ethical issues in mental health
TRANSCRIPT
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Ethical Decision-Making in Mental Health
Kim Jameson, MA, PhD CandidateEthicist, Vancouver Coastal Health
Co-Author: Bethan Everett, MBA, Ph.D.Ethicist, Vancouver Coastal Health
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Objectivesu Introduction to VCH Ethics Servicesu Name ethical principlesu Overview of the ethical decision-making processu Present a case scenariou Describe concepts of risk and capacityu Name the factors that help determine when and
how to interveneu Discussion
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Ethical Decision-making
Virtually all health care decisions have an ethical component
i.e. What is the right thingto do given the circumstances?
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VCH Ethics ServicesRole: ØTo provide support to those confronting difficult
ethical concerns, questions and/or issues related to health care.
Primary Functions:ØCase ConsultationØEducation and capacity buildingØ Input to guidelines/policies
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Top Ethical Issues in Mental Health
• Refusal of life-sustaining/saving medical treatment when mental health issues are present
• Disagreement over appropriate psychiatric care• Discharging at risk• Confidentiality and family involvement • Addressing requests for Medical Aid in Dying
(MAID)
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Ethical Principles
Non-maleficence
Beneficence
Autonomy
Justice
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Phase 3Proposing Options and applying principles
Phase 2Gathering Facts
Phase 1Planning & Framing
the IssuesPhase 5Implementing & Evaluating
Phase 4Decision- making
* Team Members *Client
Family & friendsCare providers
Health Professionals
w Why are we here?w Who should be here?w What are the issues?w What are our values and biases?
w What does the client want? w What could we do?w What other options are available?w What ethical principles apply to the various options?
wWhat criteria are we using to make decision?w What’s the ‘best choice’ available? w What’s our back up plan?
w Who’s responsible for what?w Does anyone need debriefing?w Can we live with this?w Have we documented the process?
w What are the facts?w What are the risks?
ETHICAL DECISION-MAKING FRAMEWORK
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Medical health issuesHealth care needsDiagnosis/prognosisRisks/benefits of interventionGoals of interventions
Client/surrogate wishesWhat does client wantIs there a substitute decision maker (SDM)What does SDM wantIs client informed/is consent needed
Quality of life
How will intervention change quality of lifeWho defines qualityWhat is the harm/benefit ratio Is this a holistic approach
Contextual featuresWho else is affectedWhat costs are involvedProfessional practice/legal implicationsSocietal considerationsAre there risks? (How probable, severe, and who is at risk?)
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Ethical Process• All parties should be involved• All parties should have the information needed
to come to a decision• Communication should be open, honest,
transparent• Relationships should be respectful• Promises should be kept• There should be an awareness and
accommodation for differences in power
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Case ScenarioChao-xing has schizophrenia and has been diagnosed with early-stage breast cancer. She is being held in hospital under the Mental Health Act, and the Public Guardian and Trustee (PGT) is her health care decision-maker. The client has refused further testing and treatment for breast cancer because she does not believe she is ill. Despite having received consent from the PGT to undertake testing, Chao-xing’s oncologist refuses to proceed.(J. Young & B. Everett (2015). “Cause of Death: Schizophrenia?” BC Medical Journal, 57 (10), 434-437)
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Capability
• How do we know if a person is capable?
• What does capable mean?
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Client
Specific decision/choice
Capablei.e. understands and appreciates
Client is Decision Maker
Not capable
Substitute decision maker Advance Directive
WHO MAKES THE DECISION
Substituted decision Best interest decision
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RiskThe chance or probability of a negative outcome or consequence of an action, inaction, behavior or decision
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6 elements of intolerable risk• A change that impairs one’s ability to protect oneself
or others from harm• Evidence of current decline /severe change in
condition• High probability that decline or severe change will
occur• Severity of anticipated harm• Imposition of risks on others• Inability to choose to be at risk
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Ethical analysis of risk• Which principles are in
conflict?
• Risk to who?
• Is the Client capable
• What is nature of risk?
• Can the risk be brought to acceptable level?
Autonomy/ Non Maleficence/ Beneficence/ Justice
Self? Others?
Capable or Incapable (ethical and legal)How serious/ probable/ Evidence vs Speculation
Yes or No?
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When do we intervene?• Encumbered- decreased capacity for whatever
reason and autonomy may be compromised
Mental illnessEmotional stateUndue influence
Lack of Information
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risk capability/competence
mental illness
emotional state
undue influence
information interference
not permanentor serious orprobable(tolerable)
client can understand & appreciate risks, outcomes, consequences
none absent absent client has full information
explain
argue
permanent, & serious & probable(intolerable)
understands
does not understand
mild
significantseriously impairing
seriously impairing
client has little or no information
pressure
physically coerce
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5 Ethical Criteria
• Interfere only if it will be– Effective– Benefits >harm– Non-discriminatory– Least intrusive– If at all possible, thought justified by person upon
whom it is imposed
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Case Discussion
• Client’s refusal (autonomy) vs duty to promote well-being (beneficence) and do no harm/ reduce harms (non-maleficence) through safe and effective care– Client’s decisional capacity– Consent to mental and physical health care– Risk and benefits in immediate and long term
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Thank You!
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Ethics Service Contact Information
Ø If an ethicist is not available please call anyone on this list:
Ø Bethan Everett: First on call for Acute - VGH and UBC Hospitals, Vancouver Community, GF Strong Rehab Centre and George Pearson Centre ~ 604-266-6264 (office); 778-870-2805 (cell) [email protected]
Ø Terry Anderson: First on call for Richmond, Bella Coola and Bella Bella ~ 604-538-8180
Ø Kim Jameson : First on call for Coastal (North Shore, Sea-to-Sky, Sunshine Coast and Powell River ~ 778-877-7208 [email protected]
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