Presidential address: Ethics in Precision Psychiatry

INTRODUCTION

Precision medicine is an approach that is therapeutic and preventive, and it enables healthcare providers to make clinical decisions based on specific individual characteristics.^[1] The foundation of precision medicine lies in personalized clinical prediction models, which have various applications such as screening, diagnosis, prognosis, and treatment planning.^[2]

Psychiatry’s individualization is usually based on the clinical impression rather than the “objective” criteria that precision psychiatry can provide.^[3,4] Precision psychiatry is gaining momentum and is expected to change especially when combined with preventive psychiatry but its transition into clinical practice is still in its early stages.

In addition, there is a need for a cogent ethical framework that everyone can agree on to guide future research and practice in this area.^[3]

Key principles of precision psychiatry are divided into two categories^[5] [Figure 1]:

• For clinicians:

  1. Autonomy

  2. Non-maleficence

  3. Competency

• Researcher-oriented:

  1. Justice

  2. Veracity

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Figure 1:

Key ethical principles.

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AUTONOMY

Autonomy refers to the ability of individuals to make informed decisions about their mental health care based on personalized and precise information. Also known as self-determination, it involves empowering patients to actively participate in their unique genetic, environmental, and lifestyle factors.^[5] Autonomy extends beyond the informed consent process. When introducing routine and novel interventions or therapies, clinicians must ensure that patients and their caregivers are aware of the potential risks, benefits, and alternatives. This allows patients to actively participate in the decision-making process and make choices that align with their values and preferences.^[3]

One such example is the use of genetic testing to guide treatment selection for psychiatric disorders. Genetic testing can provide valuable insights into an individual’s makeup and how they may respond to different medications.^[6] By incorporating this, clinicians can help patients make more informed choices about which medications are likely to be most effective and have fewer side effects for them personally.^[7]

Recent practice of autonomy lies in the use of digital health technologies, such as smartphone applications or wearable devices, to monitor and track mental health symptoms.^[8] These technologies can provide individuals with real-time data about their own mental well-being, allowing them to actively participate in self-management and treatment planning. Patients can use this information to make informed decisions about when to seek additional support or ask for change in their treatment strategies.^[9,10]

NONMALEFICENCE

Nonmaleficence, or the principle of “do no harm,” is a fundamental ethical principle in healthcare. In the context of precision psychiatry, it means tailoring treatments based on unique characteristics and understanding the balance between potential aid and harm that may occur.^[5] Nonmaleficence can be applied in several ways, like being careful while considering the invasiveness and risk of harm from a procedure. When determining the most appropriate treatment approach, healthcare providers must weigh the potential benefits against the potential risks and adverse effects, that is, if a particular treatment option carries a high risk of severe side effects or complications, it may not be recommended for patients who are at a higher risk or have a poor prognosis. Another ethical concern is considering the severity and prognosis of the illness. For instance, for individuals with severe mental illnesses who have not responded well to standard treatments, more aggressive interventions may be considered, but only after carefully weighing the potential risks and benefits.^[3]

Nonmaleficence also requires taking into account the psychosocial context of each patient. Mental health is influenced by various factors such as social support, living conditions, job, financial status, and cultural background. For example, the side effect of tremors in hands with antipsychotics has much more severe implications for a surgeon than a patient who works as a fruit seller.^[3]

However, one should also remember that neglecting to implement effective precision methods in psychiatry could also harm the patients due to missed opportunities to do better.

COMPETENCY

Competency in precision psychiatry refers to the knowledge, skills, and abilities that mental health professionals need to effectively utilize and integrate precision-based approaches into their clinical practice. In simpler words, it means staying up to date with the latest advancements, understanding the complexities of precision medicine, and being able to interpret and apply precision-based information in a clinically meaningful way.^[5]

One application of competency in precision psychiatry is the ability to interpret genetic or biomarker information accurately. The approaches often involve analyzing genetic variations or biomarkers to guide treatment decisions.^[6,11,12] Another example is the competence to navigate and utilize digital health technologies effectively. As discussed earlier about digital tools such as smartphone applications, wearable devices, and online tools, clinicians should be competent and familiar with these transformative technologies, understand their limitations, and be able to interpret the data generated.^[10,13,14] Psychiatrists need to be aware of the potential for false positives or false negatives in genetic testing, as well as the ethical considerations surrounding privacy and confidentiality when using digital health technologies.^[15]

Furthermore, competency in precision psychiatry requires ongoing professional development and abreast of the latest research and advancements in the field. This includes attending conferences, participating in continuing education programs, and engaging in peer-reviewed literature to stay informed about emerging precision-based interventions and best practices.

JUSTICE

This ethical principle refers to the fair and equitable distribution of resources, benefits, and opportunities in mental healthcare. It involves addressing disparities and ensuring that all individuals, regardless of their background or circumstances, have equal access to personalized and precise mental health interventions.^[5] It is the effort to reduce health disparities by increasing access to precision-based interventions for underserved populations.^[16] This can be achieved by implementing strategies to reach individuals who may face barriers to accessing mental healthcare, such as those from low-income communities or marginalized groups. Precision psychiatry aims to ensure that everyone has an equal opportunity to benefit from advances in personalized treatment approaches, by the inclusion of diverse populations in research studies and clinical trials. Historically, certain groups have been under-represented in mental health research, leading to a lack of understanding about how different populations may respond to specific treatments. Precision psychiatry seeks to address this by actively recruiting participants from diverse backgrounds, including individuals with different ethnicities, socioeconomic statuses, and cultural backgrounds. In addition, justice in precision psychiatry involves considering the affordability and accessibility of precision-based interventions.

VERACITY

Veracity in precision psychiatry refers to the importance of truthfulness, honesty, and transparency in the field. It involves providing accurate and reliable information to patients, clinicians, and researchers, as well as promoting ethical conduct in the collection and interpretation of data.^[5]

A way of practicing veracity is by transparent reporting of research findings, it is crucial for researchers to accurately report their methods, results, and any potential limitations or conflicts of interest. This ensures that the scientific community and clinicians have access to reliable information that can guide decision-making and inform clinical practice. Even when collecting and handling patient data for precision-based studies, researchers must adhere to strict ethical guidelines. Veracity also extends to the informed consent process. When discussing precision-based interventions with patients, clinicians must provide clear and accurate information about the risks, benefits, and uncertainties associated with these approaches.

By upholding veracity in precision psychiatry, trust is fostered between patients, clinicians, and researchers.

SO FAR THE ETHICAL IMPLICATIONS OF PRECISION PSYCHIATRY

CONCLUSION

Precision psychiatry is at the forefront of mental health innovations, but it also raises unprecedented ethical concerns at the individual, healthcare, and whole societal levels.

Ethical concerns regarding autonomy, nonmaleficence, competency, justice, and veracity have slowed the implementation of precision psychiatry into clinical practice.

While these concerns are valid and need to be carefully navigated, the risk of harm from slow or absent implementation is often overlooked.

By carefully considering and addressing ethical challenges, the implementation of precision psychiatry can advance more rapidly, with the goal of improving patient care and making the fruits of scientific research more equitably distributed.

As pioneers in this field, let us proceed with rigor, empathy, and commitment to ethical principles, paving the way for improved patient care for generations to come.