ASOCIACION MEDICA MUNDIAL
Documento:
MEC 201/Mental Illness COM REV/Oct2015
Título:
REVISION PROPUESTA DE LA DECLARACION DE LA
AMM SOBRE LOS PROBLEMAS ETICOS DE PACIENTES
CON ENFERMEDADES MENTALES
Comité de Etica Médica
201ª Sesión del Consejo
Asamblea General de la AMM 2015
World Trade Center Moscow
Moscú, Rusia
14 - 17 octubre 2015
Destinación:
Nota:
Original:
Inglés
Medidas necesarias:
Para consideración
La Declaración de la AMM sobre los Problemas Eticos de Pacientes con Enfermedades Mentales fue
adoptada en Bali, Indonesia, en septiembre de 1995 y revisada en Pilanesberg, Sudáfrica, en octubre de
2006. Después de la publicación del informe anual 2013 del Sr. Méndez, Relator Especial de la ONU para
la tortura, que se centra en los abusos de pacientes y personas bajo supervisión médica en los
establecimientos de salud, el grupo de trabajo de la AMM HCiD , presidido por la Prof. V. Nathanson,
decidió preparar una revisión de la política de la AMM en esta materia para actualizar la imagen de la
psiquiatría y la función del médico. El relator es el Dr. M.R. Jorge.
Abbreviations Key:
AMA
AMC
AMV
BMA
CMA
ChMA
American Medical Association
Austrian Medical Chamber
Vatican Medical Association
British Medical Association
Canadian Medical Association
Chinese Medical Association
1
MEC 201/Mental Illness COM REV/Oct2015
CNOM
FMA
GMA
IMA
JMA
KMA
LMA
NMA
SMA
Conseil National de l’Ordre des Médecins (France)
Finnish Medical Association
German Medical Association
Israeli Medical Association
Japan Medical Association
Korean Medical Association
Latvian Medical Association
Norwegian Medical Association
Swedish Medical Association
GENERAL COMMENTS
It should be clarified in the statement that support to mentally ill patients can and should not only be provided by psychiatrists, but by other
AMC
physicians as well. Psychotherapeutic interventions must only be carried out by adequately trained doctors and psychotherapists. See
specific comments below.
AMV
The Vatican Medical Association supports the new version of this important document.
BMA
The new paragraph 6 should be moved ahead of the current para 4
Para 7. The first sentence should be amended to read "The physician's primary role is relieving suffering. This must not be undermined…"
Para 16. Second bullet point report to read "Call for full respect- at all times - of the dignity etc."
ChMA
Principles from “Ethical Principles” are too concrete, they are more like recommendations. And the recommendations lack detail and
guidance. Suggest to combine “principles” and “recommendations” together. With the first sentence is principle, and the following
sentences are recommendations.
FMA
Finnish Medical Association is in favour of the proposed amendments.
GMA
The GMA thanks the WMA’s Health Care in Danger workgroup for its revisions, which have, in our opinion, strengthened and enhanced
this important statement.
Overall, this is a good document and the Israeli Medical Association notes our support of it. We would like to add a point regarding the use
of patients suffering from mental illnesses in medical research.
The JMA agrees to the proposed revisions.
IMA
JMA
2
MEC 201/Mental Illness COM REV/Oct2015
KMA
KMA supports the proposed revision in general.
NMA
The Norwegian Medical Association supports this revision with some minor amendments.
SMA
The proposed revision is well-written and we support its adoption.
* Numbering will be deleted (or adjusted) when the revised text is adopted.
No
1
Moved
from 3
Texto propuesto: MEC 201/Mental
Illness/Oct2015
INTRODUCCION
Históricamente, muchas sociedades han
considerado al paciente con enfermedad mental
como una amenaza para los que lo rodean, en
lugar de una persona que necesita ayuda y
atención médica. En consecuencia, por falta de
tratamiento eficaz muchos pacientes con
enfermedad mental eran enviados a asilos por
largos períodos o de por vida. El objetivo del
encierro era evitar la conducta autodestructiva y
agresiva hacia otras personas.
Specific Comments
Additions: bold/underlined
Deletions: lined-out
Comments only: [italic]
Texto propuesto por el relator y
president del GT - MEC
201/Mental Illness REV/Oct2015
Historically, many societies have regarded patients
with mental illness as a threat to those around them
rather than as people in need of support and care.
Therefore, In the absence of effective treatment, to
prevent self-destructive behaviour or harm to
others, many patients persons with mental illness
were confined to asylums for all or part of their
lives. The aim of such confinement in these cases
was to prevent behaviour that was self-destructive
or aggressive toward others. [AMA]
Históricamente, muchas sociedades
han considerado al paciente con
enfermedad mental como una
amenaza para los que lo rodean, en
lugar de una persona que necesita
ayuda y atención médica. Por falta
de tratamiento eficaz, para evitar la
conducta autodestructiva y agresiva
hacia otras personas, muchas
personas con enfermedad mental
eran enviadas a asilos por largos
períodos o de por vida.
En la actualidad, el progreso en el
tratamiento psiquiátrico permite
una mejor atención de los pacientes
con enfermedad mental.
Medicamentos eficaces e
intervenciones psicosociales
pueden dar resultados que van de
un completo restablecimiento a
Move paragraph 3 with amendments:
Today, progress in psychiatric treatment allows
for better care of patients with mental illness.
Efficacious drugs and psychosocial interventions
offer outcomes ranging from complete recovery
to remission for varying lengths of time [AMA]
3
MEC 201/Mental Illness COM REV/Oct2015
2
La adopción en 2006 de la Convención de la
ONU sobre los Derechos de las Personas con
Discapacidad constituyó un gran paso para
considerar a las personas con discapacidad
como miembros plenos e iguales en la sociedad.
Es el primer tratado de derechos humanos
completo del siglo 21. Su objetivo es promover,
proteger y reforzar los derechos humanos y la
dignidad de todas las personas con
discapacidad, incluidas las que tienen
deficiencia mental.
3
At the present time, progress in psychiatric
treatment allows for better care of patients with
mental illness. Efficacious drugs and
psychosocial interventions can result in
outcomes ranging from complete recovery to
temporary remissions of varying lengths for
patients whose conditions are more serious.
recuperaciones de duración
variable.
La adopción en 2006 de la
…It is the This first comprehensive human rights
st
treaty of the 21 century. It aims to promote, protect Convención de la ONU sobre los
Derechos de las Personas con
and reinforce the human rights and dignity of all
Discapacidad constituyó un gran
persons with disabilities, including those person
paso para considerarlas como
with mental impairments. [AMA]
miembros de la sociedad con los
mismos derechos que cualquiera.
The adoption in 2006 of the United Nations
Es el primer tratado de derechos
Convention on the Rights of Persons with
humanos completo del siglo 21. Su
Disabilities constituted a major step towards
objetivo es promover, proteger y
viewing them persons with disabilities as full and
reforzar los derechos humanos y la
equal members of society with the same rights as
dignidad de todas las personas con
everyone else. It is the first comprehensive human
st
rights treaty of the 21 century. It aims to promote, discapacidad, incluidas las que
tienen deficiencia mental.
protect and reinforce the human rights and dignity
of all persons with disabilities, including those with
mental impairments. [CNOM]
Move after paragraph 1 with amendments. [AMA]
At the present time, progress in psychiatric therapy
treatment allows for better care of patients with
mental illness. Efficacious drugs and other
treatments psychosocial, psychosomatic and
psychotherapeutic interventions can result in
patient outcomes ranging from complete alleviation
of symptoms to long recovery to temporary
remissions of varying lengths for patients whose
conditions are more serious. [AMC]
At the present time, progress in psychiatric
treatment allows for better care of patients with
4
Cambiado a después del párrafo 1
con enmiendas.
MEC 201/Mental Illness COM REV/Oct2015
mental illness. Efficacious drugs and psychosocial
interventions can result in complete recovery to
temporary or remissions of varying lengths for
patients whose conditions are more serious.
[CNOM]
RIGHT TO HEALTH CARE [AMA]
New
[AMA: Added to clearly identify a key issue
addressed by this statement]
Move ahead of paragraph 4. [BMA]
Moved
from 6
4
Los pacientes con enfermedad mental deben
considerarse, tratarse y poder tener el mismo
acceso a la atención médica que cualquier otro
paciente. Por lo tanto, el psiquiatra o cualquier
otro profesional de salud mental debe derivar
estos pacientes a otros médicos cuando sea
necesario.
Those Persons [AMA] with major mental illnesses
and those with learning disabilities disability
[CMA] have the same right to preventive
services and interventions to promote health as
are more likely to live unhealthy lifestyles than
others members of the in their communityies, for
which they often have greater need because they
are more likely to live unhealthy lifestyles. They
must be offered the same opportunities for
health promotion interventions (such as smoking
cessation) and treatment of physical illnesses as
any other person. [AMA]
Move paragraph to “Ethical Principles” [ChMA]
Los que tienen enfermedades
mentales importantes y los que
tienen discapacidad para aprender
tienen el mismo derecho a servicios
e intervenciones preventivas que
los otros miembros de la
comunidad, porque tienen a
menudo más necesidades, ya que es
más probable que tengan estilos de
vida no saludables.
Los pacientes con morbilidad
psiquiátrica también pueden sufrir
enfermedades no psiquiátricas. Las
Patients with mental illness should be viewed,
treated and enabled to have the same access to care personas con enfermedad mental
as any other medical patient. However, this is often tienen el mismo derecho a la
not enough since patients with mental illnesses may atención médica que cualquier otro
paciente. El psiquiatra y el
not know when to seek treatment for somatic
profesional de salud que presta
problems. Therefore, the physician psychiatrist or
any other mental health professional should actively servicios de salud mental debe
5
MEC 201/Mental Illness COM REV/Oct2015
refer these patients to other physicians when
necessary. [NMA]
Patients Persons with mental illness should be
viewed, treated and granted enabled to have the
same right access to health care as any other
medical patient. However, this is often not enough
since patients with mental illnesses may not know
when to seek treatment for somatic problems.
Therefore, the physician Psychiatrists or any and
health care professionals who provide other
mental health professional services should
actively refer these patients to other appropriate
professionals when patients need medical
care.physicians when necessary. Health care
professionals should never decline to provide
needed medical care solely because the patient
has a mental illness. [AMA]
Patients with mental illness should be viewed,
considered and enabled to have the same access to
care treated the same as any other medical patient
and should have the same access to health care.
Therefore, the psychiatrist or any other mental
health professional should actively refer these
patients to other physicians when necessary.
[CNOM]
Add in at the beginning: Patients with psychiatric
morbidity may also experience non- psychiatric
illness. [BMA]
[AMA: the last sentence seems to be a necessary
6
derivar estos pacientes a otros
profesionales apropiados cuando
necesiten atención médica. Los
profesionales de salud nunca deben
declinar la prestación de la atención
necesaria únicamente porque el
paciente tiene una enfermedad
mental.
MEC 201/Mental Illness COM REV/Oct2015
corollary to the duty to refer.]
[NMA: In many countries people with mental
health problems are treated in general practice.
Also general practitioners must refer these patients
to other physicians or specialists. We would
therefore prefer to keep physician in the last
sentence and strike out “psychiatrist” and “any
other”.]
[ChMA: This is more a principle. Suggest this
article be moved to the part of “Ethical
Principles”]
[AMC: A definition of what is meant by “other
mental health professionals” is required from our
point of view].
5
El médico tiene las mismas obligaciones con su
paciente con enfermedad mental que como con
cualquier otro paciente.
Move paragraph to “Ethical Principles” [ChMA]
Replace by: Physicians have the same obligations
to all patients, including patients with mental
illness. Psychiatrists or other physicians who
treat patients with mental illness must adhere to
the same ethical standards as any physician.
[AMA]
El médico tiene las mismas
obligaciones con todos los
pacientes, incluidos los que tienen
una enfermedad mental. Los
psiquiatras y otros médicos que
tratan a pacientes con
enfermedades mentales deben
respetar las mismas normas éticas
como cualquier otro médico.
[ChMA: Same as above. Move to the part of
“Ethical Principles”]
6
Los que tienen enfermedades mentales Those Persons [AMA] with major mental illnesses
importantes y los que tienen discapacidad para and those with learning disabilities disability
aprender es más probable que tengan estilos de [CMA] have the same right to preventive
7
Cambiado a antes del párrafo 4
MEC 201/Mental Illness COM REV/Oct2015
vida no saludables que otras personas en sus
comunidades. Se les deben ofrecer las mismas
oportunidades de intervenciones de promoción
de la salud (como cesación del tabaquismo) y
tratamiento de enfermedades físicas al igual que
cualquier otra persona.
.
services and interventions to promote health as
are more likely to live unhealthy lifestyles than
others members of the in their communityies, for
which they often have greater need because they
are more likely to live unhealthy lifestyles. They
must be offered the same opportunities for
health promotion interventions (such as smoking
cessation) and treatment of physical illnesses as
any other person. [AMA]
Those with major mental illnesses and those with
learning disability are more likely to live unhealthy
lifestyles than others in their communities. They
must be offered the same opportunities for
preventative health measures health promotion
interventions (such as smoking cessation) and
treatment of physical illnesses as any other
person.[CNOM]
[BMA: The new para 6 should be moved ahead of
the current para 4]
[AMC: This claims needs to be supported by
evidence in scientific literature]
7
Las funciones principales del médico como
sanador de pacientes no debe verse afectada al
ser agente de la sociedad, excepto en casos de
peligro para sí mismo o para otros.
The physician's primary role as healer therapist of
patients must not be undermined by serving as the
agent of the greater society, except in instances of
danger to the public himself/ herself or to others
due to mental disorder. [NMA]
The physician's primary role as healer of patients
obligation is to the patient and physicians must
8
La principal obligación del médico
es para con el paciente y no ser
agente de la sociedad, excepto
cuando un paciente representa un
claro peligro para sí mismo o para
otros debido a su enfermedad
mental.
MEC 201/Mental Illness COM REV/Oct2015
not compromise their role as healers by serving
as the agents of society, must not be undermined
by serving as the agent of the greater society,
except in circumstances when a patient presents
a clear danger to the himself or others. instances
of danger to the public himself/ herself or to
others. [AMA]
The physician's primary role as healer of patients
must not be undermined tainted by his or her role
in serving as the agent of the greater society, except
in instances of danger to himself/ herself or to
others. [CNOM]
The physician's primary role is relieving suffering
as healer of patient. This must not be undermined
by serving as the agent of the greater society,
except in instances of danger to himself/ herself or
to others. [BMA]
[NMA: In Norway healer is associated with
alternative treatment. We would prefer therapist.
We also suggest to add “due to mental disorder”
to make it more precise.]
8
Las mismas obligaciones y limitaciones se
aplican a los psiquiatras u otros médicos que
traten a pacientes con enfermedades mentales.
Remove paragraph [NMA + AMA + CNOM]
Move to “Recommendations”[ChMA]
The same ethical obligations and limitations would
apply to psychiatrists or other physicians who are
treating patients with mental illness. [SMA]
9
MEC 201/Mental Illness COM REV/Oct2015
[NMA: It seems like there is some overlap between
item 5 and 8. We suggest deleting item 8 and
keeping item 5.]
[AMA: This concept is incorporated in parag. 6]
The normal human behaviour as grief, sadness
and other emotions that are reactions to events
in human life should not be medicalized by
psychiatrists or other physicians when persons
are looking for support and reassurance. [LMA]
New
9
PRINCIPIOS ETICOS
PHYSICIANS’ ETHICAL PRINCIPLES
RESPONSIBILITIES [AMA]
RESPONSABILIDADES ETICAS
DEL MEDICO
El estigma y la discriminación asociados a la
psiquiatría y a los enfermos mentales debe ser
combatida. Este estigma y discriminación a
menudo desalientan a las personas que
necesitan atención médica, lo que agrava su
situación y los deja en riesgo de daño emocional
o físico.
All efforts should be made to eliminate the The
stigma and discrimination associated with
psychiatry and the mentally ill should be fought.
[CMA]
El estigma y la discriminación
asociados a la psiquiatría y a los
enfermos mentales debe ser
eliminada. Este estigma y
discriminación puede desalentar a
las personas que necesitan atención
médica, lo que agrava su situación
y los deja en riesgo de daño
emocional o físico.
The stigma and discrimination associated with
psychiatry and the mentally ill should be fought
eliminated [AMC]…
Physicians have a responsibility to oppose the
stigma and discrimination associated with
mental illness and psychiatric care and to
remove barriers that discourage people in need
from seeking or receiving appropriate care. The
stigma and discrimination associated with
psychiatry and the mentally ill should be fought.
Stigma and discrimination often discourages people
in need from seeking psychiatric medical care,
10
MEC 201/Mental Illness COM REV/Oct2015
thereby aggravating their situation and placing them
at risk of emotional or physical harm. [AMA]
The stigma and discrimination associated with
psychiatry and the mentally ill should be eliminated
tackled. Stigma Stigmatisation and discrimination
often discourages people in need from seeking
medical care, thereby aggravating their situation
and placing them at risk of emotional or physical
harm having a negative effect on their physical
and psychological state. [CNOM]
…Stigma and discrimination often discourages may
discourage people in need from seeking medical
care, thereby aggravating their situation and placing
them at risk of emotional or physical harm. [BMA]
Move the second sentence to “Preamble”[ChMA]
Moved
from
11
Move paragraph 11 with amendments
Physicians have a responsibility to respect the
autonomy of all patients. When patients who are
being treated for mental illness have decisionmaking capacity, they have the same right to
make decisions about their care as any other
patient. Because decision-making capacity is
specific to the decision to be made and can vary
over time, including as a result of treatment,
physicians must continually evaluate the
patient’s capacity. When a patient lacks
decision-making capacity, physicians should seek
consent from an appropriate surrogate in
accordance with applicable law. [AMA]
11
Los médicos tienen la
responsabilidad de respetar la
autonomía de todos los pacientes.
Cuando los pacientes que son
tratados por enfermedad mental
tienen la capacidad de tomar
decisiones, tienen el mismo
derecho de tomar decisiones sobre
su atención como cualquier otro
paciente. Puesto que la capacidad
para tomar decisiones es específica
a la decisión que se tomará y puede
cambiar en el tiempo, incluso como
resultado de un tratamiento, los
MEC 201/Mental Illness COM REV/Oct2015
[AMA: This needs to be stated more clearly,
especially to distinguish clinical determination of
capacity to participate in treatment from legal
determination of competence, which can cover a
much wider range of decision situations.]
10
El médico aspira a una relación terapéutica
fundada en la confianza mutua. Debe informar
al paciente la naturaleza de su condición, los
procedimientos terapéuticos estándares,
(incluidas posibles alternativas y el riesgo de
cada una) y el resultado esperado.
The physician aspires for a therapeutic relationship
between physician and patient is founded on
mutual trust, and physicians have a responsibility
to seek patients’ informed consent to treatment,
including patients who are being treated for
mental illness. . He/she Physicians should inform
the all patients of the nature of the patient's their
the nature of the psychiatric or medical
condition, the standard therapeutic procedures
(including possible alternatives and the risk of
each), and the expected benefits, outcomes, and
risks of treatment alternatives. for the available
therapeutic choices. [AMA]
The physician aspires for a therapeutic relationship
founded on mutual trust. He/she should inform the
patient of the nature of their condition, the standard
therapeutic procedures (including possible
alternatives and the risk of each), and the expected
outcomes. A doctor owes to any patient that he
examines, advises and treats, honest, clear and
appropriate information about his state of health
and the investigations and treatment proposed.
12
médicos deben evaluar
continuamente la capacidad del
paciente. Cuando un paciente no
tiene la capacidad de tomar
decisiones, los médicos deben
obtener el consentimiento de un
representante apropiado, conforme
a las leyes vigentes.
La relación terapéutica fundada
entre médico y paciente está
fundada en la confianza mutua. El
médico tiene la responsabilidad de
obtener el consentimiento
informado del paciente para el
tratamiento, incluidos los pacientes
que son tratados por enfermedad
mental. El médico debe informar a
todos los paciente la naturaleza del
estado médico o psiquiátrico y los
beneficios esperados, resultados y
riesgos de las alternativas de
tratamiento.
MEC 201/Mental Illness COM REV/Oct2015
Throughout the patient’s illness, the doctor
should tailor his explanations to the patient’s
personality and do his or her best to ensure that
they are understood. However, a doctor must
respect a patient’s request not to be informed of
a diagnosis or a prognosis, unless others are in
danger of contamination. Great care must be
taken in revealing a terminal prognosis, but
persons close the patient should normally be
informed, unless the patient has already
indicated that he does not wish them to be
informed or has designated third parties to
whom the information should be given. [CNOM]
11
Si no existe el fallo legal de incapacitado, los
pacientes psiquiátricos deben ser tratados como
si fueran capacitados legalmente. Se debe
respetar su opinión en las áreas donde puede
tomar decisiones legalmente, a menos que
represente un serio riesgo para ellos o para
otros. Un paciente con enfermedad mental
incapaz de ser autónomo legalmente debe ser
tratado como cualquier otro paciente que está
temporal o permanentemente incapacitado
desde el punto de vista legal. Si un paciente no
puede tomar decisiones sobre su atención
médica, se debe obtener el consentimiento de un
representante, conforme a las leyes vigentes.
Como la incapacidad varía según la decisión y a
lo largo del tiempo, en sí o como resultado del
tratamiento, la autonomía del paciente debe ser
evaluada constantemente y considerada.
Remove paragraph [AMA]
In the absence of legally adjudicated incompetence,
psychiatric patients must be dealt with as though
they are legally competent. The patient's judgment
wishes should be respected in areas where he/she is
legally capable of making decisions, unless they
present a risk of serious harm to themselves or
others. A patient with mental illness who is
incapable of legally exercising his/her autonomy
should be treated like any other patient who is
temporarily or permanently legally incompetent. If
the patient lacks the capacity to make a decision as
to his/her medical care, surrogate consent should be
sought from a representative in accordance with
applicable law. As incompetence varies from with
decision to decision and along the time, by itself or
as a result of treatment, a patients’ autonomy needs
to be constantly evaluated and taken into
13
Cambiado a antes del párrafo 10
con enmiendas.
MEC 201/Mental Illness COM REV/Oct2015
consideration. [CNOM]
…If the patient lacks the capacity to make a
decision as to his/her medical care, surrogate
consent should be sought from a [IMA]
representative in accordance with applicable law.
Where advance directives are available, they
should be consulted. [CMA] As incompetence
varies from decision to decision and along the may
change over [CMA] / over [IMA] time, by itself
or as a result of treatment, patients’ autonomy needs
to be constantly evaluated and taken in into
consideration. [IMA & CMA]
…As incompetence varies from decision to
decision and along the over time, by itself or as a
result of treatment, patients’ autonomy needs to be
constantly evaluated and taken in consideration.
[SMA]
Move
from
13
Move from parag. 13 with amendments:
Physicians should always base treatment
recommendations on their best professional
judgment and treat all patients with solicitude
and respect, regardless of the setting of care.
Physicians who practice in mental health
facilities, the military, or correctional
institutions may have concurrent responsibilities
to society that create conflicts with the
physician’s primary obligation to the patient. In
such situations, physicians should disclose the
conflict of interest to minimize possible feelings
of betrayal on the patient’s part. [AMA]
14
Los médicos siempre deben basar
las recomendaciones de tratamiento
en su mejor opinión profesional y
tratar a todos los pacientes con
diligencia y respeto,
independientemente del lugar de la
atención. El médico que trabaja en
una institución de salud mental, el
ejército o una cárcel, puede tener
responsabilidades simultáneas ante
la sociedad que crea conflictos con
su principal obligación ante el
paciente. En estas situaciones, el
MEC 201/Mental Illness COM REV/Oct2015
médico debe revelar el conflicto de
intereses, a fin de disminuir al
mínimo los posibles sentimientos
de traición de parte del paciente.
12
La hospitalización forzada de pacientes
psiquiátricos evoca una controversia ética.
Aunque la legislación sobre la hospitalización y
tratamiento forzadas varía en el mundo, por lo
general se reconoce que esta decisión de
tratamiento requiere lo siguiente: a) grave
trastorno mental que impide que la persona
tome sus propias decisiones sobre el tratamiento
o b) la posibilidad de que el paciente pueda
lesionarse o lesionar a otros. Los médicos deben
considerar la hospitalización obligada como
excepcional y utilizar este recurso sólo cuando
sea indicada de manera científica y
médicamente necesario y por el período más
breve posible, según las circunstancias. Cuando
sea posible y conforme a la legislación local, los
médicos deben incluir un abogado para los
derechos de ese paciente en el proceso de
decisión.
Move paragraph to “Recommendation” [ChMA]
El tratamiento y la hospitalización
forzada de personas con
Involuntary treatment or hospitalization of
enfermedades mentales es
psychiatric patients evokes persons with mental
éticamente controversial. Aunque
illness is ethically controversial. While laws
la legislación sobre la
regarding involuntary hospitalization and treatment hospitalización y el tratamiento
vary worldwide, it is generally acknowledged that
forzadas varía en el mundo, por lo
this treatment decision without the patient’s
general se reconoce que esta
informed consent or against the patient’s will is
decisión de tratamiento sin el
ethically justifiable only when: requires the
consentimiento informado del
following: (a) a severe mental disorder that prevents paciente o contra su voluntad es
the individual from making his/her own
justificable éticamente sólo cuando:
autonomous treatment decisions; and/or (b) There a) un grave trastorno mental impide
is significant the likelihood that the patient may
que la persona tome sus propias
harm him/her self or others. Physicians should
decisiones sobre el tratamiento o b)
consider compulsory Involuntary treatment or
la alta posibilidad de que el
hospitalization should be exceptional and
paciente pueda lesionarse o lesionar
physicians should utilize it only when there is
a otros. El tratamiento y la
good scientific evidence that it is medically
hospitalización forzada deben ser
appropriate and necessary and should ensure
excepcionales y los médicos deben
that the individual is hospitalized for the shortest utilizar este recurso sólo cuando
duration feasible under the circumstances.
exista gran evidencia de que es
scientifically indicated and medically necessary,
médicamente apropiado y necesario
and for the shortest duration feasible under the
y deben asegurarse de que la
circumstances. Wherever possible and in
persona sea hospitalizada por el
accordance with local laws, physicians should
período más breve posible, según
include an advocate for the rights of that patient las circunstancias. Cuando sea
in the decision process. [AMA]
posible y conforme a la legislación
15
MEC 201/Mental Illness COM REV/Oct2015
Involuntary hospitalization of psychiatric patients
evokes ethical controversy. While laws regarding
involuntary hospitalization and treatment vary
worldwide, it is generally acknowledged that this
treatment decision requires the following: (a) a
severe mental disorder that prevents the individual
from giving consent to treatment making his/her
own treatment decisions; and/or (b) the likelihood
that the patient may harm him/her self or others.
Physicians should consider compulsory
hospitalization to be exceptional and should utilize
it only when it is considered scientifically indicated
and medically necessary and justified from a
medical point of view, and for the shortest duration
feasible possible under considering the
circumstances. Wherever possible and in
accordance with local laws, physicians should
include an advocate for the rights of that patient in
the decision process. [CNOM]
….. Physicians should consider compulsory
hospitalization to be exceptional and should utilize
it only when it is scientifically indicated and
medically necessary, and for the shortest duration
feasible under the circumstances. Wherever
possible and in accordance with local laws,
physicians should include an advocate for the rights
of that patient in the decision process. [NMA]
[AMA: The reference to law is ambiguous.
Perhaps the intended meaning is that physicians
should comply with legal requirements when there
16
local, los médicos deben incluir un
abogado para los derechos de ese
paciente en el proceso de decisión.
MEC 201/Mental Illness COM REV/Oct2015
is applicable law about the role of the advocate--how to choose an appropriate advocate, what
authority the advocate has, etc.]
[NMA: We think it is not necessary to have
“scientifically indicated” as an extra criterion for
compulsory hospitalisation. A medical decision
should be based on science and should therefore be
sufficient for compulsory hospitalisation.]
13
Cada médico debe ofrecer al paciente la mejor
terapia disponible, según sus conocimientos, y
lo debe tratar con la preocupación y respeto que
corresponde a todos los seres humanos. El
médico que trabaja en una institución
psiquiátrica, el ejército o una cárcel, se puede
ver enfrentado a un conflicto entre sus
responsabilidades hacia la sociedad y sus
responsabilidades con el paciente. La primera
lealtad y deber del médico debe ser hacia el
paciente. El médico debe asegurarse que se
informe al paciente del conflicto de intereses, a
fin de disminuir al mínimo los sentimientos de
traición y debe ofrecerle la oportunidad de
comprender las medidas ordenadas por las
autoridades legales.
Move under parag. 11 with amendments [AMA]
Every physician should offer to the patient the best
available therapy according to his/her knowledge,
and should treat the patient with the solicitude and
respect due to all human beings. The physician
practising in a psychiatric institution, the military or
a prison can be faced with a conflict between
his/her responsibilities to society and the his/her
responsibilities to the patient [CMA]
Every physician should offer to the patient quality
care based on scientific facts the best available
therapy according to his/her knowledge, and should
treat the patient with the solicitude and respect due
to all human beings. The physician practising in a
psychiatric institution, the military or a prison can
be faced with a conflict between his/her
responsibilities to society and the responsibilities to
the patient. The physician's primary loyalty priority
and duty must be to the patient's best interest. The
physician should ensure that the patient is made
aware of the any conflict of interest in order to
17
MEC 201/Mental Illness COM REV/Oct2015
minimize any loss of confidence for the patient
feelings of betrayal, and should offer the patient the
opportunity to understand measures mandated by
legal authority. [CNOM]
[ChMA: The last sentence is not clear. Also need
attention that it is usually not possible because
some mental health patient can’t understand]
14
New
Se debe salvaguardar el secreto y privacidad de
todos los pacientes. Cuando lo exija la ley, el
médico revelará sólo la información específica
requerida y solamente a la entidad que tiene
autoridad legal para hacer dicha solicitud o
demanda. Los bancos de datos que permiten el
acceso o la transferencia de información de una
autoridad a otra pueden ser utilizados, siempre
que se respete la confidencialidad y que dicho
acceso o transferencia cumpla plenamente con
la ley vigente..
Physicians must protect Tthe confidentiality and
privacy of all patients should be safeguarded. When
legally required to disclose patient information
required by law, the physician should disclose only
the required relevant minimum relevant
information necessary material and should
disclose such material and only to an entity the
entity having legal authority legally authorized to
make such a to request or require the
information. or demand. When Data banks
databanks that allow access to or transfer of
information from one authority to another may be
used provided that medical confidentiality must be
is respected and such access or transfer is fully
compliant must comply fully with applicable law.
[AMA]
Los médicos deben proteger la
confidencialidad y la privacidad de
todos los pacientes debe ser
salvaguardada. Cuando la ley exija
revelar información del paciente, el
médico debe revelar sólo la
información mínima pertinente
necesaria y solamente a la entidad
que tiene autoridad legal para pedir
la información. Cuando los bancos
de datos permiten el acceso o la
transferencia de información de una
autoridad a otra se debe respetar la
confidencialidad y dicho acceso o
transferencia debe cumplir
plenamente con la ley vigente.
Individuals with psychiatric illness have the
right to participate in research in order to
further the understanding of mental illness and
to advance available treatment options. In such
case, research should be conducted at the highest
standards of informed consent, moral integrity
and respect for human dignity. It is critical that
La participación de personas con
enfermedades psiquiátricas en
investigación debe estar en
completo acuerdo con las
recomendaciones de la Declaración
de Helsinki.
18
MEC 201/Mental Illness COM REV/Oct2015
the boundary between research and clinical care
is made clear at all times with any conflict of
interest potentially influencing professional
integrity being declared. [IMA]
15
El médico nunca debe hacer uso de su
posibilidades profesionales para violar la
dignidad o los derechos humanos de ningún
individuo o grupo y nunca debe permitir que los
deseos personales, necesidades, sentimientos,
prejuicios o creencias interfieran con el
tratamiento. Tampoco el médico debe
aprovechar su posición profesional o la
vulnerabilidad de un paciente para abusar de su
autoridad
A pPhysicians must never use their his/her
professional position to violate the dignity or
human rights of any individual or group, and should
never allow their his/her personal desires, needs,
feelings, prejudices or beliefs to interfere with the a
patient’s treatment. Neither should a physician take
advantage of his/her professional position or the
vulnerability of a patient to abuse his/her authority.
Physicians must never abuse their authority or
take advantage of a patient’s vulnerability.
[AMA]
A physician must never use his/her professional
position to violate the dignity or human rights of
any individual or group, and should never allow
his/her personal desires, needs, feelings, prejudices
or beliefs to interfere with the treatment. [CMA]….
A physician must never use his/her professional
position to violate the dignity or human rights of
any individual or group, and should never allow
his/her personal opinions desires, needs, feelings,
prejudices or beliefs to interfere with the treatment.
Neither should a physician take advantage of
his/her professional position or the vulnerability of
a patient to abuse his/her authority position.
[CNOM]
19
El médico nunca debe hacer uso de
su posibilidades profesionales para
violar la dignidad o los derechos
humanos de ningún individuo o
grupo y nunca debe permitir que
los deseos personales, necesidades,
sentimientos, prejuicios o creencias
interfieran con el tratamiento del
paciente. El médico nunca debe
abusar de su autoridad o
aprovecharse de la vulnerabilidad
de un paciente.
MEC 201/Mental Illness COM REV/Oct2015
Recomendaciones
16
Se insta a la Asociación Médica Mundial y a las
asociaciones médicas nacionales a:
16.1
Publicar esta Declaración y utilizarla como base
para reafirmar las fundaciones éticas del
tratamiento de pacientes con enfermedades
mentales
Al hacerlo, llamar al total respeto – en todo
momento – de la dignidad y los derechos
humanos de los pacientes con enfermedades
mentales.
16.2
RECOMMENDATIONS [IMA & AMA]
Publicize this Statement and use it as a basis for
affirming affirm the ethical foundations for
treatment of patients with mental illness; [AMA]
While doing so, call for the full respect – at any
time – of Insist that at all times the dignity and
human rights of patients with mental illness be
respected; [AMA]
Recomendaciones
Se insta a la Asociación Médica
Mundial y a las asociaciones
médicas nacionales a:
Publicar esta Declaración y
reafirmar las fundaciones éticas del
tratamiento de pacientes con
enfermedades mentales
Al hacerlo, llamar al total respeto –
en todo momento – de la dignidad y
los derechos humanos de los
pacientes con enfermedades
mentales.
While doing so, call for the full respect [BMA] – at
any time all times – of the dignity and human rights
of patients with mental illness; [CNOM + BMA]
16.3
Crear conciencia de la función clave del médico
en apoyar a los pacientes con enfermedades
mentales, con el fin de promover una relación
privilegiada en base a la confianza, el
profesionalismo y la confidencialidad.
Raise awareness on of [CMA] the key role played
by physicians in support treatment of patients with
mental illness, aiming to promote a privileged
relationship based on trust, professionalism and
confidentiality; [AMC]
Raise awareness on the key role played by
physicians in of physicians’ responsibilities to
support of the well-being and rights of patients
with mental illness, aiming to promote a privileged
relationship based on trust, professionalism and
confidentiality; [AMA]
Raise awareness on the key role played by
physicians and health professionals working to in
20
Crear conciencia de la
responsabilidad del médico en
apoyar el bienestar y los derechos
de los pacientes con enfermedades
mentales.
MEC 201/Mental Illness COM REV/Oct2015
support of patients with mental illness, aiming to
promote a privileged relationship based on trust,
professionalism and confidentiality; [CNOM]
16.4
Promover el reconocimiento de la
relación privilegiada entre médico
y paciente, en base a la confianza,
el profesionalismo y la
confidencialidad.
Advocate for appropriate resources and capacities
Abogar por obtener recursos
for care facilities – including psychiatric institutions apropiados para satisfacer las
– dedicated to meet the needs of persons patients necesidades de las personas con
with mental illness. [AMA]
enfermedades mentales.
Promote recognition of the privileged
relationship between patient and physician
based on trust, professionalism and
confidentiality. [AMA]
New
Abogar por obtener recursos y capacidades
apropiados para los establecimientos de salud –
incluidas las instituciones psiquiátricas –
dedicados a los pacientes con enfermedades
mentales.

14.09.2015
21