AAPEL
Borderline Personality Disorder (in French-"état limite")
The patient's right to a diagnosis and to information.
The doctor's rights and duty concerning information.
The medical code of ethics for French doctors.
Meme page en Francais / Same page in french
Introduction
The patient has a right to refuse to accept the doctor's information or diagnosis and it is the duty of the therapist to provide him with a maximum of information concerning his illness, treatment and possible evolution of the illness.
From the moment a patient sets foot in the doctor's office with a complaint (be it physical or somatic) or just "I have a problem", the latter has a duty, with respect of the patient, to do everything he can to establish a diagnosis; even if it is not necessarily THE diagnosis that the patient expected (refer to example on this page, under depression). Where necessary he should refer the patient to the appropriate specialist if he himself does not have the aptitude to treat this type of ailment.
Furthermore he must do his utmost to make the patient accept and agree with this diagnosis. In case of uncertainty concerning the diagnosis, the practitioner has the duty to inform the patient of the possible differential diagnoses and the means to obtain a definitive diagnosis throughout the duration of the treatment.
There are still many (too many?) practitioners today who believe themselves to be in the 19th century, i.e. omniscient (all-knowing), omnipotent (all-powerful) and who speak down to their patients. Such methods are outdated and no longer in keeping with the respect due to a human being.
The code of medical ethics adheres totally to respecting the patient and information. Therapists have a moral duty to apply this code…to such an extent that one can call it a legal obligation.
The patient has the right to self-respect even if he is "mentally ill".
Bellow are several striking extracts from the French medical code of ethics as well as the point of view of certain French-speaking specialists. (The texts concerning psychotic patients are particularly interesting).
Extracts from the French medical code of ethics
Questions asked to the conseil national de l'ordre
What professionals say
.
Code of ethics of the Medical Association and the French Public Health code (extracts)
Article 11 - Continuing training
Article 33 - Diagnosis
Article 35 - Informing the patient
Article 109 - Doctor's commitment to respect the ethic code
Article 11 (continuing training)
Every doctor should maintain and improve his knowledge; he should take every measure to attend professional training courses

1. Medical Skills
The code of ethics demands that a doctor administer a treatment which complies with data learn from research. A doctor has no right not to be familiar with medical progress in every domain; clinical, biological, technological, etc.
Due to the growing complexity of medical science, it has become increasingly difficult to satisfy this obligation. However, despite this fact, a doctor should always bear in mind that he is responsible and he should be aware of his lack of knowledge which could have serious consequences for the patient. (before planning some possible forensic consequences).

2. Continuing training
Edict no.96-345 of April 1996 relating to the control of medical spending on health, underlined, in article 11, the legal obligation of doctors to undertake continuing medical training. It set out a system of regulations and verification to ensure that this duty has been carried out.;
These measures not having been put into place, a new project is presently being drawn up.

3. Assessment of practice
The participation of a doctor in the assessment of professional practice… The wording does not make this compulsory but it is strongly recommended. The abundance of information, (sometimes contradictory and not always objective), reinforces the necessity to assess practices and techniques in order to be familiar with the different terms: indications, efficiency, tolerance, and thus enables the patient to benefit from them without impose them to others.
Without this being a permanent obligation for every doctor, such assessments should be encouraged for individuals within the framework of a team or network, an institution or co-operating group.
Ideally, each doctor should occasionally take part in an inquiry or assessment in order to have the opportunity of meeting with fellow practitioners or researchers and to familiarise himself with appreciable working methods which could stimulate his discernment and have a favourable impact on his practice.
Such measures correspond to the public demand for quality and safety.

Article 33 (diagnosis)
The doctor should take great care in arriving at a diagnosis; taking his time and using the most appropriate scientific methods and, where necessary, seeking appropriate assistance.
Reaching a diagnosis is the first step towards treating a patient. Certain initial observations, conscientiously set down in writing, could help to establish and lead to an etiological diagnosis. It is therefore a very important moment, the quality of which, conditions the doctor's approach and often that of other participants.
Medicine requires that the nature and the origin of an illness be recognised in order to treat it correctly. It is particularly important in serious cases, but in the first instance, one can sometimes only diagnose a "state", which requires a temporary symptomatic treatment. Especially in the case of heart failure where urgent treatment can be life-saving --- an in-depth diagnosis can be postponed according to the importance of the problem in question.
Diagnosis can sometimes be difficult; even the most experienced doctor can have doubts. Hesitation, lack of an initial diagnosis or an error of judgement are not reprehensible as long as the examination is carried out correctly and given suitable consideration. Neither is it reprehensible if the doctor feels obliged to prescribe a temporary treatment.
It is considered a fault not to seek to diagnose correctly and to remain vague, leaving the subsequent outcome to chance, or to prescribe a standard treatment indiscriminately, thus not adapting the diagnosis or therapy to the circumstances and personal situation of the patient. In-depth questioning and taking into account previous complaints, could be of great help during this initial step in patient care...
...A diagnosis determination is desirable in principal, but unacceptable if the motive is scientific curiosity or if the patient does not get to benefit from the consequences; especially if the outcome is purely palliative treatment and does not change the prognosis...
...If a doctor is unsure of his diagnosis he should refer to a consultant or specialist or put the patient under observation. This deontological rule has been recommended to practitioners since ancient times. This referral implies that the doctor chooses to whom he will address the patient according only to the colleagues skills and with his consent and not according to any other consideration which might not be in the patient's best interest in a given situation...
...A third party who is not a medical professional, could be asked to act as an intermediary for the doctor. This could be for the purpose of collecting clinical information which is indispensable for assessing the situation or he could be required to carry out certain vital urgent gestures to avoid fatal complications…
Article 35 (informing the patient)
(commentary revised in 2OO3)
The doctor owes it to the patient, to give him information which is true, clear and appropriate about his state, examinations and treatment proposed.Throughout the illness, he should take into account the patient's personality when giving an explanation, and he should ensure that the explanation is understood.
However, a patient may be kept in ignorance if the prognosis is particularly serious and if the doctor legitimately believes that it is in the patient's best interest...

1 - Duty to inform
Today is a general trend to reverse the usual lack of information which was largely deplored by patients in the past. In France, as well as in other Western countries, the most common complaint heard against doctors is, "He didn't tell me anything".

2  The right to be informed
 « Everyone has the right to be informed about one's state of health; this information concerns the different examinations, treatments or prevention; their use, possible urgency, consequences and any frequent or serious risks expected. The patient should also be informed of any alternative solutions and the possible consequences, should he refuse the doctor's advice. Whenever... new risks are identified, the person should be informed about them immediately, unless he cannot be found.
All health professionals have a responsibility to give this information according to their skills and in respect of the professional regulations which refer to them. Only in the case of an emergency or impossibility can he be exempt from giving information...
A person's wish to be kept in ignorance of his diagnosis must be respected, except if there is a risk of transmission to a third party

3  Truthful, clear and appropriate information

  • Clear, The information given to a patient must be understandable to him…
  • Appropriate,(to the circumstances), Information must be appropriate according to the following factors…
  • The illness and the prognosis
  • The consequences of the treatment
  • The moment of the evolution in the illness...
  • Last but not least, the patient himself. Psychiatric disorders related to the illness or age should not be considered a reason for withholding information. Pour chaque personne au contraire il faut parler et expliquer, en exploitant toutes les possibilités de compréhension du patient, possibilités qui se révèlent dans leur étendue et leurs limites au cours de l'exercice…
  • Truthful,is the keyword and also the first word in article 35. Lies must not be told to a person for whom one has respect. Truthfulness does not imply brutal, heatless frankness. But a cover-up or lie should be excluded, except in the case of certain restrictions which we are going to see and which should become rare…
  • Thus defined, this information should enable the patient to reach the decision required by the situation. He is not a victim of blind fate or mysterious decisions. Instead, he receives  an explanation of the decisions reached by the doctor concerning his state of health.
    In every case of serious or prolonged illness, information should be given more than once throughout the duration of the illness and reinforced at crucial moments.
    Quality information is a prerequisite to enlightened consent. This consent is the corner-stone in the doctor-patient relationship and in medical practice in general.
    It is the normal price of the inordinate power given to the doctor to undermine the person integrity...
    ...The doctor can be held responsible if he doesn't give the patient the necessary information. He can be ordered to compensate the latter; not for the totality of the bodily harm incurred, but for the loss of opportunity to avoid the risk run and of which he is a victim.

    4 - Diagnosis and serious prognosis
    After principle statement : which authorises, for legitimate reasons and in his best interest, keeping the patient in ignorance of a diagnosis or serious prognosis.
    In some cases the doctor might judge that revealing a diagnosis could have a devastating effect or that a very serious prognosis could be dangerous or damaging. A doctor should never incite despair.
    ...However, nowadays, with the evolution of people's mentality and an improved psychological approach, the practice of "charitable silence" has greatly diminished. The truth can be withheld temporarily, only for reasons pertaining to the patient. The doctor takes into account his own degree of certitude as well as the patient's personality and the risk of causing distress or despair.
    Due to medical progress, certain diagnosis which were considered hopeless in the past are no longer incurable. It is no longer necessary to hide a diagnosis of tuberculosis for example. Nevertheless, certain diagnosis, such as cancer, can and should be disclosed because, thanks to medical progress, they are no longer considered necessarily "incurable". Also because the information is essential in enabling the patient to come to terms with the reality of the illness and to undergo treatment without delay.

    Article 109 (Engagement du médecin de respecter le code de déontologie )
    Tout médecin, lors de son inscription au tableau, doit affirmer devant le conseil départemental de l'ordre qu'il a eu connaissance du présent code et s'engager sous serment et par écrit à le respecter.
    ...Ce code a valeur d'un règlement d'administration publique, il indique aux médecins leurs obligations, et sert de référence à la juridiction professionnelle. Les dispositions du code s'imposent à tous les médecins inscrits au tableau...

    (tous droits réservés)

    Questions posées au conseil national de l'ordre des médecins (français)
    Voici deux des questions que nous avons posées à la mi-février 2OO4
    - Le médecin psychiatre est-il aussi et avant tout un médecin ? (je suppose que la réponse est oui sinon il perdrait toute légitimité par rapport à un psychologue)
    - Un médecin psychiatre, a t'il comme tout autre médecin le devoir d'appliquer dans son quotidien, le code de déontologie médicale et notamment les articles 11, 33 et 35

    Réponse du conseil de l'ordre du 27 février 2OO4 - Dossier LJC/SB/PS/EDA/D.04.057.900
    "En réponse à votre courrier télématique du 17 février 2OO4, je vous confirme qu'un psychiatre est comme tout médecin tenu au respect du code de déontologie médicale, dans toutes ses dispositions" (Docteur Louis-Jean Calloc'h, secrétaire général, conseil national de l'ordre des médecin)

    AAPEL:Cela ne saurait être plus clair, la réponse est sans appel, il est bien précisé "toutes ses dispositions". Cela confirme bien qu'un médecin psychiatre a notamment obligation de diagnostic, etc...

    What others have to say about this subject
    * "There are several obligations.Information should concern the nature of the illness, its foreseeable evolution, the tests and treatment as well as any risks involved. Naturally this is less simple when dealing with psychiatric patients. Nevertheless, a doctor should do his utmost to keep such a patient informed. A court ruling in October 1997, decreed that a case concerning a dispute between a doctor and patient about information, would rule in the patient's favour "(J. Starkman Dr, D. Arnaud Dr, "NOUVEAUX CHAMPS D’ACTION ET LIMITES DE LA PSYCHIATRIE", société psychiatrique de marseille Communication Journée Psychiatrique du Sud-Est C.H. de Montavet fev.2OO3)

    * "General practitioners are generally the first to be approached. Patients usually seek medical rather than psychiatric causes to explain their tiredness, sleeplessness, lack of appetite etc. For numerous digestive or heart complains, patients consult their local G.P. first of all. The doctor may detector sense psychiatric troubles behind the complaint but he is under obligation to come up with a precise diagnosis. This requires a certain amount of rigour. According to diagnostic criteria in DSM IV a temporary period of sadness or anxiety does not constitute a state of major depression." (Unaformec - Union Nationale des Associations de Formation Médicale Continue, "MIEUX PRENDRE EN CHARGE LE PATIENT DEPRESSIF", 2001 Montreuil)

    * "Patients can be referred to the CMP (psychological treatment centre) by a doctor, psychologist, teacher, social services, as well as by the police or municipality. Some go there on their own initiative. The patient is met there by a medical professional and a nurse and a diagnosis is established and a treatment prescribed. If the pathology requires hospitalisation, this can take place in a specialised psychiatric hospital or clinic. Outpatient care can be arranged for less acute pathologies according to the time required and the therapy envisaged" (Dr Bernard MONIER, "Le suivi du malade", Session du Conseil national de l'Ordre des médecins juIy 2001)

    * "The general aim in informing patients and their close circle is to engage him as an active, responsible partner in decision-making and in negotiating the treatment. The reading of the  prescribed treatment should be treated as a deal between two parties. The modern prescriber seeks to enter into an alliance with his patient.
    In 1997 Rigo Van Meer calculated that in the Netherlands, 80% of patients were aware of their diagnosis and 20% were informed by their doctor on request. They seemed to be satisfied and more motivated and there was no increase in the death or suicide rate.

    In France, a cursory survey of the last decade reveals at least five proofs of this remarkable evolution and cultural change. There is now less reserved silence or evasion in response to enquiries about a diagnosis (e.g. What's wrong with me/him/her?) and about the evolution and  therapy (e.g. Why should I take this medicine?/Is he going to get well?)
    Further proof can be found in the recommendations issued in January 1994 at the conference concerning the consensus for long term therapeutic strategies for schizophrenic psychosis.
    (6)The medical team should build a relationship based on trust and should listen attentively to a patient's complaints. They should also inform the patient and those close to him about the illness, the symptoms, the eventual remaining symptoms or warning signs of a relapse, the names of the medicines prescribed, their expected therapeutic effect and possible undesirable effects.
    In March 2000 "l'agence nationale d'accréditation et d'évaluation en santé"
    stressed this programme under "recommendations relating to informing patients". (14) This document does not specifically mention "psychiatry" but it does underline the need to inform the patient about his illness, treatment any side effects, whatever the pathology.

    This information must be validated, explained in order of importance as well as being understandable and synthesised. The patient should be made aware of any serious risk in taking the treatment including any which might put into play the vital prognosis or alter a vital function.
    The authors conclude that the level of comprehension in schizophrenics is globally satisfactory even if it takes longer to present the information to them.
    A great deal depends on the quality of the relationship and "compliance should be mutual".(Blondiaux et coll., 5)
    It is essential for the doctor to want to keep the patient informed about his illness and treatment and to put himself at his disposal. "Compliance" in a therapeutic relationship depends on several factors; the "style" of the consultations, their frequency and duration and on the negligence, forgetfulness or delay on the part of the doctor. it also depends on the medical attitudes emerging from the anthropological and psychological doctor-patient relationship.
    Finally certain doctors may be reluctant to give out information in the fear of having their knowledge put into doubt.
    Remember that our objective is to obtain the patient's adhesion... " (B. Garré, P. Duverger, B. Gohier, H. Pettenati, K. Rannou-Dubas,"Information du patient et observance dans les Pathologies PSYCHOTIQUES", Service de PSYCHIATRIE et de PSYCHOLOGIE MEDICALE CHU Angers 2OO3)
    .

    In Quebec ?
    * "3.8 The diagnosis should be recorded in the patient's medical file. If a diagnosis has not yet been established, the doctor should write down a differential diagnosis
    …5.4 A patient file presenting mental health problems
    In order to establish a diagnosis whenever a patient consults for mental health problems, the doctor should carry out a comprehensive psychiatric examination containing the following elements: the motive for consulting and the history of the present complaint, any previous complaints, the medication prescribed, habits, the case history and the actual mental health examination.
    The psychiatric diagnosis
    The psychiatric diagnosis should comply with recognised nomenclature. (CIM10 5 or preferably DSMIV 6) and, where necessary, the actual or other pertinent diagnosis.
    7.3 Access to the medical file and the passing on of information. in accordance with present day law, the patient has a right to consult his medical file and to obtain a copy of it." (Service d’inspection professionnelle, "Guide concernant la tenue du dossier par le médecin en cabinet de consultation et en CLSC", college des médecins du quebec 4e trimestre 1996)
    Please read
    Rights in illness and dignity (in french)
    The ethics of the AAPEL (French Borderline Association)
    Discuss of one's personality disorder with one's psychiatrist/psychologist ? (in french)
    Is DSM "useful", "necessary" or "dangerous"?
    Categories of mental health professional (in french)

    AAPEL - Back to BPD summary page
     

    ,
    Warning:
    All the information in this site is aimed at helping people understand a "rather particular" and puzzling kind of disease
    But more especially, to support everyone affected by it, sick or not.  In any case, it is ESSENTIAL to see a therapist who specialises in this field they can confirm or give an alternative diagnosis
    The name of what you’ve got doesn’t matter so much, getting the right treatment for the right patient does
     

    last update november 2007
    (creation february 15th 2OO4)
    www.aapel.org/bdp/BLmedecinUS.html
    Copyright AAPELTM - All rights reserved
    EmophaneTM is a trademark of Alain Tortosa
    Author, Alain Tortosa, psychotherapist, founder president of the Aapel
    (Translated from french with maureen's help)

    Trouble de la personnalité borderline, état limite, TPL, personalité, border line, bordeline, boderline, border-line, maladie, syndrome, désordre, psy, définition, definition, borderlines