that patient to a third party that includes another professional, paraprofessional or outside practitioner.
   6. The Psychiatrist shall supervise trainees and provide appropriate professional support and guidance to trainees in psychiatry or other allied mental health professions, thus enabling them to provide the best available service to the patient.
   7. The Psychiatrist shall not misuse the inherent power imbalance and refrain from exploiting the relationship with trainees under their supervision for financial, personal or sexual gains.
   8. The Psychiatrist shall attend to their own health and wellbeing and that of their colleagues, trainees and students.

8. Psychiatrists shall adhere to national and international guidelines in carrying out research

   1. The Psychiatrist shall get ethical approval from established ethical committees prior to carrying out research and adhere to approved protocols
   2. The Psychiatrist shall ensure that the research is scientifically and ethically sound.
   3. The Psychiatrist shall obtain valid consent prior to research and ensure that the vulnerability or therapeutic dependence of participants has not interfered with the consenting process.
   4. The Psychiatrist shall ensure that minors are involved in consent procedures for research on children even if they lack capacity to give consent and consent is obtained from parents or guardians as well.
   5. The Psychiatrist shall critically analyze the need for obtaining a consent on a research that involves participation of people who lack capacity to give consent due to mental illness or developmental problems.
   6. The Psychiatrist shall ensure that the patients or caregivers shall not be coerced to participate in research or not penalized in any way for refusing to participate in the research.
   7. The Psychiatrist shall ensure the safety of the participants and confidentiality of the information and any safety concerns or breach of confidentiality shall be fully discussed with participants prior to getting their consent.
   8. The Psychiatrist shall consider all potential conflicts of interest prior to conducting research and ensure that they do not interfere with the research or treatment.
   9. The Psychiatrist shall ensure that the said research publication focuses only on improvement of scientific knowledge and not on any personal gains, and even negative results or outcomes shall be published.
   10. The Psychiatrist shall maintain honesty and integrity during the whole research procedure including publication.
   11. The Psychiatrist shall ensure that the research they undertake complies with intellectual property standards.

9. Psychiatrists shall strive to uphold the integrity of the profession

   1. The Psychiatrist shall promote mutual respect among colleagues, other health professionals and patients.
   2. The Psychiatrist shall take appropriate action, according to the health and legal regulations in the country when they become aware of unethical practice or behavior of a colleague that may dishonor and harm the patients, profession or themselves.
   3. The Psychiatrist shall endeavor to promote a working / professional environment of mutual respect free from any form of discrimination.
   4. The Psychiatrist shall inform the relevant authorities and arrange necessary supportive care for the colleague who becomes impaired ( who is unable to fulfill professional or personal responsibilities)
   5. The Psychiatrist shall take appropriate actions to protect the rights of patients whenever incapacity of a colleague is brought to their attention.
   6. Psychiatrists shall express their views respectfully in a manner that avoids self promotion or denigration of others

10. Psychiatrists shall work to improve mental health services in the country, to reduce stigma and discrimination of patients with mental illness and treat and prevent mental illness

    1. The Psychiatrist shall take leadership or join other administrators to improve psychiatric services in the country and promote the wellbeing of patients with mental illness and of the community at large.
    2. The Psychiatrists shall advocate to ensure best available care for patients with mental illness.
    3. The Psychiatrist shall protect identity of patients and desist promoting their self-image whenever speaking to the public including the media and focus on disseminating scientific and evidence-informed knowledge.
    4. The Psychiatrist shall ensure people with mental health problems can easily access treatment close to their homes in least restrictive settings by closely working with primary health care teams.
    5. The Psychiatrist shall ensure continuity of care by breaking barriers between various health care levels.
    6. The Psychiatrist shall endeavor to reduce stigma and discrimination towards people with mental illness by educating about mental illness and treatment to service providers in the government, non-government organizations as well as the community at large.

11. Psychiatrists shall interact and work in an ethical and transparent manner when dealing with industries and other entities including pharmaceutical companies , NGOs and other organizations

There is potential for psychiatrists to be influenced by competing interests when dealing with the primary interest that is the patient’s welfare or validity of research. Psychiatrists shall endeavor to avoid yielding to this influence and shall declare if there is any conflict of interest

1. 1. Working with industries and other entities
      1. The Psychiatrist shall ensure that any contributions received from industries and other entities and other entities will be handled in a transparent and accountable manner
      2. The Psychiatrist shall refrain from working, or avoid been seen to be working in agreement with industries and other entities to promote their wares or products.
      3. The Psychiatrist shall ensure that patient care and medical judgement are not compromised or appear to be compromised by any incentives offered by the industries and other entities.
   2. Gifts and grants
      1. The Psychiatrist shall desist from accepting any gifts or grants from industries and other entities if that acceptance influences clinical judgement, selection of drugs, devices or other modalities of treatment.
      2. The Psychiatrist shall ensure that any gifts accepted by psychiatrists shall be of modest value and benefit the patients and serve an educational function Eg.textbooks, journals, audio visual aids.
      3. The Psychiatrist shall refrain from accepting any gifts from industries and other entities given in recognition of their nature of practices.
   3. Contributions to CME activities, CPD activities, conferences, symposia, seminars and workshops
      1. The Psychiatrist shall ensure that all contributions to above shall be made through professional organizations, associations or institution
      2. The professional body shall have full control of the title, educational and/or scientific content of any event or product and the level of advertising.
      3. Entertainment, hospitality or any gifts offered shall be secondary to the main purpose of the meeting and not be ostentatious or extravagant and shall not extend beyond immediate family.
      4. The sponsorship by industries and other entities shall be clearly stated at the conference or any published proceedings.
      5. Every effort must be made to attract a wide range of advertisers – including government agencies, charitable trusts and foundations, as well as commercial and other organizations – so that the professional body is not overly dependent on any one source of commercial funding.
      6. Gifts and promotional items on exhibitors’ stands shall be inexpensive and educational in nature.
      7. Any advertisement shall not be construed as if the professional body endorses any product.
      8. Every effort shall be taken to prevent inappropriate dominance or intrusive presence of commercial or other organizations at meetings by professional bodies.
      9. The professional body shall not grant implicit or explicit endorsement when a pharmaceutical or other commercial organization organizes its own educational meeting.
      10. The Psychiatrist shall ensure that all fellowships and sponsored trips are limited to educational purposes.
   4. Psychiatrists shall ensure that whenever they have financial or commercial interest in organizations providing health care, pharmaceutical or biomedical companies and NGOs these must not affect their prescription, referral or treatment pattern.
   5. College representatives and College activities
      1. The Psychiatrist shall declare any competing interests in the event of being appointed to the Council of the College or being involved in College activities.
      2. The Psychiatrist shall declare any conflict of interest whenever they deliver academic lectures or author scientific publications.
      3. The Psychiatrist shall undertake to attend any meetings organized by industries and other entities only if they are satisfied that these meetings are primarily educational in nature
   6. Psychiatrist shall refrain from accepting any honoraria from industries and other entities to speak at any College meeting
   7. Psychiatrists shall disclose conflict of interest to relevant parties when it is going to interfere with patient care and other duties

References

• Guidelines on ethical conduct for medical & dental practitioners registered with Sri Lanka Medical Council. Sri Lanka Medical Council. July 2009Sri Lanka medical council.
• Instructions on serious professional misconduct to medical practitioners and dentists. Sri Lanka Medical Council. July 2009Royal college of psychiatrists. Good psychiatric practice. Code of ethics. CR 186. Royal college of psychiatrists. 2014
• Royal college of psychiatrists. Good psychiatric practice. Relationships with pharmaceutical and other related organisations. CR 202. Royal college of psychiatrists. 2016
• Royal Australian and New Zealand college of Psychiatrists. Code of ethics. Fifth edition. Royal Australian and New Zealand college of Psychiatrists. 2018
• American Psychiatric Association. The principles of medical ethics with annotations especially applicable to psychiatry. 2013 edition. American Psychiatric Association. 2013