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Ethics in Mental Health Care

Willard P. Green, Ph.D.

Drs. Roberts and Dyer have written an exceptional "guide" for those professionals who work in the mental health field. In fact, this is an appropriate and excellent text for anyone working in the healthcare arena. Although designed as a "Guide" rather than an in-depth treatise on medical ethics, the authors address all the important topics one would expect to discover in a more scholarly approach to the topic.

In the first six chapters, the authors focus on ethical concerns stemming from the relationship between the mental health profession and the patient. The fundamental issues of informed consent, relationships of power, confidentiality and truth-telling, and the nature of moral reasoning in the clinical context are addressed.

Each chapter concludes with a few case scenarios designed to focus attention on the several aspects of the chapter’s main ethical issue. Although one might wish that more than two or three sentences were devoted to fleshing out the scene in which the ethical issue is presented, enough information is provided to direct the reader’s attention to a significant real-life drama.

The authors take a slightly different approach to their discussion of autonomy than is usually found in medical ethics texts. They reframe the discussion of autonomy in terms of voluntarism; how it is that an action a person takes reflects that person’s choice. This approach acknowledges the context in which a person acts voluntarily to a greater degree than does the single focus on the concept of "autonomy." Using "voluntarism" as the way to talk about autonomy lessens the need to discuss determinism as a foil for autonomy. Voluntarism enriches the way to look at agency by bringing the various relationships in which the agent finds herself into the picture.

When writing about decisional capacity, the authors make a distinction between a patient’s cognitive abilities and his competence. Competency would appear to be an "all-or-nothing" affair; either you are declared competent by the courts or you are not. Decisional capacity does not fall prey to such a strict dichotomy. This way of describing a person’s cognitive abilities allows for the possibility that decisional capacity is not bound to a particular age or symptom-free psychological state. Such an approach is especially important when thinking about the issues embedded in a discussion of informed consent.

The chapter on confidentiality and truth-telling centers on the central dilemma that arises when these two ethical principles conflict. The situations are especially telling in the mental health arena, where so much is known about a patient’s "inner" life and how that might affect the welfare of other people. The authors offer six strategies clinicians can use as they seek to resolve the numerous and significant dilemmas that can and do arise in multiple practice settings.

In the next five chapters, the authors focus on the caring relationship between clinicians and a few specific patient populations that give rise to special considerations. They apply the ethical principles analyzed in the preceding chapters to these populations: children, people with addictions, the "difficult" patient, boundary issues in small communities, and persons who are facing crisis as their life is nearing completion. For example, applying the principle of informed consent to situations involving children is clouded by the addition of the role of parents or other guardians. Numerous states make a distinction between "mature minors," those individuals who possess "the requisite cognitive ability and maturity to understand the meaning and consequences of the proposed treatment (p 121)," and minors whose consent is secondary to the consent of their guardian. Here, the concepts of "decisional capacity" and "voluntarism," addressed earlier in the text, fit nicely. Although a mature minor still has a guardian, if her or his decisional capacity makes it possible for the proposed decision to be voluntary and reflect the person’s intentionally-chosen interests, there is no obligation to gain the parent’s consent. Unfortunately, most states recognize this limit on parental consent only in situations involving substance abuse, mental health, and sexual activity.

The application of the ethical principle of confidentiality is exceedingly complex when working in small communities. Concern over breeches of confidentiality may limit what a patient is willing to tell the professional. As the authors point out, the mere act of entering the building where mental health counseling takes place may be open to public notice and grist for the rumor mill, thereby inhibiting a person in need of care from taking the steps necessary to obtain that care.

In the discussion of caring for patients who are in the end stages of life, the authors mention six domains—diagnosis, comfort, capacity, clarity, controversy and clarification—around which a clinician might organize the approach to caring for patients belonging to this particular patient population. They then shift to an exceedingly complex issue: a patient’s request for "assisted death" and how much such a request reflects a voluntary decision on the patient’s part. It is far from clear that a patient’s request for assistance in dying accompanied by the refusal of therapies that may benefit the patient stems from an unfettered decisional capacity.

The last six chapters deal with several specific areas of ethical concern: psychiatric genetics, managed care, the health of a clinician, clinical training, psychiatric research, and ethics committees. As in the earlier chapters, the authors apply the primary ethical principles to these unique issues.

Although the ability to uncover genetic markers for certain mental illnesses or embark on a course of gene therapy is still in the future, it is important to begin thinking about the ramification of these issues on ethical practice. The probabilistic nature of genetic information provides a cautionary base for informed consent. Persons who are not cognitively impaired have a difficult enough time in taking probabilities into consideration when making a decision; for cognitively impaired individuals, it becomes even more problematic. This is particularly true in light of the fact that at this point in time and for some time to come, therapeutic interventions are seldom available. The authors also point out the ethical difficulties around the principle of confidentiality. Given the nature of genetic markers, the individual tested is seldom an isolated case; that is, the familial nature of genetic markers brings other family members into the equation. Once a clinician has certain information about a particular inheritable mental disease, do the findings of Tarasoff apply? The authors see an increasing emphasis on contacting family members, even in those instances when the patient does not provide consent.

Managed mental health services often place the clinician between the ethical principle of beneficence, doing good for the patient, and "shared clinical resource needs of a larger set of individuals (pp 226–227)." In these settings, the authors maintain that the "key principles such as respect for persons, truth-telling, fairness, and confidentiality should not be compromised (p 227)." Yet the role of the clinician in resource distribution cannot be ignored. Indeed, the authors point out that some individuals are highlighting the importance of this role by claiming that it is itself a "new moral principle (p 229)."

Clinical training itself is accompanied by its own set of ethical issues, and the authors mention four of them: 1) professionals in training often perform a significant amount of direct patient care; 2) knowledge acquisition is accomplished by learning from patients directly; 3) clinical trainees often are placed in settings that elicit strong negative feelings on their part; and 4) the trainee is placed under a great deal of stress during the learning process. The authors recognize the critical importance of these four aspects of clinical training.

For each of the remaining chapters, the authors highlight the significant ethical issues. Upon completing the text, the reader will have been exposed to a host of significant ethical issues that a mental health professional will confront. Having the opportunity to consider them before experiencing them directly will be of great benefit to patient care. Having a text of such richness at hand as one is impaled upon the horns of a particular ethical dilemma will enrich the patient encounter immeasurably.

FOOTNOTES

 
Dr. Green is Professor of Medical Ethics in the Health and Society Programs in the College of Nursing and Health Professions at Drexel University, Philadelphia, PA.

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