From a historical perspective, Engel¹ conceptualized psychopathology as resulting from an interaction of three orders of factors: biological, psychological and social. The first half of the 20th century has been mostly devoted to conceptualizing the psychological component of mental disorders, the second half to the understanding of the biological component. We are now, in the 21st century, busy at better understanding the role of social processes that impact treatment approaches to psychopathology as well as the psychiatrist-patient relationship.

Even more than other medical disciplines, psychiatry is influenced by external events that plague society, such as epidemics, natural disasters and wars. These events often require the involvement of ethics committees that will determine the duties and rights of the physician in potentially conflictual ethical contexts, such as triage situations (i.e., choosing whom to treat first). The COVID-19 pandemic has shown how deeply interwoven the epidemiology of mental disorders and the access to mental health services are with both social factors and somatic health. Grief, isolation, loss of income and fear exacerbate existing mental health problems or create new ones. The pandemic has demonstrated that the biological and social dimensions of medicine and public health are inextricably linked².

Profound changes in social values and norms, such as the legitimization of medical procedures for transgender individuals, or the availability of euthanasia in some countries, require a redefinition of the psychiatrist's role within the medical staff, and the development of ethical guidelines that take into account a variety of emotional, religious and ideological aspects pertaining to both the patient and the physician.

This changing scenario is extensively reflected in Galderisi et al's paper³. I will focus here on three of the issues discussed by the authors. The first is stigma related to mental disorders in society in general, and particularly in the medical world. Studies documenting the importance of social/environmental components in the development of psychopathology⁴, as well as those showing the close relationship between physical illness and emotional states, have contributed to reduce that stigma. The inclusion of psychiatric wards within general hospitals has been both a consequence and a further determinant of this evolution. Likewise, the importance of the psychiatrist's presence in transdisciplinary medical teams, as well as in hospital ethics committees, has become more obvious than in the past. It is also increasingly clear that codes of ethics of physical medicine and psychiatry overlap to a large extent, especially with regard to the therapist-patient relationship.

The second topic I wish to emphasize is the changing relationship between psychiatrists and representatives of patients and families. In the recent past, we witnessed against-psychiatry demonstrations by former hospitalized patients, their families and human rights organizations. Our involvement at the societal level has led to a move from a paternalistic stance to a more listening, egalitarian position. We have started to invite those demonstrators to “cross the street”, to come and participate in our meetings to share with us their point of view and to discuss with us the dilemmas regarding issues of quality of life, patients’ rights, effectiveness of our treatments versus side effects, and coercive situations, in a context marked by mutual respect. Today, in many countries, representatives of psychiatric patients are invited to participate in committees that discuss these issues and allocate resources for research. In some countries, former patients and/or their relatives also participate in teaching medical students and residents. This collaboration has increased the transparency of our ways of thinking and working, and is contributing to reduce the stigma attached to psychiatry. This change of attitude is clearly reflected in the WPA Code of Ethics².

One of the issues that remain conflictual, and feed the stigma towards the psychiatric profession, is the use of coercive measures, that seems to deny the patient's right to autonomy, one of the four basic principles of any medical code of ethics, along with beneficence, non-maleficence and justice⁴. The term autonomy reflects the patient's right to refuse medical treatment. In the case of a psychotic patient, the definition of “autonomy” is very complex, as the patient's “free” will is colored by his/her psychotic symptoms and lack of insight. The goal of treatment, including coercion, is to restore the patient's judgment capacity necessary for independent functioning. The growing attention to this issue has already led in many countries to a decrease in the number of involuntary hospitalizations and physical coercive measures, and the increasing use of alternative treatment solutions, such as the development of crisis units and “balancing houses” in the community, as an alternative to hospitalization^{5, 6}.

Another issue related to the patient's right to autonomy is that of euthanasia. What is the psychiatrist's role, if any, in the process of fulfilling a patient's desire to end his/her life while freely choosing to prioritize quality of life over longevity? The renowned surgeon C. Bernard stated: “I have learned in my many years that death is not always the enemy. Sometimes it is the right medical treatment. It often achieves what medicine could no longer offer – an end to suffering”⁷. In my opinion, the psychiatrist has two roles in this respect: the first is to make sure that the patient's request is given out of “clarity of mind”, the second is to ascertain that the patient's wish to die is not a masked suicidal intent secondary to the psychopathology from which he/she suffers. Unfortunately, tools for a truly reliable assessment of these issues are not available.

A recent development regarding euthanasia is the ethical legitimation for the psychiatrist to act in accordance with his/her moral and/or religious views, possibly (but not necessarily) deferring the question to a colleague who agrees to be part of the medical team that is supposed to examine the request. It is important to discuss this issue with medical students and residents during their professional training.

Unfortunately, teaching of ethics does not occupy an adequate place in professional curricula, in psychiatry as in other medical disciplines. Also, the number of national psychiatric associations that have produced their own code of ethics is minimal, probably also due to the feeling that the existence of a code of ethics is a coercive factor that limits the clinician's freedom of action. We need to emphasize the advantages of having a code of ethics, such as the personal moral and legal protection that a set of guidelines provides to the psychiatrist in the implementation of his/her values and expertise. This protection is very important, especially in situations where the patient's best interest is not clear or is in conflict with the professional best practice.

Particularly neglected in psychiatry and other medical professions is the ethics of clinical management in children and adolescents. For example, to whom should the psychiatrist extend fidelity: to the child, to the guardian, to the family as a whole, to the referring agency, to the institution that pays him/her? Even though the child's consent is clinically essential, it is not required by law. Nevertheless, the psychiatrist should aspire for the child to have a good understanding of the therapeutic process, according to his/her age and cognitive and emotional development.

In conclusion, we better appreciate nowadays the interplay between society and psychiatry. National and international ethics committees must be involved in this “dialogue” between the patient's rights and the psychiatrist's duties and rights. Increasing transparency of the diagnostic and treatment processes can lead to a partial, but very significant, reduction of the stigma attached to mental disorders and our profession.

从历史的角度来看，恩格尔¹将精神病理学概念化为生物、心理和社会这三个因素相互作用的结果。 20 世纪上半叶主要致力于概念化精神障碍的心理成分，下半叶则致力于理解其生物学成分。现在，在 21 世纪，我们正忙于更好地了解影响精神病理学治疗方法以及精神病医生与患者关系的社会过程的作用。

与其他医学学科相比，精神病学更容易受到困扰社会的外部事件的影响，例如流行病、自然灾害和战争。这些事件通常需要伦理委员会的参与，该委员会将确定医生在潜在冲突的伦理环境中的义务和权利，例如分诊情况（即选择首先治疗的人）。 COVID-19 大流行表明，精神障碍的流行病学和获得精神卫生服务与社会因素和躯体健康有着多么紧密的交织。悲伤、孤立、收入损失和恐惧会加剧现有的心理健康问题或产生新的问题。此次疫情表明，医学和公共卫生的生物和社会层面有着千丝万缕的联系² 。

社会价与患者和医生有关的各种情感、宗教和意识形态方面。

Galderisi 等人的论文³广泛反映了这种不断变化的情况。我将在这里重点讨论作者讨论的三个问题。第一个是与整个社会的精神障碍相关的耻辱，特别是在医学界。研究记录了社会/环境因素在精神病理学发展中的重要性⁴ ，以及表明身体疾病和情绪状态之间密切关系的研究，有助于减少这种耻辱。综合医院内纳入精神科病房既是这一演变的结果，也是这一演变的进一步决定因素。同样，精神科医生在跨学科医疗团队以及医院伦理委员会中的重要性也比过去变得更加明显。越来越明显的是，物理医学和精神病学的道德规范在很大程度上是重叠的，特别是在治疗师与患者的关系方面。

我想强调的第二个主题是精神科医生与患者和家属代表之间不断变化的关系。最近，我们目睹了前住院患者、他们的家人和人权组织的反对精神病学示威活动。我们在社会层面的参与导致从家长式立场转变为更加倾听、平等的立场。我们已经开始邀请那些示威者“过马路”，来参加我们的会议，与我们分享他们的观点，并与我们讨论有关生活质量、患者权利、我们的政策有效性等问题的困境。在相互尊重的背景下进行治疗与副作用和胁迫情况的比较。如今，在许多国家，精神病患者的代表被邀请参加讨论这些问题并分配研究资源的委员会。在一些国家，前患者和/或其亲属也参与医学生和住院医生的教学。这种合作提高了我们思维和工作方式的透明度，并有助于减少精神病学的耻辱。这种态度的转变清楚地反映在 WPA 道德准则²中。

仍然存在冲突的问题之一是使用强制措施，这给精神病学行业带来了耻辱，这似乎剥夺了患者的自主权，这是任何医疗道德准则的四个基本原则之一，与仁慈一起、非恶意和正义⁴ ．自主一词反映了患者拒绝医疗的权利。对于精神病患者来说，“自主”的定义非常复杂，因为患者的“自由”意志受到他/她的精神病症状和缺乏洞察力的影响。治疗（包括强制）的目标是恢复患者独立运作所需的判断能力。对这个问题的日益关注已经导致许多国家非自愿住院和身体强制措施的数量减少，并越来越多地使用替代治疗解决方案，例如在社区中建立危机单位和“平衡之家” ，作为住院治疗的替代方案^{5, 6} 。

与患者自主权相关的另一个问题是安乐死问题。在满足患者结束生命的愿望，同时自由选择优先考虑生活质量而不是寿命的过程中，精神科医生的作用是什么？著名外科医生 C. 伯纳德 (C. Bernard) 表示：“多年来我了解到，死亡并不总是敌人。有时这是正确的医疗方法。它常常能达到医学无法提供的效果——结束痛苦” ⁷ 。在我看来，精神科医生在这方面有两个作用：第一是确保病人的请求是出于“头脑清醒”而提出的，第二是确定病人的死亡愿望不是带有掩饰的自杀意图。继发于他/她所遭受的精神病理学。不幸的是，还没有真正可靠地评估这些问题的工具。

关于安乐死的最新发展是精神科医生按照他/她的道德和/或宗教观点行事的道德合法性，可能（但不一定）将问题推迟到同意成为医疗团队成员的同事应该检查该请求。在专业培训期间与医学生和住院医师讨论这个问题非常重要。

不幸的是，伦理学教学在专业课程、精神病学和其他医学学科中并没有占据足够的地位。此外，制定自己的道德准则的国家精神病学协会的数量也很少，这可能也是因为人们认为道德准则的存在是限制临床医生行动自由的强制因素。我们需要强调拥有道德准则的优势，例如一套指导方针为精神科医生在实施其价值观和专业知识时提供个人道德和法律保护。这种保护非常重要，特别是在患者最大利益不明确或与专业最佳实践相冲突的情况下。

在精神病学和其他医学专业中，特别被忽视的是儿童和青少年临床管理的道德规范。例如，精神科医生应该向谁忠诚：儿童、监护人、整个家庭、转介机构、向他/她支付费用的机构？尽管儿童的同意在临床上是必要的，但法律并不要求这样做。尽管如此，精神科医生应该根据孩子的年龄、认知和情感发展，让孩子充分了解治疗过程。

总之，我们现在更好地理解社会与精神病学之间的相互作用。国家和国际伦理委员会必须参与患者权利与精神科医生义务和权利之间的“对话”。提高诊断和治疗过程的透明度可以部分但非常显着地减少对精神障碍和我们职业的耻辱。