Ethical challenges in contemporary psychiatry: an overview and an appraisal of possible strategies and research needs

May combine two claims.

In severe mental illness, peer support has some evidence of benefit for hope, recovery and empowerment, but no evidence of benefit for hospitalization or overall symptoms.

“For patients with severe mental illnesses, for instance, there is some evidence of positive effects on measures of hope, recovery and empowerment, but there is no evidence of an impact on other important outcomes, such as hospitalization or overall symp toms.”

May combine two claims.

In addiction, peer support can encourage abstinence and lead to greater participation in Alcoholics Anonymous.

“For patients with addiction issues, peer support can pro mote abstinence and result in increased involvement with Al co hol ics Anonymous 319 .”

• cites [319]Not checked yet

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May combine two claims.

Psychiatry shares most ethical issues with other medical fields but also confronts distinctive ethical challenges.

“Psychiatry shares most ethical issues with other branches of medicine.However, it also has to confront special ethical challenges.”

May combine two claims.

The WPA has issued a position statement and set up a task force to implement alternatives to coercion in mental health care.

“Hence, the WPA has issued a position statement and set up a task force to implement alternatives to coercion in mental health care 34,35 .”

• cites [34]Not checked yet

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• cites [35]Not checked yet

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Classified as probably not a substantial claim.

The CRPD, as interpreted by some experts and stakeholders (contested by others), raises concerns about involuntary psychiatric treatment and conventional mental health laws.

“The CRPD, as interpreted by some experts and stakeholders (though contested by others), has also raised concerns about some psychiatric practices, in particular those pertaining to treatment of persons against their will, and about conventional mental health laws.”

Probably not a substantial claim: may not pass S4 (based). May combine two claims.

The implementation and sustainability of community-based care differ significantly across countries and regions, and their outcome depends on a socio-economic-political landscape that discourages discrimination and supports social inclusion and equitable access to health care.

“The implementation and sustainability of these changes differ significantly across countries, and even across regions within the same country.Their outcome crucially depends upon a socio-economic-political landscape that discourages discrimination and supports social inclusion and equitable access to health care, including mental health care.”

Probably not a substantial claim: may not pass S4 (based). May combine two claims.

While coercive interventions may sometimes be required as life-saving or to restore autonomy, their widespread over-use reflects risk aversion in society.

“While it can be argued that coercive interventions may sometimes be required as a life-saving measure or to restore autonomy, the widespread over-use of these interventions in psychiatry is a function and reflection of risk aversion in society.”

• AssumptionRests on an assumption: Coercive and restrictive interventions continue to be over-used in psychiatry.

Classified as probably not a substantial claim. May combine two claims.

The human rights framework encourages psychiatry to move away from paternalism and institutional mentality toward respecting autonomy and dignity of PWLE, while advocating for necessary supports.

“The age-old principles of beneficence and non-maleficence must be respected, but the human rights framework encourages the profession of psychiatry to emancipate itself from a paternalistic and institutional mentality, and shift the pendulum towards respecting the autonomy and dignity of PWLE, while also advocating for necessary supports to be available 36 .”

• cites [36]Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

End-of-life decisions are more controversial in psychiatry than in general medicine because certain symptoms may interfere with competent decision-making.

“This issue is currently debated in general medicine, but is much more controversial in psychiatry, where certain symptoms may interfere with competent decision-making.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The WPA Code of Ethics calls for respecting autonomy and dignity but recognizes involuntary psychiatric interventions may be required as a last resort when less restrictive interventions have failed, to protect safety and restore autonomy.

“Accordingly, the WPA Code of Ethics calls for respecting the autonomy and dignity of persons with mental health conditions, but recognizes that involuntary psychiatric interventions may be required, as a last resort, when less restrictive interventions have failed, to protect safety and to restore the person's autonomy 4 .”

• cites [4]Not checked yet

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May combine two claims.

The power imbalance between users and physicians is generally more pronounced in mental health than in other specialties, and has contributed to abuse in some contexts.

“Moreover, the power differential that exists in all medical specialties between users and physicians tends to be more pronounced in the mental health field, and this has contributed to generate, in some contexts, various forms of abuse that have raised widespread ethical concerns [1][2][3] .”

• cites [1][2][3]Not checked yet

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May combine two claims.

Mental health and human rights are inextricably related in three ways: mental health policy/practice can protect or violate rights; human rights violations adversely impact mental health; and promotion of mental health and human rights mutually reinforce each other.

“Both mental health and human rights are concerned with social justice and social responsibility 18 , and they are inextricably related in three ways 20,21 : mental health policy and practice can either protect or violate human rights; conversely, human rights violations adversely impact mental health; and finally, the promotion of mental health and human rights mutually reinforce each other.”

• cites [20]Not checked yet

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• cites [21]Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

All human rights are interdependent, interrelated, and indivisible.

“However, it is well rec og nized that all human rights are interdependent, interrelated and indi visi ble 14,18,19 .”

• cites [14]Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The CRPD was adopted by the UN in 2006 after five years of negotiations involving various stakeholders including PWLE and family supporter bodies, and entered into force in 2008.

“The CRPD was adopted by the UN in 2006, after five years of negotiations between various stakeholders, including government delegations, UN representatives, human rights agencies and organizations working in the field, and, uniquely, PWLE and family supporter bodies 10 .The Convention entered into force in 2008.”

• cites [10]Not checked yet

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Probably not a substantial claim: may not pass S2 (checkable).

No real progress of psychiatry is likely without strong collaboration among professionals, PWLE, family/informal supporters, and policy makers.

“No real progress of psychiatry is likely to occur without a strong collaboration among professionals, PWLE, family/informal supporters, and policy makers 13 .”

• cites [13] sourceNot checked yet

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Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

Social justice requires equal rights through equitable access to resources and opportunities, especially for people living in poverty or with disability, or who are marginalized.

“Social justice requires equal rights through equitable access to resources and opportunities, especially for people living in poverty or with disability, or who are marginalized in various ways 41,42 .”

• cites [41]Not checked yet

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• cites [42] sourceNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The CRPD Committee states that the best interpretation of the will and preferences of the individual should be considered, which in practice may be very close to substitute decision-making.

“In such circumstances, the CRPD Committee states that the "best interpretation of the will and preferences of the individual" should be considered.In practice, this principle may be very close to "substitute decision-making".”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The MI Principles were criticized for failing to include organizations representing PWLE and for offering weaker protection on consent to treatment.

“Moreover, they were criticized on several grounds, including failing to include organizations representing PWLE in their development, and appearing to offer weaker protection than other pre-existing human rights instruments, particularly on matters of consent to treatment 25,26 .”

• cites [25]Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

The modern human rights framework is based on respect for inherent dignity of all humans.

“The modern human rights framework is based on the concept of respect for the inherent dignity of all humans 14 .”

• cites [14]Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Medical professionals contend that substitute decision-making is sometimes required to protect other key rights, including the right to health or life.

“Medical professionals contend that there are occasions when substitute decision-making is required to protect other key rights, including the right to health or the right to life [31][32][33] .”

• cites [31][32][33]Not checked yet

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Classified as probably not a substantial claim. May combine two claims.

Early intervention in psychiatry is consistent with ethical and health care principles and promising for reducing disability burden, but raises ethical concerns due to overmedicalization of transitory conditions and unwanted consequences of risk/vulnerability labels.

“While consistent with important ethical and health care principles, and a feasible and promising way to reduce the disability burden related to mental disorders, early intervention is raising ethical concerns due to the risk of overmedicalization of transitory conditions, and the possibility of unwanted consequences of risk/vulnerability labels.”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing). May combine two claims.

Other commentators regard this interpretation as absolutist or radical and unrealistic, arguing it may be difficult to determine the will and preferences of the individual.

“However, other commentators regard this interpretation as "absolutist" or "radical" and unrealistic.They have argued that, despite support, it may be sometimes difficult to determine what are the will and preferences of the individual concerned.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Some scholars, organizations, and the CRPD Committee interpret CRPD articles as prohibiting involuntary psychiatric hospitalization and treatment, and substitute decision makers, in any circumstances.

“Some scholars and organizations, as well as the UN Committee set up to monitor the implementation of the Convention (CRPD Committee), interpret these articles as prohibiting involuntary psychiatric hospitalization and treatment, as well as the appointment of substitute decision makers, in any circumstances 29,30 .”

• cites [29]Not checked yet

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Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

Human rights and social justice are complementary to promotion of mental health at a population level.

“Human rights and social justice are complementary to promotion of mental health at a population level 39,40 .”

• cites [39]Not checked yet

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May combine two claims.

Continuing to use coercion where resources are scarce generates a vicious cycle and allows the system to keep underfunding services.

“Continuing to use coercion where there are scarce resources generates a vicious cycle, and allows the system to keep on underfunding services 38 .”

• cites [38]Not checked yet

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Classified as probably not a substantial claim. May combine two claims.

Ethical dilemmas can arise when these principles conflict, and ethical issues evolve with changing professional and socio-cultural contexts.

“However, ethical dilemmas may arise when the above prin-ciples seem to clash.Furthermore, ethical issues associated with psy chiatry evolve as the professional and socio-cultural contexts change and new sensitivities emerge.”

Probably not a substantial claim: may not pass S2 (checkable).

Overt paternalism cannot be replaced by neglect and abandonment of PWLE.

“Overt paternalism cannot be replaced by neglect and abandonment of PWLE.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Advance directives are a valuable tool to support autonomy in a decision-making capacity-based regime.

“Advance directives are a valuable tool to support persons' autonomy in a decision-making capacity-based regime.”

Classified as probably not a substantial claim. May combine two claims.

In this proposal, involuntary treatment would only be permitted when the objecting person has an impairment of decision-making ability from any cause and if treatment is in the person's best interests.

“In this proposal, involuntary treatment would only be permitted when the objecting person has an impairment of decision-making ability -from any cause -and if treatment is in the person's best interests.”

• cites [50]Not checked yet

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• cites [51]Not checked yet

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• cites [56]Not checked yet

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Probably not a substantial claim: may not pass S2 (checkable).

A person's best interest is served primarily by acting to give effect, as far as possible, to the person's will.

“A person's best interest is served primarily by acting to give effect, as far as possible, to the person's "will".”

Classified as probably not a substantial claim. May combine two claims.

The focus on human rights requires a shift from paternalism to greater emphasis on autonomy and dignity, raising concerns about mental health law and involuntary treatment.

“As previously discussed, the focus on human rights requires a shift in the pendulum of ethics in psychiatry from paternalism to a greater emphasis on respecting the autonomy and dignity of all people.This raises concerns about the principles governing the usual forms of mental health law and the treatment of persons against their will [49][50][51][52] .”

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Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

Support may be needed to enable the person to express that free will.

“Support may be needed to enable the person to express that "free will".”

May combine two claims.

Conventional mental health law does not consider how proposed treatment is in the person's best interests, and adopts the clinician's perspective rather than the service user's.

“Nor does the question arise of how the proposed treatment is pur ported to be in the person's "best interests".The perspective is es sentially the clinician's, not the service user's one.”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing).

In situations where it is impossible to know the person's will, it has been proposed that the default position should be to consider relevant human rights as a guide for the decision.

“In such cases, it has been proposed that the default position would be to consider the human rights relevant to the situation as the guide for the decision to be made 64,65 .”

• cites [64]Not checked yet

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• cites [65]Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

This interpretation has stirred much controversy.

“This interpretation has stirred much controversy 59 .”

• cites [59]Not checked yet

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Probably not a substantial claim: may not pass S2 (checkable).

If this analysis is accepted, similar consideration should be given to the person's will even without a written advance directive, if expressed through statements and life choices evidenced by close relatives and friends.

“If this analysis is accepted, it would follow that we should give similar consideration to the person's "will" and its bearing on a decision ("preference") even if the person had not made a written advance directive, but had expressed that "will" through various statements and life choices, evidenced by people who know him/ her well -for example, close relatives and friends.”

Probably not a substantial claim: may not pass S4 (based). May combine two claims.

Reference to the CRPD's expression "will and preferences" is common, yet no authority, including the CRPD Committee, has provided a definition.

“Reference to the CRPD's expression "will and preferences" is now common, yet no authority, including the CRPD Committee, has provided a definition.”

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

The focus on human rights is relevant to the digital turn in psychiatry.

“The focus on human rights is also relevant to the digital turn in psychiatry.”

Classified as probably not a substantial claim. May combine two claims.

A distinction is maintained between legal capacity and mental/decision-making capacity, and the latter cannot justify deprivation of the former.

“A distinction is maintained between "legal capacity" and "mental" or decision-making capacity, and it is argued that the latter cannot provide a justification for a deprivation of the former.”

Classified as probably not a substantial claim.

The CRPD Committee argues that Article 12 entails all persons, regardless of decision-making ability, must enjoy legal capacity on an equal basis with others.

“The Committee argues that Article 12 of the Convention entails that all persons, regardless of their decision-making ability, must enjoy "legal capacity" on an "equal basis with others" 29 .”

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May combine two claims.

In jurisdictions with well-developed laws for non-consensual treatment in general medicine, non-consensual treatment is only permitted when the person lacks decision-making capacity and treatment must be in the person's best interests.

“In jurisdictions with well-developed laws governing non-consensual treatment in general medicine, it is only when a person lacks the decision-making capacity to consent to a treatment that the possibility of non-consensual treatment enters the frame.There is usually a further requirement: treatment must be in the person's "best interests".”

Classified as probably not a substantial claim.

Digital psychiatry has given rise to a wide range of ethical and legal issues warranting urgent attention.

“However, digital psychiatry has given rise to a wide range of ethical and, in some cases, legal issues that warrant urgent attention.”

May combine two claims.

Digital technology can improve availability of quality information, increase awareness of support, promote early identification and treatment, and help monitor and coordinate service provision.

“Digital technology can also improve the availability of quality information to increase awareness of relevant forms of support, promote early identification and treatment, and help in monitoring and coordinating service provision.”

Classified as probably not a substantial claim. May combine two claims.

Legal capacity involves the right to be recognized as a person before the law and the right to legal agency.

“Legal capacity involves the right to be recognized as a person before the law, as well as the right to legal agency, that is, to have one's decisions legally recognized.”

Probably not a substantial claim: may not pass S3 (load-bearing).

In this view, an advance directive is based on the difference between the person's will at Time 1 and anticipated preferences at Time 2 that the person asks to be ignored.

“In this view, an advance directive is based on the difference between "the will" of a person (and its associated preferences) expressed at Time 1, and the "preferences" that the person anticipates will be expressed at Time 2 and which the person asks to be ignored as they are not what he/she "truly wills".”

Probably not a substantial claim: may not pass S3 (load-bearing).

A single law covering all medical settings, including psychiatry, has been proposed to eliminate discrimination, applicable when a person has difficulty making a serious treatment decision.

“To eliminate the above forms of discrimination, a single lawcovering all medical settings, including psychiatry -has been proposed.This would be applicable when a person has a difficulty in making a serious treatment decision 50,51,56 .”

• cites [50]Not checked yet

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Probably not a substantial claim: may not pass S2 (checkable).

We generally honor the person's Time 1 will when the instruction reflects deeply held beliefs and values.

“We generally honor the person's Time 1 "will", when the instruction reflects the person's deeply held beliefs and values.”

Classified as probably not a substantial claim.

Measures can be devised to ensure PWLE are not regarded as lacking decision-making ability simply because they disagree with their doctors.

“Measures -for example, the involvement of those who know the person well, independent advocacy, second opinions, appeals to a tribunal when there is disagreement -can be devised to ensure that PWLE are not regarded as lacking decision-making ability simply because they disagree with their doctors.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Digital psychiatry promises improved equity and accessibility of care, meeting some key principles of global codes of ethics.

“This turn promises improved equity and accessibility of care, thus meeting some key principles of global codes of ethics.”

Probably not a substantial claim: may not pass S1 (asserted), S4 (based).

In an advance directive, a person at Time 1 states that a future preference at Time 2 should not be regarded as their true autonomous desire.

“In an advance directive, a person, when having clear decisionmaking ability (Time 1), states that, if a future episode of illness should occur (Time 2), he/she -on the basis of past experience -will likely express a preference (e.g., refusal of treatment) that is not to be regarded as what he/she truly or "autonomously" desires, and thus should not be respected.”

Probably not a substantial claim: may not pass S3 (load-bearing).

A pertinent ethical dilemma for psychiatrists is the opportunity cost of dedicating time to public mental health promotion and prevention when they have heavy service commitments.

“A pertinent ethical dilemma for many psychiatrists is the opportunity cost of dedicating time to public mental health promotion and prevention when they have heavy service commitments requiring their time.”

Probably not a substantial claim: may not pass S2 (checkable).

The stronger the case for involuntary intervention, the greater the threat to the person's will.

“The stronger is the case for an involuntary intervention, the greater is the threat to the person's "will" -that is, to his/ her deeply held beliefs and values, commitments and life projects -that would result from the person enacting a contradicting "preference".”

Probably not a substantial claim: may not pass S3 (load-bearing).

A common concept of "will" is a higher-order motivating or self-governing mental structure that determines which desires, wishes, or preferences should be translated into acts, with values playing a key role.

“However, reasonably common is the concept of the "will" as a kind of higherorder motivating or self-governing mental structure that determines which desires, wishes or "preferences" should be translated into acts, and in which the person's "values" play a key role 60,62 .”

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Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

Normally will and preferences run together; problems arise when they diverge and a serious decision is needed.

“Normally, "will" and "preferences", by and large, run together.It is when "the will" and "a preference" diverge or are contradictory, and a person needs to make a serious decision, that a problem may arise.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The CRPD Committee provides no guidance on which preference (Time 1 or Time 2) should be respected in an advance directive scenario.

“The CRPD Committee provides no guidance on the question.”

Probably not a substantial claim: may not pass S3 (load-bearing).

This approach has similarity to the German Federal Constitutional Court's distinction between natürlicher Wille and freier Wille.

“This approach has some similarity to the position taken by the German Federal Constitutional Court, based on a distinction in German Law between a person's natürlicher Wille ("natural will") and freier Wille ("free will") 63 , akin to the distinction between "a preference" and "the will", respectively.”

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Probably not a substantial claim: may not pass S4 (based). May combine two claims.

These principles reflect prejudicial stereotypes that people with mental illness are necessarily incapable of sound judgments and intrinsically dangerous to others.

“They reflect deeply rooted prejudicial stereotypes of people with mental illness, i.e., that they are necessarily incapable of making sound judgments and intrinsically dangerous to others.”

Probably not a substantial claim: may not pass S2 (checkable).

Treatment decision-making ability is undermined when there is a serious divergence or incoherence between the person's will and a currently expressed treatment preference.

“Treatment decision-making ability is undermined when there is a serious divergence, or incoherence, between the person's "will" and a currently expressed treatment "preference".”

Probably not a substantial claim: may not pass S2 (checkable).

This analysis adds a further dimension to the meanings of decision-making capacity and best interests, which may warrant significant reformulation.

“This analysis of "will and preferences" adds a further dimension to the meanings of "decision-making capacity" and "best interests", which may warrant a significant reformulation.”

Classified as probably not a substantial claim.

The CRPD Committee insists that involuntary treatment of people with psychosocial disabilities is prohibited.

“As previously noted, the CRPD Committee insists that involuntary treatment of people with mental health (or "psychosocial") disabilities is prohibited 29 .”

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Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

The concepts of capacity and best interests have advanced over the years, particularly regarding assessment of use/weigh elements and special regard to beliefs and values.

“The concepts of "capacity" and "best interests" have advanced over the years, particularly in relation to the assessment of the "use" and "weigh" (or "appreciation" and "reasoning") elements of the former, and the special regard to be given to the person's beliefs and values in the assessment of the latter.”

May combine two claims.

Clear potential benefits of digital developments include web-based and ICT-based support that breaks down geographical barriers and facilitates confidential and anonymous help-seeking.

“Clear potential benefits heralded by digital developments in psychiatry include web-based and other information communication technology (ICT)-based forms of support, helping to break down geographical barriers [66][67][68] , and facilitate confidential and anonymous help-seeking.”

• cites [66][67][68]Not checked yet

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Classified as probably not a substantial claim.

Conventional criteria for compulsion are the presence of a vaguely defined "mental disorder" and a risk of harm to self or others.

“The conventional criteria for compulsion are the presence of a "mental disorder", usually vaguely defined, and a risk of harm to the person or to others.”

Probably not a substantial claim: may not pass S2 (checkable).

The "disorder + risk" schema discriminates against people with a mental health condition by depriving them of rights enjoyed by those without such a diagnosis.

“Such a "disorder + risk" schema can be seen as discriminating against people with a mental health condition, depriving them of rights enjoyed by those without a mental disorder diagnosis.”

Classified as probably not a substantial claim.

Patients with physical disorders who have decision-making capacity can refuse treatment even when refusal may carry grave consequences.

“It is accepted that patients with "physical" disorders, if they have decision-making capacity, can make treatment refusals even when this may carry grave consequences.”

Probably not a substantial claim: may not pass S2 (checkable).

A distinction can be drawn between "the will" and "a preference": the will is a manifestation of deeply held, stable, coherent beliefs, values, commitments, and conception of the good, not the same as a present desire or preference.

“Thus, a distinction may be drawn between "the will" and "a preference"."The will" can be taken to be a manifestation of a person's deeply held, reasonably stable and coherent personal beliefs, values, commitments and conception of the good.In this sense, it is not the same as a desire, inclination, or "a preference", held in the present, even a strongly expressed one.”

Probably not a substantial claim: may not pass S3 (load-bearing).

People with disorders that were not rapidly fatal but involved severe irremediable distress argued that limiting physician-assisted death to terminal cases was irrational and discriminatory.

“However, people with disorders that were not likely to be rap-idly fatal, but were associated with severe irremediable distress, soon argued that the restriction of physician-assisted death to terminal cases was irrational and discriminatory 220 .”

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May combine two claims.

The right of competent individuals to refuse life-sustaining treatment is widely recognized, as is their right in some countries to specify in advance which interventions will be used and under what conditions.

“The right of competent persons to refuse life-sustaining treatment has been widely recognized 216 , along with their right in some countries to determine in advance which interventions will be applied (e.g., cardiopulmonary resuscitation, ventilators), and under what conditions 217 .”

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May combine two claims.

Conflicts of interest may threaten the quality of clinical care, the integrity of research and education, and public trust in science and medicine, including psychiatry.

“CoIs may threaten the quality of clinical care as well as the integrity of research and education, and may jeopardize public trust in science and medicine, including psychiatry 236,239 .”

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May combine two claims.

The failure of mental health apps can no longer be explained by a digital divide in technology access, though equitable access to ICTs for people with lived experience remains a problem.

“This failure can no longer be attributed to a "digital divide" concerning access to technology, although equitable access to ICTs by PWLE remains an issue 108,109 .”

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May combine two claims.

AI algorithms can be susceptible to biases from their training data, exacerbating existing disparities.

“Artificial intelligence (AI) algorithms, for example, can be susceptible to biases arising from the data they are trained on, thus exacerbating existing disparities, because AI learns from humans and society.We must understand how AI makes decisions in various critical settings 70 .Implicit and explicit biases that can be captured by AI algorithms have been well-documented 71 .”

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May combine two claims.

In March 2023, the US FTC filed a complaint against BetterHelp, which was fined US$7.8 million for allegedly revealing consumers' data to Facebook, TikTok, and other technology firms.

“In March 2023, for example, the US Federal Trade Commission filed a complaint against the online therapy company BetterHelp 74 , which was fined US$ 7.8 million for allegedly revealing consumers' data to Facebook, TikTok and other technology firms.”

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May combine two claims.

Prevention has become a social and ethical imperative in psychiatry, largely because most mental disorders begin at a young age and access to suitable care is greatly delayed.

“Prevention has become a social and ethical imperative in psychiatry 4,66,120 , especially because the onset of most mental disorders occurs at a young age, and access to appropriate care is significantly delayed.”

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Classified as probably not a substantial claim. May combine two claims.

Not disclosing an at-risk condition would breach respect for autonomy, which holds that people have the right to make their own choices and that psychiatrists must make them aware of the consequences of those choices.

“However, choosing not to disclose the presence of an at-risk condition would violate the principle of respect for autonomy, which states that people have the right to make autonomous choices and that the duty of psychiatrists is to make them aware of the potential consequences of their choices.”

Probably not a substantial claim: may not pass S4 (based).

The ethical and legal context of end-of-life decisions is made more complex by certain features of mental disorders, including symptoms that can interfere with competent decision-making.

“The ethical and legal background of decisions about the end of life is complicated by some aspects of mental disorders, including symptoms that may interfere with competent decision-making.”

May combine two claims.

Stigma-related stress and fear of developing a serious mental illness may reduce quality of life, increase hopelessness, anxiety and depression, and actually raise the likelihood of psychosis onset and suicidality.

“Stigma-related stress and fear of developing a serious mental illness may lead to decreased quality of life, hopelessness, anxiety and depression, and actually increase the likelihood of psychosis onset and suicidality 149 .”

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Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

Because digital mental health technologies lack unified governance, ethical principles provide the clearest guidance.

“Given the lack of any unified governance for digital mental health technologies, ethical principles offer the clearest guidance.”

• AssumptionRests on an assumption: There is no unified governance for digital mental health technologies.

Probably not a substantial claim: may not pass S3 (load-bearing).

Health care professionals, including psychiatrists, may benefit from relationships with pharmaceutical and biomedical manufacturers in ways consistent with their primary interests.

“Health care professionals, including psychiatrists, may benefit from relationships with pharmaceutical and biomedical manufacturers in ways that are consistent with their primary interests, as they can acquire information on new therapeutic options, have the opportunity to give their feedback to facilitate further development of industry products, and access resources to update their knowledge and”

Probably not a substantial claim: may not pass S2 (checkable).

Ethical frameworks remain valuable in the changing digital mental health landscape.

“Ethical schemes continue to offer value in the evolving digital mental health environment described above.”

Classified as probably not a substantial claim.

Adopting a broad definition of telepsychiatry creates an immediate problem, since varied technological practices bring varied ethical and legal issues.

“Accepting this broad definition poses an immediate challenge.Diverse technological practices often bring an equally diverse set of ethical and legal issues.”

May combine two claims.

From an ethical standpoint, telling someone about an at-risk condition may cause psychological harm, thereby conflicting with non-maleficence.

“From an ethical point of view, the information about the presence of an at-risk condition may have a negative psychological impact, thus contradicting the principle of non-maleficence.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Because some patients would be unable to take medication themselves, the practice was extended in some jurisdictions to include physician administration of medication, usually intravenously, known as euthanasia.

“Because of concern that some patients (for example, those with advanced amyotrophic lateral sclerosis) would be unable to take the medication themselves, this practice was extended in some jurisdictions to encompass physician administration of the medications, usually intravenously, a practice denoted by the term "euthanasia" 219 .”

• cites [219]Not checked yet

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Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing). May combine two claims.

Broad ethical concepts can aid general discussion, but particular technologies in particular settings usually need closer examination.

“These general concepts may be helpful for broad discussions, but specific technological practices in specific settings will typically require closer consideration.”

Probably not a substantial claim: may not pass S4 (based). May combine two claims.

Digital approaches have potential to undermine face-to-face support, degrade trust, threaten privacy/safety/security, undermine accountability/professional responsibility, and amplify discrimination and inequity along lines of race, language, gender, disability, and poverty.

“However, there is potential for digital approaches to undermine face-to-face support; degrade trust between people and their mental health practitioners; threaten privacy, safety and security; under mine accountability and professional responsibility when things go wrong; and amplify discrimination and inequity along lines of race, language, gender, disability and poverty.”

May combine two claims.

Current policies tend to regulate small benefits to individual researchers but often fail to address the effects of large amounts of institutional funding.

“However, financial CoIs do not only affect individual researchers, but also academic institutions and institutional leaders [286][287][288][289] , and current policies tend to regulate even small benefits to individual researchers (e.g., free meals), while often failing to address appropriately the effects of large amount of funding for institutions 289,290 .”

• cites [289]Not checked yet

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• cites [290]Not checked yet

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May combine two claims.

Patient advocacy groups have increasing reports of pharmaceutical funding and may participate in drug advisory committees, drug reviews, and reimbursement decisions, indirectly influencing prescription patterns.

“For instance, patient advocacy groups have been the subject of increasing reports of funding from pharmaceutical companies [265][266][267] , and may participate in drug advisory committees, drug reviews and public reimbursement decisions 268 , thus indirectly influencing prescription patterns.”

• cites [265]Not checked yet

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May combine two claims.

These indirect pathways may have cumulative effects, are far less documented, and may not be detected by policymakers.

“These pathways, which may have cumulative effects, are far less documented, and may not be detected by policy mak ers 269 .”

• cites [269]Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The WPA recommends that psychiatrists critically review industry information, limit meetings and interactions with pharmaceutical representatives, and forbid their access to patient care areas.

“The WPA warns psychiatrists to take with caution and critical review the information provided by industry representatives, and suggests that psychiatrists and health care organizations limit meetings and interactions with pharmaceutical company representatives, and forbid their access to patient care areas.”

• cites [256]Not checked yet

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May combine two claims.

Non-financial conflicts of interest are relevant to psychiatric practice, and clinical decision-making may be influenced by intellectual allegiance or defensive practices.

“Non-financial CoIs are also relevant to psychiatric practice, and clinical decision-making may be influenced in case of intellectual allegiance to a school of thought or to political ideas 12 , or in relation to defensive practices 274 .”

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May combine two claims.

Disclosure may motivate clinicians to avoid circumstances and behaviors representing potential conflicts of interest and aims to improve public trust through transparency.

“Disclosure may motivate clinicians to avoid circumstances and behaviors representing potential CoIs 261,262 , and aims to improve public trust in the health system through transparency.”

• cites [261]Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

The WPA and EPA discourage psychiatrists from displaying items bearing company logos in the presence of service users.

“In addition, both associations discourage psychiatrists from exposing items bearing companies' logos in the presence of service users, because these may influence the users' perceptions of the relationship between the industry and their doctors 258 .”

• cites [258]Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The WPA and EPA discourage accepting meals and gifts, and the WPA recommends accepting drug samples only to provide them to people otherwise unable to afford medications.

“Both the WPA and the EPA currently discourage psychiatrists from accepting meals and gifts, and the WPA additionally recommends accepting drug samples only to provide them to people who are otherwise unable to afford medications.”

• cites [256]Not checked yet

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• cites [257]Not checked yet

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May combine two claims.

The WPA endorsed concepts of involving people with lived experience in position statements in 2011 and 2023, and the WHO developed a framework for meaningful engagement of people with lived experience.

“The WPA endorsed these concepts in position statements in 2011 311 and 2023 312 , and the WHO has developed a framework for meaningful engagement of PWLE 313 .”

• cites [311]Not checked yet

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May combine two claims.

Several regulators have developed accreditation criteria limiting direct industry funding and codes of conduct requiring management and transparent disclosure of conflicts of interest.

“Several regulators [304][305][306][307][308] have developed accreditation criteria limiting direct industry funding, as well as codes of conduct requiring management and transparent disclosure of CoIs.”

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May combine two claims.

The lack of a shared standardized taxonomy of conflicts of interest and the dearth of studies testing the influence of different conflicts on research and publication limit the efficiency of restrictions.

“In addition, while current policies identify different magnitudes and types of CoIs, the lack of a shared standardized taxonomy of CoIs and the dearth of studies testing the influence of different CoIs on research and publication activities limit the efficiency of restrictions 290 .”

• cites [290]Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Pharmaceutical companies have an interest in sponsoring educational initiatives, materials, and events to promote their brands and new therapeutic options.

“For instance, as pharmaceutical companies aim to promote their brands, as well as new therapeutic options, they have an interest in sponsoring educational initiatives, materials and events.”

Probably not a substantial claim: may not pass S2 (checkable).

Much remains to be done to replace clinical practices based on the traditional therapeutic relationship with a new model of treatment.

“Much remains to be done to replace clinical practices based on the traditional therapeutic relationship -in which the roles are well defined and shaped by a thousand-year experience -by a new model of treatment that is still a work in progress.”

Classified as probably not a substantial claim.

Conflicts might arise between people with lived experience and relatives when they work together.

“However, conflicts might arise between PWLE and relatives when they work together.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Interest in peer support has waxed and waned over the years, with a tremendous amount of activity at present.

“Interest in peer support (i.e., involvement of PWLE in supporting other PWLE) has waxed and waned over the years, with a tremendous amount of activity at present 317 .”

• cites [317] sourceNot checked yet

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May combine two claims.

Participants may receive gifts, reimbursements for sponsored conferences, or scholarships, and the possibility that these marketing activities influence their prescription patterns cannot be ruled out.

“Additionally, participants may receive gifts, reimbursements to participate in sponsored conferences, or scholarships 236,303 , and the possibility that these marketing activities influence their prescription patterns cannot be ruled out.”

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May combine two claims.

These regulations have limitations and may fail to address indirect financial ties and influences.

“As noted, however, these regulations have limitations and may fail to address indirect financial ties and influences 309,310 .”

• cites [309]Not checked yet

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May combine two claims.

People with lived experience want more information and the ability to make decisions about their own care and treatment.

“They would like more information and ability to make decisions about their own care and treatment 314,315 .”

• cites [314]Not checked yet

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May combine two claims.

Peer supporters increase users' sense of hope and control, self-care, sense of belonging to a community, life satisfaction, and ability to change their lives.

“Peer supporters increase users' sense of hope and control, self-care, sense of belonging to a community, life satisfaction, and the ability to change their lives 317 .”

• cites [317] sourceNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Concerns about non-financial conflict of interest disclosure include privacy violation and irrelevance because it duplicates publicly available information.

“Concerns about non-financial CoI disclosure have included privacy violation (e.g., in the case of political or religious beliefs) and irrelevance, insofar as it duplicates publicly available information, such as intellectual positions and education, training, in stitutional and academic affiliations 298 .”

• cites [298]Not checked yet

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Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

Psychiatrists have a professional obligation to share up-to-date, evidence-based, and ethically informed knowledge.

“As such, they have a professional obligation to share upto-date, evidence-based and ethically informed knowledge 4 .”

• cites [4]Not checked yet

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May combine two claims.

Family/informal supporters often voice concerns including lack of information about a loved one's mental health status, difficult relationships with professionals, limited familial involvement, and substantial personal burdens.

“Concerns often voiced by family/informal supporters of PWLE include lack of information about a loved one's mental health status, difficult relationships with professionals, and limited to no familial involvement in their mental health treatment 320 , as well as substantial personal burdens involved in providing care.”

• cites [320]Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

Other rights listed by the CRPD may not be enjoyed, including the right to the highest possible standard of health care.

“In addition, other rights listed by the CRPD may not be enjoyed, including the right to the highest possible standard of health care.”

Probably not a substantial claim: may not pass S2 (checkable).

There is a need to consider a possible clash between the principles of autonomy and beneficence.

“In fact, we need to consider the possible clash between the principles of autonomy and beneficence.”

Probably not a substantial claim: may not pass S4 (based).

Respecting people's autonomy and decisions alone may lead physicians to neglect the ethical principle of beneficence.

“By simply respecting people's autonomy and their decisions, physicians might betray their responsibilities and neglect the ethical principle of beneficence.”

Probably not a substantial claim: may not pass S3 (load-bearing).

People with lived experience feel that the relationship between the service user and the service deliverer is the most important factor in their care.

“They feel that the relationship between the service user and the service deliverer is the most important factor in their care 315 .”

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May combine two claims.

Non-financial conflicts of interest are less often acknowledged, although they may impact research as much as or more than financial ones.

“Non-financial CoIs are less often acknowledged, although they may impact research as much as, or even more than, financial ones.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

Recent research and policy efforts have improved transparency and increased understanding of the complexity of conflicts of interest and the health care and scientific ecosystem.

“Recent research and policy efforts have improved transparency and thus increased our understanding of the complexity of the issue of CoIs, as well as of the relevant health care and scientific ecosystem.”

Classified as probably not a substantial claim. May combine two claims.

Psychiatrists often have roles as teachers, mentors, and public speakers and participate in the education of students and residents.

“Psychiatrists often have roles as teachers, mentors and public speakers, and participate in the education of students and residents.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Training family/informal supporters is one of the suggested solutions to their burden.

“Training family/informal supporters is one of the suggested solutions to their burden 321,322 .”

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Probably not a substantial claim: may not pass S3 (load-bearing).

The WPA Code of Ethics indicates that psychiatrists should present in sponsored educational activities only when they have control over the educational content.

“The WPA Code of Ethics indicates that psychiatrists should be presenting in sponsored educational activities only when they have control over the educational content 4 .”

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May combine two claims.

All these interactions carry risks of undue influences, and growing evidence shows that commercial sponsors can influence these networks at individual and institutional levels.

“However, all these interactions carry risks of undue influences, and growing evidence shows that commercial sponsors can influence these networks both at individual and institutional levels.”

May combine two claims.

People with lived experience are particularly good at engaging other people with lived experience, reducing emergency room and hospital use, and reducing substance misuse.

“In general, PWLE are particularly good at getting engagement of other PWLE, reducing the use of emergency rooms and hospitals, and reducing substance misuse 319 .”

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Classified as probably not a substantial claim. May combine two claims.

There are risks of breaching non-maleficence by providing information and intervention and of failing to provide relevant information and intervention to persons who might persist in adverse lifestyles.

“On one side, we run the risk of breaching the principle of non-maleficence by providing information and eventually intervention; on the other, we run the risk of failing to provide relevant information and intervention to persons who might otherwise, for example, persist in clinically and socially adverse lifestyles, such as substance use, social isolation, or unhealthy sleep patterns.”

May combine two claims.

Students developed increased empathy, greater awareness of stigma, and more positive views of the ability of people with lived experience to participate in their own care.

“Students developed increased empathy, greater awareness of stigma, and more positive views of the ability of PWLE to participate in their own care.”

• cites [327]Not checked yet

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Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

Adequate legislation may contribute to addressing ethical challenges if the right to autonomy and freedom does not lead to abandonment and consequent poor mental health, social isolation, and socioeconomic deprivation.

“Adequate legislation may contribute to addressing the abovementioned ethical challenges, provided that the right to autonomy and freedom for PWLE does not lead to their abandonment and consequent poor mental health, social isolation and socioeconomic deprivation.”

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based). May combine two claims.

Intuitively, earlier intervention is more likely to spare suffering, avoid failures in achieving life's milestones, and prevent the onset or worsening of a mental disorder.

“At a first glance, this is an area in which the pros of intervention outweigh the cons: intuitively, the earlier we intervene to address a mental health condition, the more likely we are to spare suffering, avoid failures in achieving life's milestones, and prevent the onset or worsening of a mental disorder.”

Probably not a substantial claim: may not pass S2 (checkable).

There is a need to improve the ability to reach people early without causing stigmatization, stigma-related stress, and fear of developing a serious mental illness.

“However, we still need to improve our ability to reach people in need of help, support and care at an early stage without causing stigmatization, stigma-related stress and fear of developing a serious mental illness, which are likely to lead to decreased quality of life, hopelessness, anxiety, depression, and even an increased risk of developing a serious mental disorder 143 .”

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May combine two claims.

Collaboration helped both academic researchers and people with lived experience to develop skills and increased the credibility of research in the broader lived experience base, resulting in more legitimacy and accountability.

“It has been found that collaboration helped both academic researchers and PWLE to develop skills, and increased the credibility of research in the broader PWLE base, resulting in more legitimacy and accountability.”

• cites [336]Not checked yet

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May combine two claims.

A quantitative review found that studies with higher patient involvement achieved higher recruitment targets and sometimes more success in funding.

“A quantitative review also found that studies with higher patient involvement achieved high er recruitment targets, and sometimes more success in funding 338 .”