Ethics in community psychiatry

Current Opinion in Psychiatry

Volumn 11, Issue 5, 1998, Pages 549-553

  Szmukler, George ^a   Holloway, Frank ^a  

^a SOUTH LONDON AND MAUDSLEY NHS FOUNDATION TRUST   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

COMMUNITY MEDICINE; CONFIDENTIALITY; HUMAN; INFORMED CONSENT; LEGAL ASPECT; MEDICAL ETHICS; PERSUASIVE COMMUNICATION; PRIVACY; RESOURCE ALLOCATION; SHORT SURVEY; SOCIAL PSYCHIATRY;

EID: 0031711120     PISSN: 09517367     EISSN: None     Source Type: Journal    
DOI: 10.1097/00001504-199809000-00023     Document Type: Short Survey

References (45)

1. Diamond RJ, Wikler DI. Ethical problems in community treatment of the chronically mentally ill. In: Training in community living model: a decade of experience. New Directions for Mental Health Services, No. 26. Stein LI, Test MA (editors). San Francisco: Jossey-Bass; 1985; 26:65-93.
2. Bloch S, Chodoff P (editors). Psychiatric ethics, 2nd edn. Oxford: Oxford University Press; 1991.
3. Christensen RC. Ethical issues in community mental health: cases and conflicts. Commun Mental Health J 1997; 33:5-11. This paper sets the ethical scene for issues of consent, paternalism, resource allocation and conflict within teams in a community mental health service setting.
4. Marshall M, Lockwood A. Assertive community treatment for mental disorders. The Cochrane Library; [CDrom] 1998: issue 2.
5. Leff J (editor). Care in the community. Illusion or reality? Chichester: Wiley; 1997.
6. Deahl M, Turner T. General psychiatry in no-man's land. Br J Psychiatry 1997; 171:6-8. This paper provides important context from the 'coal face' for discussions about the ethics of community care.
7. Dyer C. Psychiatrist resigns after second patient is charged with murder. Br Med J 1997; 314:7.
8. Peay J. Clinicians and inquiries: demons, drones or demigods? Int Rev Psychiatry 1997; 9:171-177.
9. Sheppard DS. Case study based on the Gilbert Kopernik-Steckel inquiry. Croyden Health Authority July 1997 [web page] 1997; http://www.imhl.-com/gilbert.htm This report shows how the benefits of hindsight make it easy to stray from a given brief, and how conclusions about errors can escalate in criticism despite contrary evidence presented earlier. Although clinical mistakes occurred, it is hard to see how such a sweeping indictment of a service can be justified on the basis of 48 h of out-of-hours care of a single patient with no previous psychiatric or forensic history. (Declaration of conflict of interests: we are employed by the Trust criticized in this report.)
10. Carson D. Good enough risk taking. Int Rev Psychiatry 1997; 9:303-308.
11. Holloway F. The assessment and management of risk in psychiatry: can we do better? Psychiatr Bull 1997; 21:283-285. Inner-city psychiatric teams deal with high risk situations every day. A rational risk management policy under these circumstances is a major challenge.
12. Harrison G. Risk assessment in a climate of litigation. Br J Psychiatry 1997; 170 (Suppl 32): 37-39.
13. Barrett KE, Taylor DW, Pullo RE, Dunlap DA. The right to refuse medication: navigating the ambiguity. Psychiatr Rehab J 1998; 21:241-249. This is a useful account of the pros and cons of compulsory medication and possible alternatives to compulsion that empower patients.
14. Fisher DB. Comments on the article: 'The right to refuse medication: navigating the ambiguity'. Psychiatr Rehab J 1998; 21:250-251. This article offers a consumer view of community mental health care, noting the disturbing linkage between treatment adherence and receipt of welfare benefits and other goods.
15. Eastman N. The Mental Health (Patients in the Community) Act 1995. A clinical analysis. Br J Psychiatry 1997; 170:492-496. Excellent analysis of an ill-considered piece of legislation with a political purpose rather than a clinical one. 'Supervision' is presumably meant to give the public the impression of being protected.
16. Dickenson D. Ethical issues in long term psychiatric management. J Med Ethics 1997; 23:300-304. This is a rare example of an extended philosophical discussion relating to the practicalities of mental health care in the community.
17. Petch E, Bradley C. Learning the lessons from homicide inquiries: adding insult to injury? J Forens Psychiatry 1997; 8:161-184.
18. Shepherd J. Tackling violence [editorial]. Br Med J 1998; 316:879.
19. Furlong M, Leggatt M. Reconciling the patient's right to confidentiality and the family's need to know. Aust N Z J Psychiatry 1996; 30:614-622.
20. Szmukler GI, Bloch S. Family involvement in the care of people with psychoses: an ethical argument. Br J Psychiatry 1997; 171:401-405. This is an attempt to engender rethinking, discussion and, one hopes, eventual consensus about the limits of patient confidentiality, taking account of the complexities of contemporary community care. Customary notions of confidentiality may need substantial revision, especially where obligations to carers are concerned.
21. Binder RL, McNeil DE. Application of the Tarssoff ruling and its effect on the victim and the therapeutic relationship. Psychiatr Serv 1996; 47:1212-1215.
22. General Medical Council. Duties of a doctor: confidentiality. London: General Medical Council; undated.
23. Sex Offenders Act 1997. London: HMSO; 1997.
24. Christensen RC. Psychiatrists as gatekeepers: a matter of perspective. Psychiatr Serv 1997; 48:583.
25. Schlesinger M, Dorwart RA, Epstein SS. Managed care constraints on psychiatrists' hospital practices: bargaining power and professional autonomy. Am J Psychiatry 1996; 153:256-260.
26. Backlar P. Managed mental health care: conflicts of interest in the provider/client relationship. Commun Mental Health J 1996; 32:101-106.
27. Dennis DL, Monahan J (editors). In: Coercive and aggressive community treatment: a new frontier in mental health law. New York: Plenum Press; 1996.
28. Wertheimer A. A philosophical examination of coercion for mental health issues. Behav Sci Law 1993; 11:239-258.
29. Kaltiala-Heino R, Laippala P, Salokangas KR. Impact of coercion on treatment outcome. Int J Law Psychiatry 1997; 20:311-322. This is a useful Finnish study showing that patients who perceived high coercion in their admission to hospital were more likely, at 6-month follow up, to have negative attitudes to services, to use them less, to have poor expectations of treatment and to have poorer symptomatic outcomes.
30. Hiday VA. Involuntary commitment as a psychiatric technology. Int J Technol Assess Health Care 1996; 12:585-603.
31. Munetz MR, Grande T, Kleist J, Peterson GA, Vuddagiri S. What happens when effective outpatient civil commitment is terminated? New Dir Mental Health Serv 1997; 75:49-59. Clinicians with experience of a form of outpatient commitment discuss limitations and alternatives. The conclusion is that, over the long haul, outpatient commitment is not the best way to obtain patient cooperation with treatment. (Outpatient commitment in this jurisdiction came perilously close to using deception on patients to gain their compliance with treatment.)
32. Geller JL, McDermeit M, Grudzinskas AJ Jr, Lawlor T, Fisher WH. A competency-based approach to court-ordered outpatient treatment. New Dir Mental Health Serv 1997; 85:81-95. The authors conclude from this study that outpatient commitment 'appears to have had a beneficial effect in Massachusetts, although the more rigorous the analytic framework we apply to these data the more equivocal our findings appear to become'.
33. Barel YC, Durst R, Rabinowrtz J, Kalian M, Tertelbaum A, Shlafman M. Implementation of order of compulsory ambulatory treatment in Jerusalem. Int J Law Psychiatry 1998; 21:65-71. This is an Israeli study that shows the uselessness of a form of outpatient commitment if service organization is poor. However, if services were good, would outpatient commitment offer any advantages for difficult to treat patients?
34. Draine J. Conceptualizing services research on outpatient commitment. J Mental Health Admin 1997; 24:306-315. Is an ethical-legal measure like outpatient commitment amenable to a randomized controlled trial? This intriguing paper argues that it probably is not, and that the only way in which we can empirically understand the effects of outpatient commitment is through building and testing complex statistical models.
35. Winick BJ. Mandatory treatment: an examination of therapeutic jurisprudence. New Dir Mental Health Serv 1997; 75:27-34. What we know about the effects of coercion on patients suggests that outpatient commitment should have negative effects on the patient, the therapeutic alliance and attitudes to psychiatric services. This paper argues that 'whenever possible, clinicians should use persuasion, education, negotiation, and inducement instead of coercion'.
36. Lidz CW, Mulvey EP, Hoge SK, Kirsch BL, Monahan J, Bennett NC. The validity of mental patients' accounts of coercion-related behaviors in the hospital admission process. Law Hum Behav 1997; 21:361-376.
37. Sutherby K, Szmukler G. Crisis cards and self-help crisis initiatives. Psychiatr Bull 1998; 22:3-7. 'Crisis cards' and 'joint crisis plans' may offer effective, cheap and safe means of respecting patient autonomy and at the same time effectively managing relapse in patients with psychoses. Patient and clinical team can plan in detail and in advance what should, or should not be done, in the heat of a crisis.
38. L v Bournewood Community and Mental Health Trust ex parte L. 1998 1 All ER 634. Life will never be the same again in England following this Court of Appeal ruling. After 40 years of accepted practice, persons can no longer be admitted as informal (voluntary) patients to hospital for treatment of mental disorder unless they have the capacity to agree to admission. Patients without capacity, who do not actively resist admission, must now be placed on a compulsory order if they are to be legally admitted.
39. Campbell T, Heginbotham C. Mental illness: prejudice, discrimination and the law. Dartmouth: Vermont; 1991.
40. Campbell T. Mental health law: institutionalised discrimination. Aust N Z J Psychiatry 1994; 28:554-559.
41. Law Commission Report No. 231. Mental incapacity. London: HMSO; 1995.
42. Lord Chancellors Department. Who decides? Making decisions on behalf of mentally incapacitated adults. London: HMSO; 1997.
43. McCubbin M, Weisstub DN. Towards a pure best interests model of proxy decision making for incompetent psychiatric patients. Int J Law Psychiatry 1998; 21:1-30. This is a very detailed and tightly argued analysis of what might constitute a 'best interests' justification for treatment of an incompetent patient. A 'pure best interests' model is based solely on autonomy values and entails finding ways of making substituted decisions that approach as closely as possible the patient's own values and preferences, and seek justification on that basis. Reference 42 makes a good practical attempt.
44. Halpern A, Szmukler G. Psychiatric advance directives: reconciling autonomy and non-consensual treatment. Psychiatr Bull 1997; 21:323-327. This paper argues that psychiatric advance directives made by people recovered from a psychotic episode about what should be done if they become psychotic (and incompetent) again provides a stronger ethical justification for nonconsensual treatment in the community than outpatient commitment. It examines the problems: defining the capacity necessary to make an advance directive, to trigger it and to revoke it; preventing coercion; resource implications; and relationship to mental health legislation. This is not agreeable to everyone, but it should be an option.
45. Backlar P. Anticipatory planning for psychiatric treatment is not quite the same as planning for end-of-life care. Commun Mental Health J 1997; 33:261-268. Discusses advantages, especially the active involvement of the patient in their treatment plans, and problems of psychiatric advance directives involving proxy decision makers, including a reluctance on the part of service providers to change established practices and issues of confidentiality.