* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Ethical Issues in Psychiatry
Survey
Document related concepts
Deinstitutionalisation wikipedia , lookup
Classification of mental disorders wikipedia , lookup
Diagnostic and Statistical Manual of Mental Disorders wikipedia , lookup
Anti-psychiatry wikipedia , lookup
Critical Psychiatry Network wikipedia , lookup
History of mental disorders wikipedia , lookup
Political abuse of psychiatry wikipedia , lookup
Glossary of psychiatry wikipedia , lookup
Abnormal psychology wikipedia , lookup
History of psychiatric institutions wikipedia , lookup
Mental status examination wikipedia , lookup
Emergency psychiatry wikipedia , lookup
Pyotr Gannushkin wikipedia , lookup
Moral treatment wikipedia , lookup
Transcript
Ethical Issues in Psychiatry MRCPsych course Medical ethics and principles of law • Demonstrate awareness of legal principles, consent, restraint, legal responsibilities and protection • Discuss Powers of Attorney, Enduring Powers of Attorney, management of property and testamentary capacity • Discuss the effects of psychiatric disorders on driving capability • Demonstrate knowledge of relevant mental health and human rights legislation Ethical and conceptual problems • • • • • • Demonstrate awareness of problems arising from: Different values of colleagues, patients and carers Different belief systems Limitations of paradigms The relativity of judgements of rationality The distinction between scientific/technical and ethics/value bases for clinical decisions • Demonstrate a working knowledge of: • Ethical standards, guidelines and codes of practice for the profession (incl research) • Differences in ethical, religious and other belief systems between cultures • The findings of relevant empirical research into eg. Patients’ experiences, effectiveness of different styles of communication Law – some basics Statute = laws passed by Parliament eg MHA1983, MCA2005 Precedent = principle that judges must follow decisions made in previous similar cases Common law = the accumulation of judicial decisions Respect for Autonomy • One of Beauchamp & Childress’ 4 principles of medical ethics (with beneficence, non-maleficence & justice) • Important principle in English law • Confers a prima facie right not to be hit, molested, restrained or otherwise interfered with • Infringement of this right = assault / trespass against the person Assault • Various forms, crimes and torts • Any form of unlawful touching • Need not result in physical harm – the infringement of autonomy and bodily integrity considered harmful in itself To avoid being charged with / sued for assault… • • • • Have a valid defence: Statutory provisions Consent Neccessity Consent • • • • Three vital components: Informed re nature and purpose of the act Voluntary not coerced Capacity ie ability to decide to grant consent Proxy consent • Acceptable in some circumstances: • If a child lacks capacity to consent, the parent may consent on his or her behalf (Gillick) • An adult may grant an Lasting Power of Attorney, enabling a proxy to make healthcare decisions on his or her behalf should he or she lose capacity (MCA) • The courts may appoint a deputy to make healthcare decisions on behalf of an adult who lacks capacity (MCA) • The proxy must act in the patient’s best interests Advance Directives • A person with decision-making capacity can make an advance directive, granting or withholding consent for treatment / procedures in the event of loss of capacity in the future (MCA) • Must be informed, voluntary and capacitous • Can apply to life-saving treatment, provided that it is written, signed witnessed and clear that the person meant the directive to apply in those circumstances • Cannot refuse to be treated under provisions of MHA Capacity • Defined in MCA 2005: A person is unable to make a decision for himself if he is unable— • (a) to understand the information relevant to the decision, • (b) to retain that information, • (c) to use or weigh that information as part of the process of making the decision, or • (d) to communicate his decision (whether by talking, using sign language or any other means). • Presumed present unless proven absent – you must apply the test • Decision-specific, not person-specific Treatment under MCA 2005 • If the patient lacks the capacity to consent, the Dr must act in the best interests of the patient • You have a duty where practical to consult with family/friends when determining best interests • If there are no family/friends, consult with an Independent Mental Capacity Advocate • Summary: www.dh.gov.uk/en/PublicationsAndStatistics/Bull etins/ChiefExecutiveBulletin/DH_410834 The principle of Best Interests • • • • • • Not limited to medical indications: social context patient’s wishes and values invasiveness reversibility balance of burdens and benefits Refusals of treatment • Must be respected if informed, voluntary and capacitous, even if unwise, unless the doctrine of neccessity or statutory provisions apply Neccessity • The principle developed to justify treating people who could not give consent • Originally applied to unconscious patients • Extended to cover cases where mental disorder impaired capacity to consent • That body of case law is now consolidated in the Mental Capacity Act 2005 • Neccessity still applies to the application of restraint to prevent immediate harm to others (or self if capacity not yet assessed) Treatment under the MHA 1983 • If a patient is detained under the MHA [except 5(2)/5(4)], he or she may be treated for mental disorder without consent (ss 62-63) • Applies even if the patient retains decision making capacity, has a valid LPA, or has made an advance directive refusing treatment • Consent and/or 2nd opinion required in certain specific circumstances (ss57-58) Detention under the MHA1983 • Assess against criteria for detention: • Suffering from mental disorder of nature or degree which warrants detention for assessment (s2) / makes it appropriate to receive medical treatment in hospital (s3) • Detention necessary for health or safety of patient or protection of others • Appropriate treatment available Recommending detention • If criteria for detention are met, you may recommend detention • Use clinical judgement to decide whether this is the right thing to do in the circumstances • Legal criteria do not seem to be the most important factor influencing decisions to detain – Zinkler & Priebe 2002, Appelbaum 1997 Factors affecting decisions to detain • Research (eg Engleman et al 1992) indicates that a variety of factors may influence the decision, some for legitimate reasons, some not eg: • Resource availabilty • Values of decision makers • Race, gender, age, physical stature etc • Be aware of the risk of prejudice and always aim to act in the interests of the patient Management of property • A Lasting Power of Attorney can cover decisions about managing property as well as health and social care • This replaces the previous system – Enduring Power of Attorney – which worked in the same way but could not cover healthcare decisions • Existing EPA remain valid under the new system • www.guardianship.gov.uk for details Testamentary capacity • The ability to make a will • A will is invalid if it is proven that the person who made it lacked testamentary capacity • Guidelines on assessment: www.bgs.org.uk/Publications/Compendium/comp end_2-2.htm • The test is similar to the MCA test for decision making capacity… Banks v Goodfellow • `It is essential that a testator shall understand the nature of his act and its effects; the extent of the property of which he is disposing; and shall be able to comprehend and appreciate the claims to which he ought to give effect, and, with a view to the latter object, that no disorder of mind shall poison his affections, pervert his sense of right, or his will in disposing of his property and bring about a disposal of it which, if his mind had been sound, would not have been made` Driving • Mental disorders can impair ability to drive, putting the patient and others at risk • Drivers have a duty to inform the DVLA if their health is affected in a way that could impair driving ability • Dr should inform patients of this duty • If patient refuses to inform DVLA, Dr should inform DVLA, having told patient that this is what will happen DVLA regulations • www.dvla.gov.uk/medical/ataglance.aspx • Do not drive if taking drugs that impair ability to drive (recreational or prescribed) • Severe depression, mania, acute non-affective psychosis – do not drive until 3 months after symptoms have resolved • Rapid cycling BPAD – do not drive until 6 months after symptoms have resolved • Chronic psychotic illness – may drive if symptoms and treatment do not impair ability to drive A (very) brief overview of moral philosophy • Different schools of thought have been used to attempt to balance conflicting demands arising from principles of medical ethics eg: • Deontology • Utilitarianism • Virtue Ethics • Ethics of Care Deontolgy • Classic example – Kant’s categorical imperative • Focuses on rules for conduct which must be followed • Clear cut • Difficult to work out what the rules should be • Inflexible, ‘one size fits all’ Utilitarianism • Classic example – J S Mill • Teleological - focuses on consequences rather than acts • the correct act is the one that results in the greatest happiness for the greatest number • Easy to understand, flexibility for unusual circumstances • Assumes consequences are predictable and happiness can be measured • May place an extreme burden on a minority Virtue ethics • Dates back to Aristotle, recent resurgence • Focuses on character – act as a good person (or good psychiatrist) would act • ‘The mean between extremes’ e.g. generosity • Avoids problems with inflexibility and heartlessness, provided ‘good’ can be defined… Ethics of Care • Developed out of feminist thinking by Carol Gilligan • Focuses on relationships – acts should be consistent with the needs of the person you are caring for • Advantages similar to virtue ethics, but can you really ignore the bigger picture? Codes of ethics • Classical era: Caraka Samhita, Hippocratic oath • Thomas Percival: Code of Institutes & Percepts • (Neisser, Nazism & Tuskagee) • Declarations of Geneva & Helsinki • Good Psychiatric Practice Clinical ethics • Beauchamp & Childress proposed four principles central to ethical conduct in healthcare: • Beneficence – do good • Non-maleficence – don’t do harm • Respect for autonomy – avoid paternalism • Justice – treat people fairly Facts • Statements of fact are ‘hard’, based on verifiable, reproducible data so disagreement is not rational: • The sun set at 7.30 • The patient had a fractured neck of femur • The chi squared test is appropriate to apply to this data Values • Value statements are ‘soft’, based on opinions / beliefs and not verifiable so disagreement is legitimate: • The sunset was beautiful • The patient has a personality disorder • The utilitarian calculus should be applied to this problem Ethical objectivism • The objectivist holds that there are moral truths which apply equally to all times, places and persons • The strong objectivist (eg Kant) applies this to all moral statements • The weak objectivist position holds that some fundamental principles are universally applicable eg human rights – strong moral claims that everyone is entitled to make, by virtue of being human Ethical subjectivism • You can’t derive an ought from an is – Hume • Ethical statements = value statements, recording the speaker’s beliefs about a moral position • We only believe our value statements are objective because they are so ingrained in our language – Mackie • Subjectivism and scepticism imply a duty to tolerate the moral values of others, even if we find them objectionable Values in psychiatry • In comparison to physical medicine, psychiatry is relatively value laden • The values in physical medicine are widely shared, hence often appear to be objective facts – pain, nausea and paralysis are undesireable • The values in psychiatry are more diverse, concerned with motivation, desire, affect and belief – room for disagreement Subjectivism in psyciatry • The lack of shared values in psychiatry has lead to calls for greater tolerance of the beliefs of others, strongest in the antipsychiatry movement (Szaz, Laing) • Can people who hold irrational beliefs legitimately be labelled as ill? Values-based psychiatry • Fulford argues for recognition of the value-laden nature of psychiatry, and the payment of attention to the values of patients as well as the values of professionals • He argues that the ‘disease’ model overemphasises the factual element and the ‘anti-psychiatry’ model overemphasises the evaluative element, with good practice depending on an awareness of both perspectives In the real world… • Stay informed of the belief systems of other cultures • Be aware of relevant law, codes of practice and declarations of professional bodies • Know how to make justifiable decisions • Bear patients’ beliefs / values in mind as well as your own Useful links • The GMC Code of Practice is at http://gmcuk.org/guidance/good_medical_practice/index.asp • The RCPsych publishes its own code ‘Good Psychiatric Practice’ • For an international perspective, the World Psychiatric Association’s declaration on ethics is at www.wpanet.org/about/ethic5.html The following are correctly paired except • • • • • Goffman Laing Foucault` Fulford Bleuler : The Total Institution : The Myth of Mental Illness : The Birth of the Clinic : Values Based Medicine : Splitting Select one incorrect pair: • A: Caraka Samhita: Confidentiality, and keeping abreast of medical knowledge. • B: Code of Institutes and Percepts: Thomas Percival. • C: Declaration of Helsinki: Following the Nuremberg War Trials. • D: Declaration of Geneva: Following the Nuremberg War Trials. • E: Nuremberg War Trials: Tried the Japanese Select one option that is not a feature of Teleology • A: Consequences are all-important • B: Common good takes precedence over individual interests • C: No common scale of measurement • D: Utilitarianism • E: Rights and duties determine action Select the option that refers to the ethical principles that are widely adopted in medical practice: • A: Beneficence, Good will and Duty • B: Confidentiality, Consent and Justice • C: Respect for Autonomy, Beneficence and Justice • D: Respect for Autonomy, Justice and Confidentiality • E: Respect, Justice, and Consent. According to the Mental Capacity Act 2005 a person has capacity if: • A: He is able to retain the information • B: He is able to understand the information relevant to the decision • C: He is able to use or weigh the information • D: He is able to communicate the information • E: He is not found not to have capacity