Bioethics and psychiatry: paucity of recent literature in Brazil

Abstract

Our integrative literature review sought to analyze the scientific production on bioethics and psychiatry published in Brazil in the last ten years. Bibliographic search used descriptors and search operators to relates the terms “ ética or bioética or ética médica and psiquiatria, ” resulting in thirteen articles selected, of which only two were eligible for review according to the inclusion criteria. Results show that only spirituality and pedophilia were themes addressed by the analyzed studies, both literature reviews. Despite the contemporary relevancy of bioethics and psychiatry, research on these themes is little explored and encouraged in Brazil.

Psychiatry; Ethics, research; Bioethics

Resumo

A fim de analisar a produção científica sobre bioética e psiquiatria no Brasil publicada nos últimos dez anos, realizou-se revisão integrativa da literatura disponível em bases de dados, utilizando descritores e operadores de pesquisa para relacionar os termos “ética or bioética or ética médica and psiquiatria”. O processo de busca dos estudos culminou em seleção de treze artigos, dos quais apenas dois foram elegíveis para a revisão integrativa de acordo com os critérios de inclusão. A pesquisa mostrou que apenas os temas da espiritualidade e da pedofilia foram abordados nos estudos analisados, ambos com metodologia de revisão de literatura. Apesar de os campos de bioética e psiquiatria terem grande relevância na contemporaneidade, há escassez de trabalhos científicos no Brasil sobre o tema, pouco explorado e incentivado.

Psiquiatria; Ética em pesquisa; Bioética

Resumen

Con el fin de analizar la producción científica sobre bioética y psiquiatría en Brasil publicada en los últimos diez años, se realizó una revisión integradora de la literatura disponible en bases de datos, utilizando descriptores y operadores de investigación para relacionar los términos “ética or bioética or ética médica and psiquiatría”. La búsqueda culminó con la selección de trece artículos, de los cuales solo dos fueron elegibles para la revisión integradora según los criterios de inclusión. Los resultados mostraron que solo se abordaron los temas de espiritualidad y pedofilia en los estudios analizados, ambos siguieron la metodología de revisión de literatura. Aunque la bioética y la psiquiatría tienen gran relevancia en la contemporaneidad, los estudios científicos en Brasil sobre el tema son escasos, poco explorados y fomentados.

Psiquiatría; Ética en la investigación; Bioética

Ethics or moral philosophy is the field of philosophy that studies human actions and behavior. However, morals and ethics are different concepts. Morality is related to respect for social, cultural, religious and similar norms, while ethics seeks to establish the foundation of the way of living based on human thought ¹ . In 1971, cancerologist Van Resselaer Potter published Bioethics: a bridge to the future . Subsequently, the term bioethics was adopted to define the interdisciplinary field of study that involves ethics and biology, founding the ethical principles related to the risks that the sciences can bring to life ² , ³ .

Published in 1978, the Belmont Report introduced principles to guide research with human beings and, in 1979, Beauchamp and Childress ⁴ extended their use to medical practice and other health care professionals. These principles were inspired by major ethical systems of philosophers such as Kant and Mill. Thus, bioethics develops in a line called “principlism,” based on four basic principles of a deontological character (nonmaleficence and justice) and teleological character (beneficence and autonomy) ⁴ , ⁵ .

In Principles of biomedical ethics , Beauchamp and Childress ⁴ define these four basic principles as follows:

• Nonmaleficence (do not cause intentional harm to patients);

• Beneficence (act with the best interest of others in mind);

• Autonomy (prevent any kind of obligation, preserving the autonomy of the one who is responsible for oneself and decides whether one wants to be treated or whether one wants to participate in a research); and

• Justice (create a regulatory mechanism, submitted not only to the medical authority, but to justice, which will judge conflicts of interest or damages).

The first document to introduce central ethical principles (benevolence, autonomy, nonmaleficence and distributive justice) was the Hippocratic Oath , still in the fifth century B.C. Already in the twentieth century, bioethics began to explore the moral relation between human beings and their world.

In this context, the Code of Medical Ethics, prepared by the Federal Council of Medicine (CFM) ⁶ , addresses the principles, rights and duties of physicians. The chapters are divided according to the themes: fundamental principles, physicians’ rights, professional responsibility, relationship with patients and family members, organ and tissue donation, relationship between physicians, professional remuneration, professional secrecy, medical documents, medical audit and forensic medicine, medical advertising and general provisions.

When bringing this discussion to psychiatry, it should be taken into consideration that its specialty is to deal with people with mental and behavioral disorders, working with prevention, diagnosis, treatment and rehabilitation of the different manifestations of these conditions ⁷ .

Lock, Gauer and Kipper ⁸ discuss how the physician-patient relationship has peculiar characteristics given the vulnerability of many of their patients with mental disorders. In certain situations, psychiatrists are at risk of violating basic human rights, and can also easily manipulate patients. Thus, psychiatry has the challenge of following the four ethical principles, in addition to dealing with additional issues, such as limited therapeutic resources, stigma of mental illness, discrimination, and heterogeneity of psychiatric practices between different places and even between professionals of the same origin ⁷ , ⁹ .

It is also noted that psychiatric aspects can result in ethical difficulties, and that some psychiatric interventions can bring ethical dilemmas. As examples of psychiatric aspects related to ethical difficulties, we can mention: psychopathology in any of those involved in the ethical conflict; personality styles and psychodynamic problems; family dysfunction; interpersonal conflicts between patient, family and health care professionals; conflicts or non-cooperation within the health care team; countertransferential reactions of health care professionals in relation to patient, family and other professionals; and disproportionate involvement or rejection of the health care team ¹⁰ .

In turn, some types of psychiatric intervention with ethical problems are: treating personal psychological problems; evaluating decision-making capacity; restoring, improving, stabilizing decision-making capacity; improving dysfunctional family dynamics; diagnosing and improving team, patient, and family problems; using the psychiatrist’s ability to involve other caregivers, if necessary; recognizing and minimizing cultural or religious incongruities; evaluating and optimizing the contribution of social or community actors ¹⁰ .

Given the relevance of this theme, we note the need to expand discussions in the fields of bioethics and psychiatry. This would enable constant analysis of guidelines to be applied not only in the relationships between physicians, patients, health care professionals and society, but also in medical and psychiatric education. To this end, we carried out this integrative review with the objective of learning from the scientific literature how the discussion on bioethics and psychiatry has been developing in Brazil in the last ten years. Thus, we aim to establish prospects for future objects of study and research in the area.

Method

An integrative literature review was carried out through the following steps: definition of the guiding question; search in the databases; collection of information; categorization and analysis of the studies; discussion and conclusion ¹¹ . The following research question was established to delimit the theme: “What has been published on bioethics and psychiatry in Brazil in the last ten years?”.

The following databases were employed: PubMed, Virtual Health Library (VHL), and SciELO. The search was based on the Health Sciences Descriptors (DeCS). The terms “ethics or bioethics or medical ethics and psychiatry” were used as Boolean descriptors and operators, and Brazilian articles in Portuguese from 2012 to 2022 were selected.

The inclusion criteria encompassed original articles and literature reviews that discussed the theme to be reviewed. We excluded: duplicate publications; restricted-access manuscripts; incomplete works; manuscripts of editorial, opinion or gray literature sections; and articles from studies inconsistent with the theme.

Results

The study selection process was based on the instrument Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). The electronic database search was carried out in December 2022 and resulted in a total of 13 articles available in Portuguese and published between 2012 and 2022. Two articles were excluded for being duplicate. The 11 articles resulting from the selection were assessed as to the inclusion and exclusion criteria, and only two articles were eligible for the integrative review ¹² . The process is presented in Figure 1 .

Figure 1
PRISMA flowchart

The study categorization phase involved the adaptation of the data collection instrument of Silveira ¹³ , which comprises the following items: identification of studies (title, author, year), methodological characteristics (types of study), main results, and conclusions found. The studies were analyzed and classified according to data collection and categorization criteria, in order to guarantee the validity of the review ¹³ , ¹⁴ . After the inclusion and exclusion criteria were applied, two articles were categorized and analyzed in full. Subsequently to data analysis, the results were presented as charts to make the reading dynamic and accessible (Charts 1 and 2).

Chart 1
Summary of publications on bioethics and psychiatry in the databases, by year, language and main results

Publication	Database	Year of publication	Journal	Main results
“ Psiquiatria e espiritualidade: em busca da formulação bio-psico-socio-espiritual do caso” (1) 15	VHL	2018	HU Revista	It emphasizes the importance of the biopsychosocialspiritual perspective in the daily clinical practice of psychiatrists and other mental health professionals, considering this approach more integrative than the only biopsychosocial model, from a diagnostic and therapeutic point of view.
“Castração química em casos de pedofilia: considerações bioéticas” (2) 16	VHL	2014	Revista Bioética	It discusses that the concepts of chemical castration as sentence, medical treatment and scientific experiment are intrinsically linked, despite the ethical issues specific to each one.

Chart 2
Categorization of studies on bioethics and psychiatry in Brazil

Article	Location	Method	Sample	Main subject addressed
1	Center for Research in Spirituality and Health (Federal University of Juiz de Fora)	Review	112 articles from PubMed and Psychoinfo databases	Update article on the relevance of the approach to religion and spirituality in clinical practice, especially in psychiatry.
2	Graduate Program in Bioethics (University of Brasília)	Review	Search in SciELO, PubMed, Google Scholar and VHL databases	Update article on chemical castration in pedophiles and its bioethical implications.

Discussion

The scarcity of indexed scientific studies on the theme of “bioethics and psychiatry” in the searched databases should be noted, especially when considering that broad descriptors were used for searches in three relevant databases.

Chart 2 shows the methodological design of the studies, with both being review studies. This suggests that research and assessment studies have not been carried out in Brazil or have not presented the proper methodological rigor for publication in journals indexed in the searched databases.

It is also noted that both works analyzed were from centers associated with the specific study of bioethics and from the group’s area of study. It is possible that other areas, such as psychiatry itself, are not properly exploring the medical ethics. If confirmed, this problem could be addressed, for example, through incentives for undergraduate and graduate studies, including interinstitutional partnerships and coordinations.

In addition to the evolution of science and society, there is a growing demand for innovation. However, innovation does not always follow ethical premises. In turn, advances in science and technology have made the physician-patient relationship more complex. Consequently, it is essential to include in medical training—as is done in undergraduate programs—education geared toward discussing ethical issues that arise in the practices of the area, developing and enhancing a more humane physician-patient relationship in a continuous and permanent manner ¹⁷ .

The research showed that only the themes of spirituality and pedophilia were addressed in the studies analyzed. However, discussions on ethics and psychiatry transcend the most diverse areas of health care and society, and should be part of basic courses of the various health-related undergraduate programs, and research on ethics and psychiatry should be duly fostered. This finding reinforces the importance of initiatives toward this purpose, such as those of the Federal Council of Medicine, seeking to fill this scientific gap in the country ¹⁸ .

The intimacy that is established between psychiatrist and patient is much more complex than in other specialties. Thus, the relations between bioethics and psychiatry have great social relevance, as they also involve themes such as secrecy, informed consent, involuntary hospitalizations, suicide and assisted suicide, judgment of reality, self-neglect, psychotherapy, forensic issues, medical use of cannabis and psychedelics, stigma, research, among many other ethical dilemmas ¹⁹ .

In addition, the negative view regarding people with mental disorders brings to bioethics the challenge of dealing with social values that stigmatize them and lead to them not being considered as citizens. In this context, their exercise of citizenship is limited and sometimes legitimized by stigma ²⁰ .

Promoting mental health goes far beyond treating an organic disease. It means building citizenship, social life and culture in a manner that is healthy for individuals, which enables them to develop psychological aspects, potential, and skills. It is necessary to respect the patient, the disease, and the suffering, manage negative situations, and improve the quality of life, and foster social and mental well-being ²¹ .

The limitations of this review include researching only results in Portuguese. For a new integrative review on the subject in question, the search can be expanded to more databases and include languages such as English and Spanish.

Final considerations

Despite the major relevance in contemporary times, there is a scarcity of scientific works in Brazil on the theme of “bioethics and psychiatry,” which is still little explored and fostered in a specific manner. It is necessary to consider the significant increase in mental illness in recent years and the rise of new ethical demands resulting from trends such as the use of technology, implementation of telemedicine, dissemination on social networks, studies with new psychotropic drugs, among others. Thus, it is urgent to broaden the discussions on the problems involving physicians, health care professionals and the general population, while also promoting initiatives to provide permanent education and raise social awareness.

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Publication Dates

• Publication in this collection
  27 Oct 2023
• Date of issue
  2023

History

• Received
  25 Apr 2023
• Reviewed
  5 July 2023
• Accepted
  27 July 2023