The 30th anniversary of the code of ethics of the Royal Australian and New Zealand College of Psychiatrists–a worthy milestone

How is the code organised?

The Code’s structure, based on that of the American Psychiatric Association’s equivalent document, has been retained throughout, testifying to its utility. Indeed, it is noteworthy that several psychiatric bodies have applied the same approach. ⁶ In essence, ethical principles central to psychiatric practice (and research) have been delineated, and each of them expounded through a series of annotations elaborating on their nature, application in practice and special cases.

The most recent revision introduced references to various college position statements and guidelines that explore in further detail ethical issues relating to specific aspects of practice, such as the assessment of asylum seekers, boundary violations, medico-legal examinations and the special needs of Indigenous Peoples. ² Footnotes have also been added to elucidate complex concepts like conflict of interest, valid consent and the definition of a minor.

What changes have been made?

On our analysis, seven major themes of change have emerged over the four revisions of the Code (described in Table 1), which we will outline below. Adjustments in style and language have accompanied these changes, which have improved the Code’s clarity and readability. Some annotations have been expanded to make their rationale more explicit, while others have been removed for the sake of concision.

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Table 1.

Major themes of change in revisions of the Code of Ethics of The Royal Australian and New Zealand College of Psychiatrists.

Key theme	Original (1992)	1st revision (1998)	2nd revision (2004)	3rd revision (2010)	4th revision (2018)
Protecting patients from exploitation	Addressed in Principle 1: ’Psychiatrists should not exploit or try to influence patients in any way’.	New dedicated principle (Principle 2), which expands on sexual relationships with current patients, and includes former patients.	No significant change.	Other forms of exploitation (e.g. financial and emotional) added to Principle 2.	Extension of protection from exploitation to family members and carers added to Principle 2.
Recognising the importance of family and carers	Mentioned briefly in Principle 2: ‘Psychiatrists shall be aware of the interests of the patient’s family and relevant other persons’.	Expanded reference to recognising the value of involving family or relevant other persons in their care in Principle 3. Addition to Principle 7: ‘Psychiatrists shall take the opportunity to learn from their patients, their families and carers and from the broader community’.	No significant change.	Elaboration in Principle 3:‘Psychiatrists shall encourage the active participation of the patient’s family (and/or others closely involved with the patient’s non-professional care) in clinical care whereconsidered appropriate,taking confidentiality,cultural features and thepatient’s wishes into account.’ Psychiatrists obliged to share their knowledge not only with colleagues and trainees, but with patients and their families (Principle 8).	Extension of protection from exploitation to family and carers (see above).
Respecting the special place of Indigenous Peoples	Not mentioned.	Expanded reference to recognising culturally specific concepts of family, particularly for Indigenous Peoples, in Principle 3.	Specific reference to Indigenous Peoples removed. Principle 3 amended to: ‘Psychiatrists shall be aware of culturally specific factors in caring for their patients’.	Principle 3 encourages enlisting the contribution of “cultural liaison colleagues” if clinically appropriate.	Recognition of Aboriginal and Torres Strait Islander Peoples and Māori as the traditional owners and custodians of Australia and New Zealand respectively, and respect for the contribution of their cultural identity to mental health highlighted in Preamble and Principle 11.
Safeguarding confidentiality	Discussed in Principle 3: ‘A careful balance must be maintained between preserving confidentiality as a fundamental aspect of clinical practice and the need to breach it on rare occasions’.	Principle 4 amended to protect the confidentiality of third-party sources of information.	No significant change.	Principle 4 amended to de- identifying patients when material about them is used for teaching or in publications.	Several adjustments to Principle 4: Sharing of information from third-party sources with the patient unless judged as harmful. Caution around treating patients who know each other. Specific mention of subpoena and limiting required disclosure to what is necessary.
Engaging patients in decision-making	Discussed in Principle 4: ‘In the case of an incompetent patient consent shall be obtained wherever possible from a close relative, guardian or other statutory agent’.	No significant change.	No significant change.	Acknowledgement that capacity to provide consent may fluctuate. Principle 5 amended: ‘Where a patient does not have the capacity to provide consent, psychiatrists shall seek consent from an authorised substitute decision maker, including taking into account any valid advance directives made by the patient. Where possible, patients should be encouraged to provide their assent’.	Emphasis on supported decision-making and the rights, will and preferences of the patient: ‘Psychiatrists shall support the decision-making of a patient with impaired capacity so that, where possible, a decision can be validly made’. ‘When valid consent cannot be given by the patient, psychiatrists shall seek consent from an appropriate substitute decision maker. This should respect the rights, will and preferences of the patient, and take into account any advance directive’.
Multidisciplinary collaboration and models of mental health and well-being	Mentioned in Principle 2: ‘Psychiatric care shall involve consideration of the patient’s physical health’. ‘Psychiatrists shall consult with experienced colleagues and other relevant health professionals about unusual or complex clinical problems’. Also mentioned in Principle 6: ‘Psychiatrists shall continue to develop their professional knowledge and share this knowledge with colleagues and other relevant health professionals’.	Inclusion of social and spiritual well-being as relevant aspects of psychiatric care in Principle 3. Principle 7 amended to remove ‘other relevant health professionals’ from people that psychiatrists are required to share professional knowledge and skills with.	No significant change	Broadening considerations to include psychological well-beingin Principle 3. Psychiatrists obliged toadvise patients where it is identified that care, otherthan psychiatric care, is needed, also in Principle 3. Principle 8 amended such that ‘other relevant health professionals’ are reinstated as people psychiatrists are required to share professional knowledge and skills with. Patients and their families and carers are also included.	Principle 3 further broadened to include considerations of cultural well-being (in addition to physical, social, spiritual and psychological previously included).
The well-being of psychiatrists	Ill health of psychiatrists mentioned in Principle 7, but only in relation to maintaining the integrity of the profession.	No significant change.	New principle (Principle 9) dedicated to the duty of care owed by psychiatrists to the health and well-being of their colleagues, including trainees. Includes recognition of power imbalance inherent in the relationship between supervisor and trainee in psychiatry. Advises that psychiatrists who supervise trainees in psychiatry shall identify their supervisory role clearly and not provide treatment.	No significant change.	Principle 9 expanded to include emphasis on psychiatrists’ need to attend to any incapacity in themselves or their colleagues. This includes options for supporting colleagues, when to notify regulatory bodies and advice about self-care. Expanded supervisory role to referring a supervisee to another practitioner if this is necessary. Principle 10 outlines an obligation to promote a professional environment free of discrimination, bullying and sexual harassment.

Protecting patients from exploitation

A significant early change was the introduction of a principle focussing on the power differential in the psychiatrist–patient relationship.^5,7 An explicit emphasis was viewed as essential on the grounds of a growing concern about boundary violations in the 1990s and echoed in the literature.^5,8 Prohibition of any sexual relationship between psychiatrist and current or former patient was the result, as was an obligation to approach all clinical encounters with an appreciation of the power imbalance in mind.

Recognising the importance of family and carers

The importance of families and carers has been increasingly recognised in the Code, not only as sources of knowledge about patients but also for their valuable insights into mental health policy and services. ⁴ Submissions from mental health advocacy organisations at the time of early revisions led to an emphasis on acknowledging the key role of families and carers in the lives of people with mental illness ⁵ and, where appropriate, encouraging their participation in clinical care. ²

Respecting the special place of Indigenous Peoples

In accordance with the RANZCP’s commitment to provide culturally sensitive mental health care for Aboriginal and Torres Strait Islander Peoples and Māori, the seminal place of culture is reflected in several revisions, including the recognition of culturally specific concepts of family ⁷ and the role of cultural experts in providing assistance, where appropriate. ⁹ In the fourth revision, Aboriginal and Torres Strait Islander Peoples and Māori were explicitly recognised as the traditional owners and custodians of Australia and New Zealand, respectively, ² and Māori language for family (i.e. whānau) was incorporated.^2,4

Safeguarding confidentiality

While patient confidentiality has always been a crucial aspect of ethical practice in psychiatry, there have been several changes to this principle over time, from the extension of confidentiality to third-party sources of information ⁷ and the de-identification of patient information for teaching and publication, ⁹ to an emphasis on sharing information from third-party sources with the patient and special cautions around treating patients who know each other. ²

Engaging patients in decision-making

The publication of international ethical statements such as the Madrid Declaration on Ethical Standards for Psychiatric Practice ¹⁰ and the Convention on the Rights of Persons with Disabilities (CRPD) ¹¹ have informed revisions of the Code. The values underlying these documents have supported, for example, a greater emphasis on involving patients with impaired capacity, as well as minors, in the process of obtaining informed consent. ⁹ The CRPD has also sharpened a focus on the psychiatrist’s responsibility to pay heed to patients’ preferences, and to support them to surmount limitations in their ability to make decisions about treatment. ²

Multidisciplinary collaboration and models of mental health and well-being

The move towards inclusive and multidisciplinary treatment is reflected in amendments requiring psychiatrists to collaborate with other health providers and to share their knowledge with colleagues from all relevant health professions, as well as with patients, their families and carers. ⁹ These changes parallel an augmented understanding of mental health and well-being. For example, social and spiritual well-being were added as important facets of psychiatric care in the first revision, ⁷ while the relevance of psychological well-being and care beyond the psychiatric was noted in a later edition. ⁹

The well-being of psychiatrists

The well-being of psychiatrists has emerged as a vital concern of the RANZCP. ⁴ Attention to psychiatrists’ ill health was included in the original Code under the principle addressing professional integrity, ¹ but was later elevated to a distinct principle dedicated to the duty of care owed by psychiatrists to one another. ¹² The latter reflected well-documented evidence of the detrimental effects of discrimination, bullying and sexual harassment in the work environment. ² Special attention has also been given to the vulnerability of trainees in the context of supervision. ¹²