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Selected Ethical Issues in Psychopharmacology

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The therapeutic relationship in medicine and psychiatry is rooted in the principles of beneficence and respect for autonomy. Historically, an emphasis on beneficence over autonomy has been the hallmark of paternalism, in which the physician acts benevolently and at times unilaterally, like a parent, in dealings with patients. By contrast, an emphasis on respect for autonomy over beneficence in the therapeutic relationship highlights the importance of patients' rights. Patients' rights in pharmacotherapy have been described as including the following: "access to treatment; provision of necessary information [about treatment]; the freedom to accept or refuse treatment; and a voice in the selection of specific drugs and the conditions under which to take them" (Brown and Pantelis 1999, p. 257). At its most extreme, a strictly beneficence-based practice may diminish the ill individual, violating the cardinal ethical principle that governs all actions in medicine and human science: respect for persons. On the other hand, a strictly autonomy-based practice at its most extreme appears to be akin to a mere business transaction—a trade of goods and services between two "equal" individuals, one with a product or service and the other with an identified interest or need, with no specific moral obligation between the two parties (Dyer 1988; Wise 2007).

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FIGURE 67–1. Elements of informed consent.Source. Reprinted from Roberts LW, Dyer AR: "Informed Consent and Decisional Capacity," in Concise Guide to Ethics in Mental Health Care. Washington, DC, American Psychiatric Publishing, 2004, p. 52. Used with permission.

FIGURE 67–2. Decision tree for ethical use of clinical innovation.
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TABLE 67–4. Working therapeutically with patients receiving involuntary medication treatment

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