ethical dilemmas in psychiatry
Hammer, Barbara In some professional minds, the chief objection to forced nasogastric administration of clozapine appears to be the association with the protests of the oppressed, evoking historical images of the treatment of political prisoners, suffragettes or detainees in Guantanamo Bay. Select the single best option for each question stem. Other commentators have offered technical objections, or recommended involuntary ECT, which appears to be at least as restrictive, invasive and hazardous (Reference BarnesBarnes 1999), especially in patients like Ben, whose physical health was compromised by dehydration and starvation. During the lock-down period, we will continue to publish content Online First, along with temporary PDFs, which will be replaced later. Any codes of ethics can be a paradigm for the clinicians but it seems that the psychiatrist should sometimes tailor what he learnt about ethics to individual cases using his judgment, experience and sense of responsibility. Although anxious about the proposal, everyone was concerned about Ben's desperate condition. Ethical disagreement in healthcare teams is clearly not new, strange or undesirable. The past five decades have seen the establishment of general hospital psychiatric units and the rise of private sector in psychiatry, bringing psychiatry closer to general medicine but as a result, psychiatry is now facing many ethical issues common to several other medical specialties. A major theme of moral psychology is the investigation of what drives moral decision-making. The complexity here is that Ben lacked capacity and therefore was vulnerable to the actions of his carers, so their intentions were therefore crucial. The SOAD, who was an independent psychiatrist appointed by the Care Quality Commission (CQC), met with nursing staff and the team psychologist before agreeing to authorise the plan. In the UK, nursing staff, and society in general, have very low approval of most restrictive practices such as mechanical restraint, although interestingly not of seclusion (Reference Whittington, Bowers and NolanWhittington 2009). Particularly in mental healthcare, without an acute crisis, there is potentially a heuristic bias against doing something rather than nothing, especially in relation to high-risk cases, i.e. The ethical dilemmas of forensic psychiatry: a utilitarian approach. for this article. Mid Staffordshire NHS Foundation Trust (2010), Mid Staffordshire NHS Foundation Trust Inquiry 2010, https://www.theguardian.com/news/2001/jul/13/guardianobituaries.books. In such situations, therapeutic intervention or even detention in a psychiatric facility against the patient’s wishes may become necessary. Psychiatrists who develop and refine their ethics “skill set” will be in a better position to anticipate and respond to ethical dilemmas as they arise in the course of their practice. We describe the ethical issues that arose in relation to a significant difference of opinion between team members about using nasogastric clozapine in the treatment of a severely ill patient. It is likely that the anxiety about doing harm made it difficult for staff to âseeâ the complexity of the different therapeutic options. It was hoped he would improve and regain some sense of reality. If such patients are not in a position to give their consent, close family members should be consulted, but the interest of the patient must remain paramount. His current team are looking to discharge him to a supported community setting. There is extensive literature on the ethics of mental healthcare, focusing on the tension between respect for autonomy and a duty of beneficence (Reference AdsheadAdshead 2000, Reference Adshead2007). This tension is exaggerated, augmented and developed by the legal process invoked. This was quite clear when nurses who spoke of their fears to the SOAD were told: âYou should not be worried about doing this; you should be worried about not doing thisâ. Team members might have felt safer in not acting, but a strict consequentialist approach treats omissions as morally significant actions, so harms from decisions not to act are as significant as harms from positive decisions to take action (which in this case entailed trying an intervention that was potentially risky). Ethical dilemmas are common in mental health settings. As far as possible, their consent must be taken for any treatment or hospital admission. Despite legal authorisation and ethical justification, anxieties among the care team remained that led to conscious (and possibly unconscious) obstructions. "openAccess": "0", When decisions of any sort are being made, decision-making that seems to be based on purely cognitive appraisal may in fact be affected by the short-term experience of positive or negative emotions (Reference Kahneman and TverskyKahneman 1979). Where this case is complex is that pursuing Ben's best mental health interests entailed a potential short-term risk to his physical best interests. Statement demanding justice for Dr Kafeel Khan, Public Statement: Gross violation of human rights due to the mandatory linking of Aadhar to health and allied social security schemes, Health Professionals’ Pledge Against Torture, Ethics of health research: developing the COHRED Fairness Index, MFC Statement on Escalating Challenges to Health in India, Medico Friend Circle condemns the arrest of Dr. Saibal Jana, MFC welcomes the stinging report on cleaning up medical education regulation, Appeal of Indian Doctors for Ethical Practice (IDEP), Public Debate EoLC @ TISS on July 16, 2016. e a psychiatrist making a decision to act should be referred to the General Medical Council for unethical practice. The cognitive neuroscience of moral judgment, In search of true freedom: drug refusal, involuntary medication, and ârotting with your rights onâ, Body, psyche, and culture: the relationship between disgust and morality, The emotional dog and its rational tail: a social intuitionist approach to moral judgment. The ethical practitioner needs to keep up-to-date with empirical findings on all somatic and psychosocial treatments, including their indications, adverse … Stephenson, Paul When considering the ethical implications of a decision: a emotional reactions are often important factors, b professionals from different disciplines will always share common value perspectives, c the success or failure of the action taken is more important than the intended aim, d in a multi-disciplinary team setting, all members must agree. They may be unaware of the different value perspectives that they are taking and of the similarities and differences between these different perspectives. How then to explain the improvement to him? Most countries have legislation that allows for some form of involuntary restraint or treatment of patients who have lost capacity to make decisions for themselves as a result of their mental disorders. The virtue-ethics framework requires that actions are driven by positive intents, such as benevolence and a desire for justice. The team worked together cohesively once Ben's condition began to improve. "isLogged": "0", Higgins, Melanie In his description of values-based practice in mental healthcare, Reference FulfordFulford (2008) argues that different ethical positions may reflect important differences in value perception and weighting, and that it is important for teams to explore this ethical âdis-sensusâ, because there may be more than one ethically sustainable argument. Although the intervention would likely cause some minimal harm (and possibly some wrong), neither would be a primary intention. One approach to the analysis of ethical dilemmas in medical practice uses the “four principles plus scope” approach. Restraint and a nasogastric tube is cruel/disgusting. Ethical Dilemmas in Psychiatry: en: dc.provenance: Digital citation created by the National Reference Center for Bioethics Literature at Georgetown University for the BIOETHICSLINE database, part of the Kennedy Institute of Ethics' Bioethics Information Retrieval Project funded by the United States National Library of … We are grateful to him for his generosity. Morgan, Kathy He had treatment-resistant schizophrenia, which for two decades had been unresponsive to multiple depot and oral antipsychotic medications, including dosages well over (up to 1000%) the British National Formulary (BNF) licensed maxima, and in combination with mood stabilisers. Further, although Ben's ability to express his autonomy was limited, he could at least scream, spit and fight. These principles are: respect for autonomy, beneficence, non-maleficence and justice, along with concern for their scope of application. Identifying details have been changed. Dilemmas often represent competing moral paradigms2. In England and Wales, where a patient cannot consent to treatment the administration of clozapine via a nasogastric tube must be approved by: a both a second opinion approved doctor (SOAD) and the patient's family, b both a SOAD and an independent mental health advocate (IMHA). In India, the National Human Rights Commission’s publication, Quality assurance in mental health, provides guidelines for the care of mentally ill in psychiatric institutions (4). However, it has been pointed out that there are other interests than medical ones, and preservation of dignity is one of them. Instead, there has been great uncertainty from external teams asked to assess patients who have markedly improved following some use of nasogastric clozapine and for whom transfer out of high secure hospital has been requested. But as well as the discussions at care team meetings, many others were involved, were seen to be involved, visited the ward and talked with staff about their judgements and reasoning. Indian Association of Private Psychiatry, 2nd Annual Conference, Jodhpur, November 2001. Reference HaidtHaidt (2001) proposes that the main purposes of moral positions are to influence others, maintain social relationships and preserve self-definitional attitudes. Ethical dilemmas posed by mobile health and machine learning in psychiatry research Nicholas C Jacobson a, Kate H Bentley b, Ashley Walton c, Shirley B Wang d, Rebecca G Fortgang d, Alexander J Millner d, Garth Coombs d, Alexandra M Rodman d & Daniel D L Coppersmith d. a. We sought the patient's permission to publish this case and he gave express consent. Although not affecting the action in this case, some ethical disagreements are irresolvable. Detained under section 3 of the Mental Health Act 1983 and lacking capacity because of his floridly psychotic mental state, Ben was subject to involuntary treatment. The intervention proposed appeared to have a high likelihood of causing some degree of harm in the form of fear and suffering during restraint. This may well have helped shift the intuitions, and hence conclusions, of opposing team members, which may have been dominated by fears, for Ben's welfare or of criticism from others. has received speaker fees from Novartis and Jansen Pharmaceuticals (none since 2009). Ethical Human Psychology and Psychiatry (EHPP) is a peer-reviewed journal that publishes original research reports, reviews, essays, commentaries, and case reports examining the ethical ramifications of unjust practices in psychiatry … Henry, Rebecca I know many successful colleagues who have rarely used ECT in the past five years or so in their private practice. Till, Alex Moral conviction: another contributor to attitude strength or something more? The ethical considerations of therapists are becoming greater in … The guiding principle is always the interest of the patient who has come for help. Whose Values? professionals may not see inaction as a form of action in itself that may cause harm (Reference Spranca, Minsk and BaronSpranca 1991). This allowed many opportunities for social persuasion, the influence of one person's judgement on the other's intuition, as well as reasoned persuasion, the influence of one person's reasoning on the other's intuition. This was a clear statement of a consequentialist position and it had a very powerful effect. This subject has been extensively debated in the medical literature in the US and Europe where there are many more psychiatrists and psychotherapy is quite common. For this reason alone, unmodified ECT should be stopped. How likely is that and what comes first anyway, the decision or the reasoning? These discussions assume something like a replicable, rational cognitive process. The decision is often made by administration for the organization, but the mental health nurse is the person who must care for the patient. The CQC was consulted as to whether the nasogastric route should be specified.Footnote a. A complete ban on all research on the mentally ill may be going to one extreme. All rights reserved | Designed & Developed by. Ethical committees may be formed at central and zonal levels. Ethical dilemmas in forensic psychiatry, Commentary: The risks of enforcing clozapine therapy, Mary Barnes: gifted artist who documented her struggle with mental illness in paint and print, International variation in containment measures for disturbed psychiatric inpatients: a comparative questionnaire survey. The authors, both child psychiatrists, discuss some of the ethical problems that arise in their practice, in relation to advice given in the British Medical Association's Handbook of Medical Ethics. A physically stronger individual, or one with greater mental capacity, might be able to resist or refuse and so, arguably, Ben's vulnerabilities were exploited (Reference PerlinPerlin 2004). Second, in no other medical specialty do patients share with their doctor so many intimate details about their personal, emotional, social or even sexual life. Health Details: Many ethical dilemmas in medicine are associated with highly unusual clinical situations and are an almost daily challenge for mental health teams. e members of the same profession are likely to follow similar decision-making patterns, regardless of the country in which the care is delivered.
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