Transcript Ethical Issues in Psychiatry

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
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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…
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Have a valid defence:
Statutory provisions
Consent
Neccessity
Consent
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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
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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
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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