Concise Guide to Ethics in Mental Health Care

by Roberts, Laura Weiss, M.D.; Dyer, Allen R.

• ISBN13: 9780880489447
• ISBN10: 0880489448
• Format: Paperback
• Copyright: 2004-03-31
• Publisher: Amer Psychiatric Pub Inc

Summary

Providing ethical care is the goal of every dedicated clinician and clinical trainee, yet fulfilling this ideal involves far more than simply being-or trying to be-good. Concise yet thorough, this pocket guide fills the void left by traditions, codes, and legal rulings to help define the real meaning of professionalism in the care of human suffering. Writing with clarity, coherence, and optimism, the authors summarize fundamental principles, enumerate essential skills, and review recent empirical findings in the overlapping areas of clinical ethics and psychiatry. Case illustrations, tables, and strategic lists enhance the book's 17 informative chapters, which are organized into three major topical areas: Psychiatric ethics-Basic principles of bioethics; core values, traditions, and skills of the clinical professions; clinical ethical decision making (including the role of health care ethics committees); genetic breakthroughs and their ethical implications; and the three ethics principles in psychiatric research: respect for persons, beneficence, and justice Clinical settings-The psychotherapeutic relationship; ethical use of power; confidentiality/privacy and truth telling; informed consent-the cornerstone of ethically sound clinical care; caregiving in small communities, which involves overlapping relationships, roles, and boundaries (e.g., the patient and the clinician grew up on neighboring farms), confidentiality (e.g., everyone in town watches who goes into the clinic, culture (e.g., a mental illness may not be acknowledged or recognize as such), and special stresses of clinicians; mentoring and support during training Clinical populations-Emotionally disturbed children, exceptionally demanding work that involves clinical and ethical complexities, such as giving food as a reward, allowing hugs, and reporting child abuse, that do not exist in work with adults; "difficult" patients, from those who refuse to take their medications to those who omit important details about their histories; resource allocation (i.e., "rationing" health care), including the disruptions in clinician-patient relationships caused by managed care; people facing the end of life; addiction psychiatry and the role of stigma; and mental health problems of colleagues. This volume in the eminently practical Concise Guides series moves us forward in our efforts to improve clinical decision-making, foster awareness, and enrich educational efforts related to the ethically challenging dimensions of mental health care. Complete with glossary, references, index, and suggested further readings, this remarkable guide offers an invaluable toolkit for mental health care students and professionals everywhere.

Author Biography

Laura Weiss Roberts, M.D., is Professor and Chair of the Department of Psychiatry and Behavioral Medicine at the Medical College of Wisconsin in Milwaukee, Wisconsin.

Allen R. Dyer, M.D., Ph.D., is Professor in the Department of Psychiatry and Behavioral Sciences at the James H. Quillen College of Medicine at East Tennessee State University in Johnson City, Tennessee.

Table of Contents

Contributors	p. xix
Introduction to the Concise Guides Series	p. xxi
Preface	p. xxiii
Ethics: Principles and Professionalism	p. 1
Traditional Principles of the Clinical Professions	p. 3
Professionalism and the Evolution of Bioethical Principles	p. 5
Principles, Rules, and Contextualism	p. 10
References	p. 16
Clinical Decision-Making and Ethics Skills	p. 19
Ethics Skills in Mental Health Care	p. 20
A Strategy for Ethical Clinical Decision Making	p. 22
Clinical Indications	p. 24
Patient Preferences	p. 24
Quality of Life	p. 26
Socioeconomic or External Factors	p. 26
Summary	p. 27
Case Scenarios	p. 27
References	p. 28
The Psychotherapeutic Relationship	p. 31
Professionalism in the Psychotherapeutic Relationship	p. 32
The Nature of the Psychotherapeutic Encounter	p. 34
Case Scenarios	p. 42
References	p. 43
The Exploitation Index	p. 45
Informed Consent and Decisional Capacity	p. 51
Elements of Informed Consent	p. 51
The Therapeutic Relationship	p. 51
Information	p. 52
Decisional Capacity	p. 54
Voluntarism	p. 57
Differing Standards for Consent	p. 59
Emergency or Acute Care	p. 60
Care for Chronic Illness	p. 62
Routine and Preventive Care	p. 64
Advance Directives and Surrogate Decision Making	p. 64
Examples of Empirical Studies Related to Consent	p. 66
Constructive Approaches to the Process of Consent	p. 69
Case Scenarios	p. 71
References	p. 72
Cases for Discussion	p. 75
Ethical Use of Power in High-Risk Situations	p. 77
Power and Vulnerability in Therapeutic Work	p. 78
Ethical Considerations in High-Risk Situations	p. 79
Suicide, Violent Behavior, and Mental Illness	p. 80
Ethical Use of Power in Situations Involving Potential for Self-Harm and Harm to Others	p. 82
Prediction	p. 82
Duty to Intervene	p. 84
Duty to Warn and Duty to Protect	p. 86
Strengths and Accountability of Mentally Ill Persons	p. 87
Ethical Use of Power and Treatment Refusal	p. 88
Ethical Use of Coercive Pressure in Mental Health Care	p. 90
Endeavoring to Use Power Ethically in Mental Health Care	p. 92
Case Scenarios	p. 94
References	p. 94
Confidentiality and Truth Telling	p. 97
Examples of Empirical Studies	p. 99
Confidentiality and Truth-Telling Dilemmas	p. 103
Responding to Confidentiality and Truth-Telling Dilemmas	p. 107
Case Scenarios	p. 115
References	p. 115
Caring for Children	p. 119
Professional Competence	p. 119
Clinical Treatment Issues	p. 121
Consent	p. 121
Confidentiality	p. 123
Practice Dilemmas	p. 125
Protecting Children and Reporting Child Abuse	p. 127
Research	p. 128
Consent	p. 129
Risk	p. 130
Dilemmas	p. 131
Conclusions	p. 132
Case Scenarios	p. 133
References	p. 134
Caring for People With Addictions	p. 137
Prevalence and Seriousness of Addiction and Comorbid Disorders	p. 137
Stigma	p. 139
Parity	p. 141
Personal Responsibility	p. 142
Criminal Justice Involvement, Truth Telling, and Confidentiality	p. 143
"First, Do No Harm"	p. 145
Harm Reduction	p. 146
Pseudoaddiction and Pain Management	p. 147
Empirical Ethics Studies	p. 148
Case Scenarios	p. 149
References	p. 150
Caring for "Difficult" Patients	p. 153
Recognizing "Difficult" Patients	p. 153
Prevalence and Attributes of "Difficult" Patients in Medical and Psychiatric Settings	p. 156
Understanding "Difficult" as a Clinical Sign	p. 158
Identifying Ethical Pitfalls in the Care of Difficult Patients	p. 159
Responding Therapeutically	p. 161
Case Scenarios	p. 165
References	p. 166
Caring for People in Small Communities	p. 167
Ethical Dilemmas of Small Communities	p. 168
Overlapping Relationships, Conflicting Roles, and Altered Therapeutic Boundaries	p. 168
Confidentiality	p. 173
Cultural Dimensions of Care	p. 174
Limited Access to Clinical Care, Mental Health, and Ethics Resources	p. 175
Stresses of Small-Community Caregivers	p. 178
Constructive Approaches	p. 179
Case Scenarios	p. 183
References	p. 183
Caring for People at End of Life	p. 185
Six Domains for Careful Attention	p. 185
Diagnosis	p. 187
Comfort	p. 187
Capacity	p. 188
Clarity	p. 189
Controversy	p. 190
Collaboration	p. 191
Emergent Ethical Questions in End-of-Life Care	p. 192
Case Scenarios	p. 194
References	p. 194
Missoula-Vitas Quality of Life Index	p. 197
Values History Form	p. 203
Ethical Issues in Psychiatric Genetics	p. 207
The Nature of Genetic Information	p. 208
Informed Consent in Psychiatric Genetics	p. 208
Confidentiality	p. 210
Considerations of Justice	p. 211
Empirical Studies on Ethical Issues in Psychiatric Genetics	p. 213
Genetic Counseling for Psychiatric Disorders	p. 214
Case Scenarios	p. 216
References	p. 217
Ethical Issues in Managed and Evolving Systems of Care	p. 219
Ethical Principles in Managed and Evolving Systems of Care	p. 220
Evolving Systems of Care for Mental Illness	p. 224
Resolving Conflicts Between the Needs of Individuals and Populations	p. 226
Case Scenarios	p. 229
References	p. 230
Ethical Issues in Clinician Health	p. 233
The Wounded Healer	p. 236
The Path to Wellness	p. 238
The VIP Syndrome	p. 238
The Impaired Professional	p. 239
Clinician Health and Training	p. 240
Case Scenarios	p. 241
References	p. 242
Ethical Issues in Clinical Training	p. 243
Special Ethical Challenges of Clinical Training	p. 245
Empirical Studies on Ethics and Clinical Training	p. 249
Educational Strategies for Ethics Education in Clinical Training	p. 253
Case Scenarios	p. 257
References	p. 257
Ethical Issues in Psychiatric Research	p. 261
Design, Methods, and the Need for Ethics Safeguards	p. 264
Ethics Safeguards	p. 266
Institutional Review and Data and Safety Monitoring	p. 266
Informed Consent	p. 268
Advance, Alternative, and Collaborative Decision Making	p. 271
Additional Expert and Peer Review Processes	p. 272
Confidentiality Protections	p. 273
Expertise, Integrity, and Conflicts of Interest	p. 273
Special Groups and Potentially Vulnerable Populations	p. 276
Animal Research	p. 280
Practical Efforts Regarding the Ethical Conduct of Research	p. 281
Case Scenarios	p. 282
References	p. 282
Roberts Research Protocol Ethics Assessment Tool (RePEAT)	p. 285
Health Care Ethics Committees	p. 295
The Rise of Health Care Ethics Committees	p. 295
Historical Background: Some Notable Faulty Medical Research Practices	p. 296
Early Forms of Hospital Ethics Committees	p. 298
Where Are Ethics Committees Today?	p. 300
What Do Health Care Ethics Committees Do?	p. 301
Ethics Education	p. 301
Policy Formulation and Review	p. 302
Case Consultation	p. 303
Who Should Be on a Health Care Ethics Committee?	p. 306
Professional Association Ethics Committees	p. 309
Summary	p. 310
References	p. 311
Cases for Discussion	p. 313
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