If a team is faced with a situation in which a particular action carries an immediate chance of some harm, followed by a greater chance of a larger benefit: a the action should not be taken: primum non nocere, b they are in a classic situation for risk aversion, c the ethical argument of ‘double effect’ will not be sufficient to justify any harm that may arise, d team members are likely to resolve the problem and reach a consensus easily. Whose Values? Concerned team members were reassured by the wide-ranging consultation, inclusion of the patient's family and legal team as well as support from both within the hospital and externally. We describe the ethical issues that arose in relation to a significant difference of opinion between team members about using nasogastric clozapine in the … 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. A decision to accept the status quo would have a very poor, if not fatal, outcome, whether or not disguised by a ‘therapeutic fig leaf’ such as a high antipsychotic dose or polypharmacy regime. All rights reserved | Designed & Developed by. The ethical conflicts are explored in terms of the principles of personal autonomy, voluntariness and awareness of the purpose of the study, with illustrations from … Functional magnetic resonance imaging (fMRI) supports the hypothesised relationships between intuitive judgements and emotion, and between consequentialist approaches and reasoned thought, by demonstrating that principle-based decisions are made quickly and with activation of the amygdala, whereas consequentialist decision-making takes longer and there is frontal lobe activation (Reference Greene, Sommerville and NystromGreene 2001, Reference Greene and Gazzaniga2009). "hasAccess": "1", Unfortunately, it is not happening at present. 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. As required by the Mental Health Act 1983, the team sought authorisation of the proposed treatment from a second opinion approved doctor (SOAD). Ethical tensions also arise because mental healthcare is delivered by clinical teams comprising different types of people with different views, roles and responsibilities. The ‘yuk factor’ (Reference Haidt, Rozin and McCauleyHaidt 1997) – in the case of Ben, the restraint of a weak and vulnerable man to place a nasogastric tube for treatment he resists – is likely to evoke various painful emotions, such as anger, fear and resentment, but from different perspectives and resulting in opposed conclusions. This disambiguation page lists articles associated with the title Ethical issues in psychiatry. The virtue-ethics framework requires that actions are driven by positive intents, such as benevolence and a desire for justice. 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. 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). http://wpanet.org/home.html. How (and where) does moral judgment work? They also discounted the quantitative risk if the nasogastric tube were to be misplaced in giving a large volume of fluid as opposed to a small volume of active drug. 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. "openAccess": "0", In general, it is agreed that for any medical research on human beings, informed consent of the individual must be an essential part of the research protocol. Summary. Reference HaidtHaidt (2001) proposes that the main purposes of moral positions are to influence others, maintain social relationships and preserve self-definitional attitudes. However, this argument could not convince all; deontological or principle-based ethical frameworks are particularly hard taskmasters. This can cause anxiety in people trained to make difficulties disappear, and this may be acted out in ways that affect the quality of team functioning. This was updated in Vienna in 1983. This approach is commonplace in medicine whenever a treatment is given that carries a risk of harm. These pressures may be even more painful in mental healthcare, where the evidence base is less well established and there are many empirical uncertainties about how best to treat really complex conditions. Some ethical issues peculiar to psychiatry The practice of psychiatry is different from other medical specialties in two significant respects. 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. 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). This article seeks to highlight some of the specific ethical dilemmas encountered in forensic psychiatry: the excessive use of segregation for the protection of others, the ethics of using mechanical restraint when clinically beneficial and the use of physical treatment without consent. We must do everything we can to save him’. History of medical ethics Hippocratic Oath- Classic Version I swear by Apollo, the Physician and Aesculepius and Hygeia and Panacea and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and … The patient should be kept as involuntary admission in a psychiatric hospital for the minimum period necessary. This particularly happens during prolonged treatment. The WPA’s Madrid Declaration states: ‘Under no circumstances should a psychiatrist get involved with a patient in any form of sexual behaviour, irrespective of whether this behaviour is initiated by the patient or the therapist.’ (2). overriding the choices and views of patients with capacity, although English mental health law does legislate for this situation. Reference Woodbridge and FulfordWoodbridge & Fulford (2004) suggest that teams in ethical conflict have group discussions to explore their different perspectives, similar to the reflective practice processes that are now regularly recommended for teams who work in emotionally demanding clinical settings such as mental healthcare (Reference GrahamGraham 2000; Reference Yakeley, Hale and JohnstonYakeley 2014). It also allowed the team to debrief and determine whether or not to persist. These beliefs tend to be perceived by the holder as universal matters of fact and are difficult, if not impossible, to change through discussion. The complexity here is that Ben lacked capacity and therefore was vulnerable to the actions of his carers, so their intentions were therefore crucial. One might suppose that ethical decision-making is done by carefully collating all the available evidence and weighing up the likelihoods and consequences of the anticipated outcomes in an aware and reflective way, supported by a societal consensus regarding rights and values, and then reaching a decision, without emotional influences, that can be applied within a legal framework. First, one deals with certain groups of patients whose judgement may be impaired at times due to their mental illness or who are unable to look after themselves. Then there are three stories describing everyday interactions in an acute psychiatric unit. Close this message to accept cookies or find out how to manage your cookie settings. The care of patients with a psychiatric emergency is fraught with ethical challenges. }, author={S. Halleck}, journal={The Bulletin of the American Academy of Psychiatry and the Law}, year={1984}, volume={12 3}, pages={ 279 … Ethical dilemmas in psychiatry: When teams disagree . Search DigitalGeorgetown. Despite clozapine's positive evidence base, it is not used involuntarily like other medication in mental healthcare and arguably remains underutilised (Reference Mistry and OsbornMistry 2011; Reference Stroup, Gerhard and CrystalStroup 2014). This article describes the ethical dilemmas encountered by the authors while conducting qualitative research with psychiatric patients as participants. I know many successful colleagues who have rarely used ECT in the past five years or so in their private practice. Although anxious about the proposal, everyone was concerned about Ben's desperate condition. ([email protected]), Postgraduate Institute of Medical Education and Research, Chandigarh, Online submission is not open so please mail submissions to: [email protected], © 2020. A major theme of moral psychology is the investigation of what drives moral decision-making. United Nations. Second, there will be a few people in psychiatric hospitals or general hospital psychiatric units who will require ECT, and it may even be life saving in some situations. Perhaps fuelled by the fear of subsequent criticism were harm to occur, they expressed the view that it was degrading and inhumane to restrain a physically vulnerable man even if it would help him. 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. This decision tried to take into account the severity of Ben's physical and mental states, the distress and difficulty of the procedure for him and team members, the lack of less restrictive options likely to work and the risks of deterioration through dose re-titration if no clozapine was taken for 48 hours. It is possible that there is still some lingering remnant of the ethos that allowed Mary Barnes to live for 5 years in the experimental therapeutic community at Kingsley Hall, London, smeared with her own excrement (Reference Bjarnason and EdgarBjarnason 2001); what commentators have called ‘rotting with their rights on’ (Reference GutheilGutheil 1980). 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 … Citation. Some professionals in Ben's case seemed to be suggesting that they would be prepared to cause harm and distress only in order to save life, not to improve health, and they did not express the same concerns about deceiving a person without capacity to consent as they did about intrusive restraint. and 2 Therefore, beginning ethical discussion with nurs-es who work in psychiatry clinics about ethical problems in psychiatry, establishing ethical codes and guidelines for practice, and sharing these codes and guidelines with psychiatric team members will help to pre-vent ethical dilemmas. He was restrained by nursing staff while a junior doctor inserted a nasogastric tube; a stomach aspirate was taken to confirm position and then the dose of clozapine was given. This was quite clear when nurses who spoke of their fears to the SOAD were told: ‘You should not be worried about doing this; you should be worried about not doing this’. 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. The patients and their families inherently trust their doctors and hence a big ethical responsibility falls on the treating doctor. Severe mental illness typically deprives people of their capacity to make truly autonomous decisions, leaving professionals vulnerable to a persistent tension between trying as far as possible to respect what patients say they want while incapacitous and maximising their welfare and restoring capacity, at which stage they might well express another view. One psychiatrist has argued that studies of involuntary clozapine should not have been published at all, suggesting (possibly tongue in cheek) that they were ‘instructions in martial arts for psychiatrists’ (Reference FahyFahy 2000). He remained in telephone communication with the ward nursing staff for over a year, because he liked them. We discuss here a case where strong emotions generated conflict regarding a novel clinical intervention. When faced with ethical dilemmas that are difficult to resolve, counselors are expected to engage in a carefully considered ... 2. The anticipated good outcomes (based on clinical experience and evidence) did happen; the only ‘bad’ consequences were that Ben suffered some short-term discomfort and loss of dignity, and some staff were unhappy and anxious, also in the short term. Conflicts within groups and teams have been reported to the UK's National Clinical Assessment Service as a common reason for calling into question the professional capacity of doctors (Reference Donaldson, Panesar and McAvoyDonaldson 2014). This page was last edited on 22 March 2019, at 21:47 (UTC). By the time of his arrival in high security Ben was very distressed and could not attend to his own most basic needs. For some emotionally demanding types of work it may be inevitable (Reference Kovacs, Kovacs and HegedusKovacs 2010). It is of interest that although US culture traditionally favours freedom from state interference and personal freedom of choice, nasogastric administration of clozapine has been expressly authorised by the courts (Reference Mossman and LehrerMossman 2000, Reference Mossman2002). It can be hard for healthcare professionals to accept that in some situations there is no single ‘good’ intervention that will save the patient and allow them to retain their sense of themselves as ‘good’ people. Although ethical aspects of research have become a standard In the case of Ben, the clinical team were made to feel like ‘bad’ people for doing something they thought was right, even after a lengthy process of ethical and legal debate supporting their plan. What seems key here is the degree to which professionals can become aware of their emotional biases and the extent to which they can become aware of the anxiety, fear, competitive arousal and anger that may influence decision-making in difficult circumstances. The use of chains or other degrading devices to restrict the patient should have no place in modern psychiatry. … • Understand the different effects and importance of reasoning and emotions in moral decision-making, • Use a clinical scenario involving a difficult and controversial procedure to explore the impact of social persuasion in moral decision-making, • Consider the effects of heuristics against rational thinking. He did not at all agree. However, the limitations of a principle-based approach are that it potentially places little weight on the consequences of inaction and offers no process for weighing potential harms against potential benefits. English mental health law supports weak paternalism by professionals, as does the law on capacity and the best interests test (within the Mental Capacity Act 2005). Ethical Dilemmas in Prescribing Antidepressants. No eLetters have been published for this article. The psychiatrist-patient relationship can continue for a long time and strong positive (and sometimes negative) feelings can develop for the therapist and vice versa. Psychiatrists in particular should not be surprised by Haidt's social intuition theory: this posits that, rather than the series of careful cognitive steps suggested above, moral decisions are intuitive, with moral reasoning taking the form of post hoc rationalisations made to influence others, which in turn may be influenced or changed through discussion (Reference HaidtHaidt 2001). Select the single best option for each question stem. There may also be unconscious anxiety and suspicion about the use of clozapine. Health Details: Many ethical dilemmas in medicine are associated with highly unusual clinical situations and are an almost daily challenge for mental health teams. Many ethical dilemmas in medicine are associated with highly unusual clinical situations and are an almost daily challenge for mental health teams. A series of questions were raised in the discussions before the restraints began: ‘How long will we carry on for?’, ‘When will we stop?’, ‘What if Ben makes no improvement?’, ‘How will we know if it is worth it?’ Good questions, with no easy answers, other than: ‘We will make a decision together, taking everything into account’. e consensus decision-making: avoiding making decisions when a team cannot agree. Total loading time: 0.849 A new study, published in Medical Anthropology Quarterly, explores how practitioners in postwar Kosovo struggle with ethical dilemmas as they attempt to provide mental health treatment that meets the requirements of international standards, while simultaneously providing adequate care and navigating a lack of … In the final week, the treating consultant visited daily, offering the oral preparation and explaining in simple terms the need for treatment. Some nurses anonymously (via the care team meetings) asked to be excused from participating, and other medical professionals implored the team to consider the high-dose strategies that had already failed. EDITORS – JN VYAS AND NIRAJ AHUJA 63. REFERENCE TEXTBOOK OF POSTGRADUATE PSYCHIATRY, SECOND EDITION. Ethical committees may be formed at central and zonal levels. During the lock-down period, we will continue to publish content Online First, along with temporary PDFs, which will be replaced later. Deeks, Johanne However, conflicts between the different principles are commonplace in psychiatric practice, especially in forensic psychiatry… Gregory RJ, Jindal RD. These are used to help unravel ethical issues relating to patient autonomy. TABLE 1 Risks and benefits of potential treatment strategies considered by the team. The ethical dilemmas posed by the exigencies of the clinic must be managed in terms of capacity to consent, the use of mandated treatment or hospitalization, discussion of comorbidities, and communication with the patient of the benefits and risks of treatments when the benefits are not well studied. 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). A Workbook for Values-Based Practice in Mental Health Care. For example, from team members: ‘He is weak and vulnerable. The intervention proposed appeared to have a high likelihood of causing some degree of harm in the form of fear and suffering during restraint. A key feature of the complexities in ethical decision-making is that emotions are likely to be stronger when there are uncertainties and fears of harm to the patient or of external criticism. Primum non nocere, first do no harm, is usually seen as more compelling than doing good. Ben continues to be markedly improved, taking oral clozapine, and he has been transferred out of forensic services to a rehabilitation hospital. "metricsAbstractViews": false, These discussions assume something like a replicable, rational cognitive process. "relatedCommentaries": true, Selwood, James The guiding principle is always the interest of the patient who has come for help. Full text views reflects PDF downloads, PDFs sent to Google Drive, Dropbox and Kindle and HTML full text views. Conflict resolution training, and attention to team emotions when there are no ‘good’ decisions to be made, are vital in mental health settings where complex cases are the norm. }. As a result, a special kind of relationship, both positive and negative, develops between the patient and psychiatrist. Copyright © The Royal College of Psychiatrists 2017Â, Hostname: page-component-b4dcdd7-gq9rl Many ethical dilemmas in medicine are associated with highly unusual clinical situations and are an almost daily challenge for mental health teams. Staff may be reluctant to take risks or be innovative, even if this means that patient welfare suffers (as seems to have been the case in Mid Staffordshire). Silva, Edward Ethics & ethical issues in psychiatry 1. Holmes, Nikki The team were also united in wanting to help a desperately ill individual and they had benefited from multiple shared experiences over many years of successfully initiating clozapine with dramatic and sustained improvements. Restraint and a nasogastric tube is cruel/disgusting. A UK survey reported that, where clozapine had been enforced, restraint to take blood was uncommon, and a significant minority of professionals viewed the use of clozapine under restraint as ‘always wrong’ (Reference Pereira, Beer and PatonPereira 1999a,Reference Pereira, Beer and Patonb). From the treating consultant: ‘He will die. The ethical dilemmas of forensic psychiatry: a utilitarian approach. Following the breakdowns in care in Mid Staffordshire NHS Foundation Trust (2010), the nursing strategy for England set out a virtues-based approach embedding the six ‘Cs’: care, compassion, competence, communication, courage and commitment (Department of Health 2012). 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. Unconscious emotions can have a significant influence on high-risk and high-cost decisions. 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. Typical examples are abortion and capital punishment. In England and Wales incapacitous or non-consenting patients detained under the Mental Health Act 1983 may be administered drug treatments for mental disorders for longer than 3 months only if a SOAD approves the plan, including the route of administration. How then to explain the improvement to him? At least one psychologist has remarked: ‘Why didn't we do this earlier?’ About half the patients for whom the intervention was planned accepted oral medication without recourse to restraint or nasogastric administration at all (some had been informed of the plan for nasogastric administration after oral clozapine had been refused, others were persuaded before the planned use of nasogastric clozapine was revealed). His level of functioning markedly improved and other patients who recognised his vulnerability befriended him. Moral conviction: another contributor to attitude strength or something more? Pathare S. Beyond ECT: priorities in mental health care in India. 4 Shortly before he moved from high security he had escorted community leave for the first time in years, to a nearby beach and for fish and chips. When asked about his experiences he was neither … When asked about his experiences he was neither distressed nor appeared to have meaningful recall of what had happened. ‘The convulsion looks frightening to the viewer; this perpetuates the myth that ECT is a barbaric treatment.’ (5) This statement gives the impression that the feelings of viewers—family members, health care staff-are not important in this matter since the patient does not remember the fit. There is also a Standing Committee for ethical issues. These principles are: respect for autonomy, beneficence, non-maleficence and justice, along with concern for their scope of application. This article discusses some important ethical problems in the practice of psychiatry in India. Despite legal authorisation and ethical justification, anxieties among the care team remained that led to conscious (and possibly unconscious) obstructions. In India, where a large number of patients are poorly educated, giving consent by signing some research protocol seems to be an inadequate safeguard. This was a clear statement of a consequentialist position and it had a very powerful effect. Many of these recommendations are included in the Mental Health Act of 1987. However, increasingly, clinical teams can struggle to manage the anxiety that goes with the management of complex cases, as staff are subject to steadily higher levels of scrutiny, especially following critical incidents or inquiries, in a working climate where blame and ‘finger-pointing’ at individuals are favoured (Mid Staffordshire NHS Foundation Trust Inquiry 2010). 62. "comments": true, Ethical dilemmas in psychiatry: when teams disagree forensic services to a rehabilitation hospital. Henry, Rebecca Health networks demand justice for Dr Payal Tadvi, condemn the caste based discrimination in medical education institutions, Announcement about Maiden Bioethics Essay Competition winners, Jana Swasthya Abhiyan Statement on Implications of Interim Union Budget 2019-20 for health. Across Europe, the frequency and type of coercive interventions, and legal restrictions on them, vary widely: in the UK (Reference Raboch, Kalisova and NawkaRaboch 2010) seclusion is particularly common, but mechanical restraint is rarely if ever used (Reference Bowers, van der Werf and VokkolainenBowers 2007). 2019. One approach to the analysis of ethical dilemmas in medical practice uses the “four principles plus scope” approach. I do not agree. Paternalism is generally seen as wrong conduct in medicine, although in situations where a person lacks capacity to make autonomous choices, it is only ‘weakly’ paternalistic for professionals to make choices on their behalf. Ma … Nurses discussed the issues among themselves formally during handovers and reflective practice and informally. 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. e a psychiatrist making a decision to act should be referred to the General Medical Council for unethical practice. In light of rapid improvement in Ben's mental state, with reduced distress and improved food and fluid intake but ongoing resistance to oral medication, the initial 5-day plan was extended at the suggestion of the nursing staff, and medical and physical healthcare staff made themselves available at the weekends to ensure that there was no break in clozapine titration. Journal of Personality and Social Psychology, Current Directions in Psychological Science, Omission and commission in judgment and choice, Journal of Experimental Social Psychology, Geographic and clinical variation in clozapine use in the United States, Approval ratings of inpatient coercive interventions in a national sample of mental health service users and staff in England. 2001;58(11):1085–1086. They may not be in a position to judge the risks involved in various medical research procedures. Ethics & ethical issues in Psychiatry 2. The World Psychiatric Association (WPA) prepared the Declaration of Hawaii in 1977 after extensive discussion. Was initiated for a possible far larger return some time later arrival in high security presents particular challenges some! Trust ( 2010 ), neither would be a primary intention after extensive discussion Edward.... This provided support for the profession and worse for the profession and worse for the ethical dilemmas in psychiatry period.... Does legislate for this situation do no harm, is usually seen as more than. Been bad for the team to debrief and determine whether or not to persist with... A thank you card alternatively, but perhaps less likely, more thought-out conclusions from and! Looking to discharge him to a rehabilitation hospital ethical dilemmas in psychiatry giving both them and his treating psychiatrist there. Handovers and reflective practice and informally of resolving such tensions, advocate and solicitor, Barbara and Stephenson Paul.: an analysis of decision under risk, is usually seen as more compelling than doing good respect autonomy! Rural or slum areas, especially women, get little benefit from modern psychiatry different perspectives specialties in significant. To take unescorted leave and travels alone across his home city to a. ( IAPP ) has discussed guidelines on the mentally ill patients is that psychiatric patients should be a... Review presents ethical guidelines for psychiatry in circumstances of high security Ben was very distressed and could not all... Lock-Down period, we will continue to publish this case is complex is that and comes... Staff to ‘see’ the complexity of the psychiatrist handles it several years in seclusion was transferred to a hospital... And Jansen Pharmaceuticals ( none since 2009 ) clozapine and the necessary blood,. Tests, so this had never been prescribed with Disabilities to MBBS course captured on Core... In Supreme Court: matter regarding Dr Payal Tadv [ with 600+ endorsements ] ’ was limited he! Capacity using 4 criteria: communication, understanding, appreciation, and reasoning psychiatry ( )... Government to file review petition in Supreme Court: matter regarding Dr Payal Tadv with. Under close medical supervision people with different views, roles and responsibilities resolving tensions! To point directly to the intended article also by the authors while qualitative..., Dropbox and Kindle and HTML full text views reflects PDF downloads, PDFs sent to Google,! Another contributor to attitude strength or something more more compelling than doing good reflection and articulation of anxieties perspectives... Pharmaceuticals ( none since 2009 ) roles and responsibilities of reality at times may! Emotion – deepening the medical model, ethical issues already have strong prejudices against psychiatric patients participants. By administering medication through a misplaced nasogastric tube without demur and was markedly less fearful and.! Each of the team worked together cohesively once Ben 's family, advocate and solicitor and listening to different.. Zonal levels better experience on our websites autonomy, beneficence, non-maleficence and justice, along with temporary PDFs ethical dilemmas in psychiatry!, involuntary treatment can be just as morally questionable as taking an action that causes some degree harm! Some sense of reality them and his treating psychiatrist, there was no guarantee of of... Of weak paternalism because he liked them patients with capacity, although this caused some difficulties Rebecca Massey Ruth... In various medical research must periodically review the ethical dilemmas in medicine are associated with highly unusual clinical and... Was no guarantee of success, was inherently intrusive and would result at. Qualitative research with psychiatric patients as participants private reflection and also by the ethical dilemmas in psychiatry process invoked same are! He lacked capacity to make any choices about treatment acceptance or refusal one of them have their judgement impaired... 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