THE ACTIVITY OF THE CHILD AND ADOLESCENT PSYCHIATRIST AS OBJECT OF ETHICS AND LEGAL MEDICINE

The paper presents ethical infringement and abuses in the paedopsychiatrical practice. We emphasize the fact that, on many occasions, these abuses are the inherent consequence of its complexity and of its socio-cultural and economic implications. Six categories of factors are identified which make the paedopsychiatrist face dilemmas, contradictory situations, loyalty conflicts, constraints and obstacles. In order to overcome them, although well intended, he/she has no choice but to go for the lesser evil, to willingly run risks and assume responsibilities, some of them having a juridical potential. As well as that, these issues have to be known by all those interested in assessing the professional activity of the paedopsychiatrist.

Irrespective of the psychiatrist’s option, the relation to his patient, even if a non-intervention one, implies assuming a risk and engaging his moral accountability. 

Medico-legal psychiatry has two distinct components outlined by Pollack in 1974 as stated by Rappeport (2000/1991). The first one is the more comprehensive, addressing medical and legal valences of psychiatry respectively, the interdisciplinary field of the two specialties, where the psychiatrist helps the law. We should point out from the very beginning that the relationship between psychiatrist and patient is compelled to abandon its private character; patient’s confidentiality and his/her right to be defended are retracted even when this is not in the interest of the latter.

The second component is the one firmly envisioned by the Hippocratic Oath. It has acquired new dimensions with the increasing interest in medical ethics and malpractice. It focuses on the psychiatrist and his work as a possible object of ethical and legal medicine norms. The paedopsychiatrist is no exception. We will further refer to him.

Areas of medical ethics and of child and adolescent psychiatric malpractice.

Keeping their own nuances, most areas are common to those found in adults.

 1. Errors in diagnosis and treatment, including the case of a healthy person. They are unintentional but serious in consequences. They are due to superficiality, carelessness, haste, excessive pride, and insufficient patient information, incorrect assessment of the risk /benefits relation, override of competencies or deficiencies in professional training. It is understood that, although unintended, the errors are attributable to the psychiatrist. This is because on the one hand, the duty of the paedopsychiatrist is that of being competent, and an excuse such as “I did not know” has no value. On the other hand, exceeding the certified level of competence, as it sometimes happens in other medical specialties, is not permitted either. Of course, such mistakes should be definitely separated from errors due to current limits of knowledge or to totally atypical manifestation of mental pathology of which, erroneously, sometimes the psychiatrist is held responsible.

– Abuse and violations of psychiatric ethics. They take many forms:

a – Intentional formulation of a psychiatric diagnosis as well as institution of a treatment to a healthy to a minor, or their deliberate modification for non-medical purposes. The act has criminal connotations. It can be made ​​at the request and the benefit of: third parties, institutions, the child’s guardians (parents, caregivers, persons or institutions invested by law with the responsibility of the child’s welfare) or the patient. Examples are numerous, abuse can take place in case of divorce, child custody, personal harm, adoption, dissolution of adoption, etc., where, by abuse, one party is favoured. Also, there are exceptions, where the diagnosis is sought for hospitalization and even institutionalization of the minor, his/her framing in a category that provides rights to different social and medical aids, exoneration from guilt of committing crimes or abortion at an age beyond the legally permitted limit and even supporting inappropriate exemptions from school. In addition, such actions can have negative consequences, both immediate and in the long term, which are ignored for the moment. Such consequences may be: risk of social stigma and exclusion, risk of the diagnosis being recorded in the health record, that may disadvantage the patient at school or professional orientation, in being employed in certain positions, when applying for a driver’s license, at marriage, when he/she is required to notify her or his partner of the situation, etc.

b – Ignoring the requirement to apply and obtain informed consent. Of course, the intervention without the minor’s consent is the usual rule. This is because, as we know, (according to the Criminal Code – 2008) by the age of 14, the minor child is considered incompetent to decide, and between 14 and 16 years of age, one must prove that he/she has such a capacity. In addition, it is not the calendar age but the mental age that is taken into account. In fact, there are not few the situations when the child does not understand why he/she is brought to a psychiatrist and has to follow a treatment, which he/she even refuses. Therefore, for any intervention in children and adolescents, there is need for consent from competent parents or guardians, and in its absence, in case of their incompetence or refusal, it is necessary to have the opinion of a committee of specialists.

c – Ignoring the justified interests of the child when they do not coincide with those of his/her parents or  guardians, of the community or of the law and the intervention is consistent with the latter’s option. This time, the paedopsychiatrist is placed in the position of passive bidder of on-demand services, which is also an abuse.

d – Abuses also include excess of investigations and polypragmasia (polypharmacy) or administration of excessive medication doses in the erroneous belief that in this way results are obtained faster or better. This type of abuse may be a result of pressures from school and from various institutions concerned to take comfort or social control over the patients with undesirable behaviour. It is known the acceptance of excessive sedation required by staff in institutions for children and even by parents or guardians, who want to have control and quiet.

e – Institutionalization without real justification. It is a form of abuse, highly publicized today with children and adults with mental disorders being placed in long stay institutions by those whose duty is to take care of the children either in the family or in the community. We believe that this kind of abuse should not be detailed as there has been a lot of debate on the subject of hospitalism and of its consequences (see also Milea -2002) and we have been witnesses to such methods of intervention subordinate to the custodial orientation that dominated the worldwide in first half of the past century. According to this orientation, more or less profiled institutions are the most recommended, efficient, and effective solutions for the care and treatment of certain categories of minors’ disabilities. Moreover, in the past, even healthy children were victims of the intention to relieve the family by placing them in weekly nurseries and homes.

f – Desinstitutionalization and brutal integration in the community has its own shortcomings (Bloch and Chodoff-1991) if made ​​without proper assessment and previous training. On this plan, there are the well-known examples from countries like Italy and the United States as well as from Romania, as we shall see further.

g – Omissions, superficial character in compiling psychiatric medical documents. The patient’s data may be recorded inaccurately or by persons without the required competence or without knowing who is responsible for what has been recorded. It is known the fact that these records may be required anytime throughout the patient’s life, being important medico-legal documents.

h – Psychiatrization of undesirable or unpleasant events or feelings or of social problems such as: suicide, sadness, misery, distress, false beliefs, opposition, nonconformity, juvenile delinquency, some forms of deviance and abuse of psychoactive substances, difficult or flighty behaviour, etc. They can easily become diagnoses (depressive disorder, anxiety, ADHD, etc.), due to the necessity to justify a consultation that it was Driven attitude and certification need a consultation (Milea – 2009), which means unnecessary treatment, stigma and even hospitalization.

i – Infringement of the right to privacy, respectively the psychiatrist’s obligation to safeguard confidentiality in relation to patient information.

j – Overriding prerogatives and formulation by the psychiatrist, in the preliminary stages of the court decisions, of opinions concerning discernment, accountability and even solutions necessary to the child because they are the exclusive tasks of justice and these facts mean interference with the functions of the court.

k – Expressing an opinion publicly, of without directly consulting minor or without making this fact known.

l – Non-intervention. We consider here a passive, resigned attitude, even refusal to provide necessary care.

m – Care provided under the optimal level is also a form of abuse, the right to receive “good” treatment is after Appelbaum and Gutheil (quoted by Brown -1991) more important than declining it.

n – Conditioning care is also an abuse with criminal connotations.

Comments

Certainly, at a superficial level, the aspects mentioned above seem easily preventable because psychiatrists know what has to be done. The following would seem sufficient: • Good professional training, • Implementation and compliance with certain firm criteria of diagnosis and therapeutic guidelines •  scrupulously obeying what Chodoff (2000/1991) called ethical behaviour and Wing (2000/1991) the central ethical principle that dictates the physician not to act knowingly against the interests of the patient and to take all measures not to act like that even unknowingly, and, of course, the Latin dictum “primum non nocere” • Request of consent and respect for the right to decide of those responsible for the child; • Refrainment from providing direct public opinion without examining the specific case and without specifying this; • Compliance with the duty to decide as opposed to the minor’s or his/her parents’ or guardians’ option, only after the opinion of a committee of specialists; • Enforcement of the law; • Cautiousness; • Strict compliance with the status of a servant of the truth.

Nevertheless, as we shall see, things are not so simple. In fact, although being good and honest-minded, the physician is faced with particular situations or contradictory dilemmas, conflicts of loyalty, constraints, etc. which he/she you cannot surpass without making a choice and thus assuming, knowingly, risks that involve moral and sometimes legal responsibility for his/her actions. So, there are not few the violations of psychiatric ethics, the abuses that the paedopsychiatrist commits, being forced or constrained or even obliged to do so without being fully guilty or that he/she could be asked to explain.  At least six groups of factors interact in various combinations in these situations.

A – In mental disorders, knowledge has still a limited character, which leaves room for the unknown, controversies, ambiguities, uncertainties and alternatives whose ending is only possibly a good one. For example, if in psychiatry one speaks of the myth of mental illness (Szasz, 1961 and the advocates of the anti-psychiatric concept), medical ethics faces two extreme views. One promotes the idea of ​​the full freedom of the individual and argues that the patient’s opinion is sovereign and that it cannot be ignored not even when it is threatening the others and that physicians should consider this option only. The second view, with paternalistic accents, equates the refusal to accept treatment with the denial of the illness, which means mental disorder, that is, incapacity of decision. Moreover, most of the time, knowledge represents statistical truths, therefore, in practice, the physician does not know if the case in question falls within the rule or is an exception. Of course, in order not to be fully responsible, the physician is obliged to observe the diagnostic and therapeutic guidelines. Even so, faced with exceptions that represent a significant percentage of cases, he takes care, at least, of his/her professional prestige. In addition, as I used to mention in 2010, the psychiatric clinic offers on show appearances, which hide very well what is essential. In this respect, the example of what today we call ADHD (Attention Deficit / Hyperactivity Disorder), which was considered a hyperkinetic disorder for decades, is far from being singular.

B -The fact that by the specificity of his/her activity, the paedopsychiatrist is, on the one hand, accountable for his/her actions, and on the other hand, his/her accountability is extended beyond the patient. Thus, he/she is obliged at the same time to observe the truth and moral codes that are not enacted, to advocate the child, to be loyal and to serve the patient, his family members, the community and the law given that their options are sometimes interested, sometimes totally different or, worse than that, unjustified and even incorrect. For example, in case of divorce or custody, the individual interests of the child and of the parents are often very different. Peele (2000/1991) states that confronted with the interests of the mentally ill, those of justice courts and of psychiatry do not overlap. While the law courts seek to do justice and to ensure the least restrictive solutions for the patient, psychiatry is concerned to restore the patient’s health and to ensure optimal environment, which means that it overrides the interests and preferences of the latter. Besides, the law does not provide absolute protection to the paedopsychiatrist, either. This is because, as Quin has pointed out (quoted by Joseph and Onek, 2000), only those outside the legal field are convinced that there is an abstract entity called law, which is safe, solid, predictable and standardized. In fact, it is unlikely that the judiciary system should consider and totally cover all ambivalent situations that the paedopsychiatrist faces in his/her job.

C- In psychiatry, almost all types of investigations and treatment are risky, have unwanted expected effects, both foreseeable and unexpected, some of them very serious. This statement is completely justified in the case of antipsychotic medication drugs, where prospects abound in warnings and dependence, the neuroleptic malignant syndrome and tardive dyskinesia lurk in the shadows. Moreover, while today the paedopsychiatrist has increasingly more therapeutic solutions for the same type of disorder, in the area of mental disorders we treat neither symptoms nor syndromes, or clinical entities but complex neurobiological dysfunctions. Their level of knowledge does not allow for certainties in the choice of effective and safe psychoactive drug with the lowest risk. In this respect, the example of depressive disorder is very conclusive. The therapist is compelled to choose between preparations with selective action on nonoamine oxidase, serotonin, dopamine, norepinephrine, histamine or melatonin without having definite landmarks as to the optimal solution.

D – The presence of what Reich (2000-1991) describes as a particular set of external factors that induce the psychiatrist (and the paedopsychiatrist) to make mistakes and to breach the norms of psychiatric ethics without a purpose, and even to commit abuse. This situation happens despite the fact that the psychiatrist has adequate professional knowledge and even good intentions, we may add. Of the above-mentioned factors, we must point out the following:

• The psychiatric diagnosis involves a variable degree of subjectivity. • Normality in the individual’s behaviour has a social connotation, which requires a variable system of norms. • It is not easy for the psychiatrist to realize, recognize and accept his/her limitations and those of the diagnostic systems he/she is using. • Psychologically, it is easier for a physician to accept and to support a diagnosis than to recognize that he/she does not know for sure what the problem is. • There is a general temptation to explain by a mental illness everything that goes out of bounds or has no reasonable explanation, respectively the ease of preferring a diagnosis for everything that is abnormal, that we do not know or we do not understand what it is. Thus, violation of rules, eccentricities, cultural influences or forms of deviant behaviour can easily get a diagnostic label. In addition, Mechanic (2000/1991) notes that the psychiatrists (and the parents or guardians who decide on behalf of the minors, we may add) are influenced by their own biographies (in this case by their own childhood, too). They may also act against the patient’s wishes because they are convinced that they know (as much as they are able to know) the patient’s best interests. Let us remember, for example, how often in the daily reality, even well-meaning parents think they know better what the best interests of their children are, forcing them to submit to their option without the ulterior reality to confirm their choice.

To these factors, we may add some more:

• The concern for an as early diagnosis and treatment as possible; (They are considered premises of a preventive attitude and of a a more favourable prognosis) i.e., when symptoms are more modest and the clinical picture incomplete; • The habit learned during the practice of general medicine, that, for precautionary reasons, when we are not sure yet, it is preferable to opt for, and proceed according to the worst hypothesis. In the case of mental illness, such an attitude may well be equated with abuse. This is because it involves high risks: adverse treatment, stigma, and marginalization. For example, it is inadmissible to diagnose schizophrenia based only on simple assumptions and then to deny it, even if with an apology. • And, of course, the strain affecting the psychiatrist and the physician-patient relationship if the former has postponed, based on objective reasons, a definite answer or the immediate institution of treatment, respectively, satisfying the patient’s right to promptly instituted measures

E – It is well known that mental disorders are closely related to and involved in the social context in which they evolve. That fact, said Bloch and Chodoff (2000/1991), generates ethical conflicts. In turn, giving more details, Mechanic (2000/1991) adds the influence of learned ideologies and of economic and organizational constraints, which adversely affect the profession.

As such, dependence of paedopsychiatric practice on socio-cultural and economic factors compels the specialist to consider not only the minor’s interest but also: • the insufficient resources and means of investigation;  • the requirement of  protecting the society and sometimes, exaggerating, the social control; • The limited nature of available solutions and of the access to services; • The cost / benefit ratio, and even, as we shall see, the political pressure.

F- There are not few the complex and even serious or urgent cases where there time to waste, there are no rigorous solutions or they do not meet consensus of all parties involved. His moral conscience prevents the paedopsychiatrist to reconcile to the situation and makes him opt for decisions based only on statistically valid facts, therefore he ignores the unknown links of reasoning and the unexpected and knowingly accepts the risk of unintended harm, which engages his accountability.

Dilemmas, particular or contradictory situations, loyalty conflicts, constraints, etc., some of them with legal potential.

Out of their great number, we shall mention a few:

a. The obligation to seek informed consent. Sometimes, it is a first difficulty whose surmounting requires an informed interlocutor, convincing effort, persistence and returning, and, of course, time. This is because, on the one hand, the ethic code requires an informed consent, which means, among many other things, explaining the meaning, at the interlocutors’ level of understanding, of what is to follow, especially the risks to be assumed. On the other hand, as we have already pointed out, in children and adolescents, usually, the consent must be obtained from the next of kin or a legally recognized substitute decision-maker, which means more parties involved. Sometimes they are not all in agreement, other times they prefer to think over and even find it difficult to understand what they are told and to accept what is requested from them. Certainly, the routine procedure, which requires only a signature at the bottom of a standard form, does not provide any legal protection declare Dermengiu and Curcă (2001).

b – The obligation to make choices when confronted with many conflicts of loyalty and responsibilities, within the same case:

• To choose, depending on the minimum predictable risk;
• To deliberately ignore the other responsibilities, that are not in agreement with the chosen solution;
• To assume consciously the risk of being responsible for negative consequences of his choice, including the defiance of obligations, which he, naturally, had no way to take into account. For example, there are situations in which the adolescent with decision-making capacity and behaviour disorders refuses to be consulted and treated. On the other hand, his caregivers and the community accuse aggressive behaviour, the school and the others in his background want him excessively sedated and even hospitalised to avoid the risk of supposed relapse or of his dangerousness, while excessively stringent rules of medical ethics consider that only the interests of the minor matter.

c – Dilemmas and acknowledged risks related to the choice of therapeutic conduct because: Very often, without having certitudes, the paedopsychotherapist is forced to decide on a solution out of several possible options, all of which with predictable and unpredictable risks, and whose effects are only likely to be good.  This particular solution holds the promise of an optimum disadvantages / benefit rate, i.e. the lowest hypothetical risk. Of course, in such cases, the informed consent is a shield that, in case of failure, protects him from the law but not from his own conscience. Particularly delicate, and not at all unusual, is the situation of the therapeutic option and consequently of acknowledged responsibility, when, for whatever reason, the paedopsychotherapist has not obtained the informed consent. Such situation may be medical emergency, absence or incapacity of those entitled to give the consent. Except for emergencies, in these cases, intervention should follow the advice of a committee required by law and established for that purpose which means the risk of delay.

Even more complicated is the situation where consent is refused, even after efforts to motivate the need for intervention. Let us not forget that there are not the few situations where the caregivers come to consultation only after insistence on the part of the school staff. They are hard to persuade to accept treatment because what they want more is the invalidation of the idea that some kind of mental illness is present. Some of them belong to a category of parents or guardians who go from specialist to specialist in hope of confirming their opinion. Others believe wrongly that only they know what is best for their child. In such situations, as appropriate, either an acceptable therapeutic alternative is found or the paedopsychotherapist recourses to the idea of a treatment enforced with the help of a committee of experts. Of course, there is the possibility of a passive attitude covered by ethical considerations stating that the option of those entitled to choose is sovereign. In fact, in terms of some ethical views, it is still questionable whether and to what extent the rights of those affected by the consent to refuse prevail over the judgment of the commission of specialists. It may however replace clinical judgment with the wish of the caregivers, which also may be considered a fault. Therefore, in case of refusal, the paedopsyciatrist is obliged, at least morally, to insist, to seek the opinion of the committee and to take risks, even higher, as he is confronted with hostile caregivers who can call him to account. In favour of an active attitude comes the common finding that, once the response to treatment becomes visible, an important part of these beneficiaries acknowledge that it was a good decision not to consider their opinion. One must add here the risk of indiscriminately applying the rule according to which refusal, in the context of adequate information, is evidence of denying the existence of disease and thus the existence of a mental disorder, which affects the ability to make decisions.

It is good to know that, in case of using the opinion of a panel of specialists, the paedopsychiatrist’s responsibility does not diminish too much because, as stressed by Chirita and Chirita (1994), in this case, the physician assumes all risks.

d – Rigorously respecting patient’s confidentiality is an apparently simple problem because it seems sufficient to keep total discretion in all data regarding the minor. This is not a situation without hopeless solutions. In this case, Joseph and Onek (2000/1991) state that, even when working with children, the ethical principles, which guide the adult psychiatrist, should be changed radically. In addition, the rules differ according the child’s age.

In fact, at this level, opinions range from the extreme views that nothing could be revealed without patient’s or caregiver’s consent, to what Sigler (1982) said speaking about confidentiality, namely that the realities of modern practice make it a decrepit concept. Anyway, there are provisions of law today, which, varying from country to country, refer to exceptions to the rule of absolute confidentiality and privacy and we speak now of extended confidentiality (Wing, 2000/1991). This means that patient information can be shared with the therapeutic team and the responsibility is  assumed by its coordinator. All these have made Chiriţă şi Chiriţă (1994) say that “every patient should be aware that his or her right to privacy is limited.”

Actually, our problems concerning the infringement of rigorous confidentiality start with the presence of the specialty name on the office door or with pronouncing the patient’s name when invited to enter the cabinet. It continues with:

• the answer, varying from one situation to another and according to age, to the questions “what, when and how can be told” to parents or guardians or to the others and vice versa, to the child;
• with the assistance of the interdisciplinary team;
• with the need to involve school or group therapy;
• with the need for and interpretation of results from different investigations by different professionals who also need to know detailed information on the case;
• with video records, presentations of cases to students or residents, the publication of data and of scientific studies without strict compliance to the consent or anonymity;
• with the case report forms kept for anyone to see, or even worse;
• with the  release of medical records for persons other than those authorized.

All these make confidential information about patients reach places where it is not imperiously necessary, thus violating the norms of medical ethics.

The paedopsychiatrist’s situation is loaded with responsibility.  In more than a few cases he is required by law to dispel the information in his possession or which he obtains, even if this disadvantages his patient, accuses him, or is against the patient’s will and he is not the employee of a third party (court, insurance company, school, etc.), as sometimes is the case. We exemplify with cases of sexual abuse, of antisocial behaviour or one that threatens other people, with cases involving the risk of recurrence of the disorder or with those where he is engaged in the conduct and resolution of all issues that concern justice or health insurance.

e- The superficial character of the records concerning the patient was and still is a problem especially with the current development of private health care, which makes the information in these records more difficult to recover, not only for privacy reasons but also because of mobility, discontinuity and convenience.

f- From an ethical standpoint, a touchstone for the paedopsychiatrist is represented by the temptation to resort easily to the solution of exoneration the minor from responsibility of his acts, in relation to the latter’s antisocial deeds with the help of a psychiatric argument. Such a solution seems justified to some extent because, for the moment, it apparently helps the child, which is the main duty of the paedopsychiatrist. The easiness is excused under certain circumstances and limitations by the belief that the first mistake is forgiven. But such an option is unacceptable from at least two sets of causes.

– First, it is neither ethical nor does it teach the juvenile that society has rules, which cannot be bypassed. In addition, it involves both the youth’s stigma and marginalization and the risk that the juvenile court, in need of sufficiently diversified solutions, might send the minor, for unclearly defined periods, to a medical-educational institution with children who have real and even serious mental problems. Moreover, in such situations, as well as whenever the child is hospitalized as a safety measure, the paedopsychiatrist (not the same one) becomes responsible  also for the hypothetical risk of relapse because he must take responsibility, difficult to accept, to  call off the measures. Of course, everything is approved by the medical commission, which exonerates the physician of culpability. However, prudence and especially lack of adequate community alternatives that may be relied upon and force the paedopsychiatrist to postpone the decision. Abuse is even worse when there is no way of knowing that the previous measure was exaggerated and thus, it is ignored the fact that the fate of a minor is at stake.

– Secondly, the court of justice is the only entity entitled to decide and assess with the necessary understanding the situation where the child with antisocial behaviour can be given a chance. In fact, a professional court is aware that even the community would prefer true educational measures instead of a “school” for criminals, namely the detention and rehabilitation institutions themselves. To do so, it is necessary to have both a court of justice specialised in juvenile issues, and a variety of appropriate solutions from which to choose. In their absence, the responsible paedopsychiatrist is compelled to accept compromise if he refuses to limit himself to the position of a supplier of services.

g – Passivity, reserve, excessive prudence, and even refusal of intervention are attitudes that are normally reprehensible and even attributable to the paedopsychiatrist. However, in the context of the peculiarities of mental health assistance and of current standards in medical ethics, in quite a lot of cases, there may motives or at least justifications to require a delay in therapeutic intervention. We consider here:

• The need for diagnostic certainty before the therapeutic decision. There are known situations, which require sometimes hard reaching investigations, or that require time for interpretation or need an appointment; other situations require interdisciplinary consultation and or, more frequently, a period of direct observation;
• Risks too big to be assumed in case of certain therapeutic solutions and for fear of taking responsibility without sufficient coverage;
• Time required to obtain informed consent, especially the commission’s opinion in case the parents or guardians  are not accessible or competent;
• And, of course, refusing to intervene in case of caregivers ’opposition; by doing so, the physician considers that he ought not to take risks without coverage.

h – Expression of opinion without consulting the patient directly, although it is in conflict with medical ethics, it has now become a habit, the media rushing to seek it and psychiatrists, being glad that they are appreciated, provide their opinion , based on information which is often approximate and even deformed. Breach of ethical norms is particularly serious since, very often, there are forensic cases and any statement can impair the fate of the patient , in one way or another.

i – We fully agree with the opinion of Chodoff and Bloch (2000/1991) who consider the social context in which the assistance of mental illness takes place as a factor generating ethical conflicts. This is because on the one hand, this context is responsible for the lack of material resources, of family and community support, specialist services, equipped, affordable and capable of providing the full range of diagnostic and therapeutic means, of the abusive pressure of the cost / benefit ratio and even of political imperatives. On the other hand, social context compels the paedopsychiatrist to protect the community and even exaggerating, to ensure social control to the detriment of the child. Of course, this time, the paedopsychiatrist is not directly responsible but we must not forget that he is one who, by will or necessity, accepts and applies compromise solutions by scarifying his ethical obligation to provide quality assistance. We shall illustrate only the above statement, because this is not the place to enumerate all that prevents today’s paedopsychiatrist to provide good quality care and thus, to obey the principles of medical ethics.

– Lack of modern means of diagnosis and treatment, and the difficult access to them due to poor socio-economic development and as such, non-observance by the community of what Rachlin (1982, cited by Miller -2000/1991) called the professional’s right necessary resources to fulfil his responsibilities. Their insufficiency causes the paedopsychiatrist to take the risk of mistakes. For example, it is known that, in many so-called functional mental disorders, positive diagnosis is obtained by excluding the disorders with organic substrate. And this cannot always be made without the help of modern diagnostic techniques. For example, for a psychiatrist, it is not anywhere easy to get approval for a free CT scan examination while families of children with mental disorders do not often have the necessary material resources for such a type of examination.

Lack of accessible means of investigation and treatment in outpatient conditions render the paedopsychiatrist to resort to unnecessary and traumatic admissions to hospital. Moreover and more severely, the lack family and community supportive solutions require the institutionalization of minors at risk of committing antisocial acts together with those with severe behaviour disorders.

– Of course, no one is reluctant to prefer the least expensive preparation out of the other equivalent ones. However, generalizing the rule that makes of the cheapest cost a determining factor in the choice of therapeutic conduct is an abuse. Fortunately, modern neuroleptics are not banned any longer in favour of the classical ones that in the past were promoted with priority. In fact, the former’s qualities of preserving the quality of life and reducing the size of unwanted events, thus hurrying the patient’s integration in the community, make them have no real competitor today. However, one should not forget that there are still patients today who have access only to classical neuroleptics.

– The pressure on the paedopsychiatrist’s responsibility for the protection of the community against the risk involved by antisocial behaviour coupled with lack of family and community support as well as with scarcity of complex means of appropriate psychological and educational therapy forces the paedopsychiatrist to prescribe excess doses of neuroleptics and even institutionalization.

– Graham, in 1991 (2000) wondered whether it is ethical for the paedopsychiatrist to consult, in  appropriate manner, only those whom he is able to during the time interval at his/her disposal or, at a more superficial level, all those patients waiting at the door.  But, in our country, it is well known the fact that the paedopsychiatry network is well below the necessary level of functionality.

– Since 1990, political pressures were meant to reduce the number of institutionalized children as fast as possible, while many of these children were suffering from neuropsychological deficiencies. Consequently, paedopsyciatrists have been helpless witnesses to a very active but superficially controlled process of international adoptions and then of family placements (foster care) at national level, where assessing compliance with minimum necessary conditions and traceability were lost into the background. Thus, quite often, it was only a single parent and not two, as it would have been natural, (not to forget that it is called “family” placement) or only the priority interest of those who accepted these children in return for the due material rights. When it comes to foster care in rural areas, the minor with neuropsychological disorders lacked the necessary rehabilitating treatment, inaccessible in the countryside. In the same context, shortly after approval of the Education Law of 1995, we witnessed the accelerated integration of children from special schools into mass education system. The integration took place without any supporting training, on either side. Instead of classes with a maximum of 20 students, a maximum of two children with special educational needs and with support teachers as provided by the optimal norms (Vrăjmaș and col. – 1996), this decision lead to the increase of the number of pupils in regular classes and to overloading the teachers’ burden, although they also lacked appropriate prior training. The effect was psychological dramas and early school leaving. A very appropriate proverb here says that “if you want to teach someone to swim do not throw him into hot water”. Therefore, we believe that, in the beginning, it should have been appropriate to pilot the new inclusive schools organised according to the proposed norms, offering new solutions as a model in order to convince with them the interested parties. Then, they would have abandoned the old models by themselves. Generalizing the integration of children with special needs had to be started only with kindergartens, which should have been adapted first to the new requirements, and process would have continued with the pre-schoolers who went on to the first grade at school.

The paedopsychiatrist as member of the forensic expertise commission and as employee of an institution or of a lawyer.

In terms of the present subject, we deal with two quite different aspects from those of the clinical paedopsychiatrist. The paedopsychiatrist, member of forensic expertise commission serves only the truth whether or not it is in the benefit of the minor.

He should:

• be certified and not only appointed in commission,
• make a clear distinction between facts and personal opinions,
• decline his authority if he is not appropriately qualified.

At the same time, he is obliged to provide the court with any mitigating circumstances that help the minor’s present and future protection and to provide reasoned opinion on the latter’s discernment, accountability and on the necessary measures.

The paedopsychiatrist employee of any type of institution (school, insurance services company, lawyer, etc.), before approaching the juvenile, his family members and the information about all of them, is first required to present his role and position and to request and obtain their informed consent for this. Of course, he cannot relinquish from the truth but he is expected to primarily promote the interests of the employee and, of course, to account for any abuses.

Impediments to the compliance with psychiatric medical ethics.

Of course, we shall not argue against such a trend in medicine. However, we cannot ignore Brown’s observation (2000/1991) that “many psychiatrists believe that the current oscillation in the patients’ civil rights may not take into account their urgent clinical needs” or the “sub-optimal patient care” either. Moreover, Appelbaum (1988) speaks also of very negative consequences.  We consider  a range of limited emergency situations, particularly bureaucratic issues in case of the patients’ refusal to accept treatment, when there is necessary to summon the committee of specialists, of subjective obstacles from those in charge to give their consent and of course, excessively prudent behaviours of the specialist facing the duty to take responsibility.

Here are some examples:

a – The request for consent itself determine the interlocutors’ reluctance, doubt, reservation, fear, delays and even rejection and the same happens when the patients or their parents or guardians read the leaflets of the prescribed drugs, full of warnings due to the need of pharmaceutical firms to protect themselves.

b – The ethical rules related to the need for informed consent and especially those concerning the opinion of specialists’ committee can delay, sometimes for an unjustified long period, the prompt institution of the treatment, as other medical procedures require it. Moreover, the refusal to consent to carry out tests or accept the administration of treatments, sometimes on obviously subjective considerations, prevents the establishment of the diagnosis and especially the access to the best therapy solution and even to a rescue. To illustrate this issue it is enough to mention the refusal to blood transfusions by the followers of certain religious sects.

c – For unknown risks, the ethical rules rightly restrict the use with minors of certain therapeutic techniques that involve psychoactive drugs, because many of them have not been tested with children yet, even though, theoretically, they are necessary and sometimes indispensable. The problem is that the only cause of this situation is the increasingly high ethical standards that raise obstacles to proving the effects of the new pharmaceutical preparations in children. Therefore, sometimes, the paedopsychiatrist is forced to resort to the use of such preparations on their own responsibility and, as Ritli (2012) has pointed out, without any compensation of the costs. But it is good to know that, this time, in case of negative consequences, the paedopsychiatrist has no coverage, apart from the consent signed by the parents or guardians who can, at any time, claim that they have not been given sufficient or understandable explanations.

d – Limitation of the paedopsychiatrist’s decisions to the norms stated in the diagnostic and therapeutic guidelines faces a series of obstacles (Milea -2009) including the patient’s deprivation of  personalized therapy and therefore of the most appropriate treatment. Going beyond the limitations implies full payment of services, assuming additional responsibilities or, to avoid negative consequences, the psychiatrist is forced to turn the atypical psychopathological manifestations into real comorbidities.

e – Finally, we must point out the risk, which cannot be neglected, of abuse by excessive application of ethical norms. We illustrate it by the compliance with refusal to receive the support of the minor child who takes drugs although usually the latter has no discernment and no fully responsible parents or guardians.

In conclusion it should be noted that by its the complexity and socio-cultural and economic implications the  psychiatric assistance given to the child and adolescent places the paedopsychiatrist in front of many dilemmas, conflicting situations, loyalty conflicts, constraints and obstacles. To overcome them, although well intended, the specialist can only choose the lesser evil, to willingly run risks and assume responsibilities, some of them having a juridical potential. All these should be known both by the welfare beneficiaries by all those called to consider allegations of breach of ethics or malpractice.

BIBLIOGRAPHY

Correspondence to:
Stefan Milea, Clinic of Child Psychiatry no 10-12 Berceni Street, Bucharest, sector 4, cp 041 915