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Psychiatric Ethics as Professional and Biomedical Ethics

Jennifer Radden and John Z. Sadler

in The Virtuous Psychiatrist: Character Ethics in Psychiatric Practice

This chapter places psychiatric ethics within professional and biomedical ethics more generally, and introduces the “role morality” notion: that some ethical imperatives derive from particular social ... More

This chapter places psychiatric ethics within professional and biomedical ethics more generally, and introduces the “role morality” notion: that some ethical imperatives derive from particular social roles. Some differences between psychiatry and other medical practices are illustrated through three issues: questions of patient autonomy, rules governing the ‘boundaries’ around the therapeutic relationship, and concerns over psychiatric diagnostic categories. Building on previous work in biomedical ethics, the authors adopt the methodology employed in the American Psychiatric Association's Annotations with Particular Application to Psychiatry (2001), which identifies the ethical implications of particular features distinctive to the practice of psychiatry. When practiced with severely ill patients, it is asserted, psychiatry makes extra ethical demands on practitioners.Less

Reply to critics

Fiona Randall and R.S. Downie

in Palliative Care Ethics: A Companion for All Specialties

This chapter presents a reply to critics. This is less because the authors wish to be defensive about the book than because the reviewers have pointed to areas of important controversy in palliative ... More

This chapter presents a reply to critics. This is less because the authors wish to be defensive about the book than because the reviewers have pointed to areas of important controversy in palliative care. There are three such areas: a more detailed discussion regarding withholding and withdrawing life-prolonging treatment; the moral problems of giving overriding power to the principle of respect for the patient's autonomy; and the provision of spiritual and emotional care.Less

Withholding and Withdrawing Curative Treatments

David J. Bearison

in When Treatment Fails: How medicine cares for dying children

This chapter discusses issues in withholding and withdrawing curative treatments for a child under palliative care. It tries to determine the proper time to discontinue the treatments and when to ... More

This chapter discusses issues in withholding and withdrawing curative treatments for a child under palliative care. It tries to determine the proper time to discontinue the treatments and when to stop. One section centers on the various ethical principles and ethical practices involved, while another studies patient autonomy in pediatrics. The rest of the chapter is devoted to providing various narratives depicting instances where medical staff deals with parents refusing to withhold or withdraw the curative treatments on their child.Less

Values, principles and standards

Charlotte Williamson

in Towards the emancipation of patients: Patients' experiences and the patient movement

This chapter examines the values and principles that give radical patient activists their sense of direction in their work. It explains that patient autonomy is a fundamental value for activists, and ... More

This chapter examines the values and principles that give radical patient activists their sense of direction in their work. It explains that patient autonomy is a fundamental value for activists, and that they identify new issues and press for higher standards in directions which support it. The chapter suggests that the principles which radical activists drew out of their experiences, discussions, and reading over the first 20 or so years of the patient movement, from the early 1960s to the late 1980s, were: choice, information, access, respect, equity, shared decision making, safety, support, representation, and redress.Less

Self-help strategies

Rodney H. Breau

in Supportive Care for the Urology Patient

This chapter gives an overview of resources available to patients and reiterates the importance of the involvement of the physician in directing patients to pertinent and applicable self-help. ... More

This chapter gives an overview of resources available to patients and reiterates the importance of the involvement of the physician in directing patients to pertinent and applicable self-help. Knowledge is not necessarily associated with improved satisfaction. It is more likely that perception of knowledge is more important. Self-help discussions address issues pertaining to patient autonomy. Self-help should be used as a tool to facilitate, not a replacement for, personal communication. Information that aids and fosters a patient's sense of control by emphasizing their role in the decision-making process could develop and enhance their feelings of empowerment. However, simply providing information and expecting patients to independently choose appropriate management should never be expected since this act undermines the value of physician training and erodes the foundation that is the basis of a trusting patient-doctor relationship.Less

Ethics and aims in palliative care

Fiona Randall and R.S. Downie

in Palliative Care Ethics: A Companion for All Specialties

This chapter begins by introducing the ethical concepts and principles that are used in contemporary discussions of health care. It then discusses the aims of palliative care, relating them to the ... More

This chapter begins by introducing the ethical concepts and principles that are used in contemporary discussions of health care. It then discusses the aims of palliative care, relating them to the general aims of health care, and finally puts the ethics and the aims together, showing how these are integrated. The chapter notes that to adopt the aims of palliative care is to adopt a moral standpoint. The intrinsic aim of palliative care, as part of health care, is the promotion of a medical good related to physical or mental illness. This professional treatment must be humane and show full appreciation of the meaning of the disease, suffering, and treatment for the particular patient, or of its place in the patient's conception of his total good.Less

Communication: Breaking the News

Richard Sloan and Dieter E. Pongratz

Gian Domenico Borasio (ed.)

in Palliative Care in Amyotrophic Lateral Sclerosis: From diagnosis to bereavement, 2nd Edn

This chapter offers some suggestions on how to communicate the diagnosis to patients with ALS. Considered a daunting task for many neurologists, many in the medical field often break the news to ... More

This chapter offers some suggestions on how to communicate the diagnosis to patients with ALS. Considered a daunting task for many neurologists, many in the medical field often break the news to their patients in a manner that dampens the last string of hope of the patients. Although patients are often given reassuring statements while the family and the relatives get the whole truth, many clinicians nowadays respect the ethical principle of patient autonomy since giving the diagnoses is the first and most delicate step in palliative care. Although the feeling of hopelessness is present in giving a diagnosis, withholding the truth to patients is not an excuse to what might be essential in the patient's life-planning. In this chapter, several procedures and steps in breaking the news to the patients are discussed to give clinicians and neurologists better ways to communicate their diagnosis regardless of how bleak the situation is.Less

Patient Autonomy—A Turn in the Tide?

Rebecca Bailey-Harris

in Law and Medicine: Current Legal Issues Volume 3

The genesis of this chapter was the decision of the Court of Appeal in St George’s Healthcare NHS Trust v. S; R. v. Collins and Others, ex parte S. The decision under consideration here highlights a ... More

The genesis of this chapter was the decision of the Court of Appeal in St George’s Healthcare NHS Trust v. S; R. v. Collins and Others, ex parte S. The decision under consideration here highlights a number of classic debates in medical ethics: autonomy versus paternalism, consequentialism versus deontological absolutism, and the nature of personhood. The particular factual context was that of refusal of medical and surgical treatment by a woman in a late state of pregnancy, but the decision is of a wider significance. The decision is concerned primarily with the power of the patient against the medical profession, rather than any conflict between mother and unborn child. This interpretation is based on three particular aspects of the judgment: the absolute nature of the autonomy right as framed by the Court of Appeal and its contextualization as a necessary freedom within a democratic society which will brook no erosion; the reasoning technique which denies the foetus the status of personhood, and thus deliberately eschews a conflict of rights analysis; and the issuing by the court of guidelines which are intended, at least procedurally, to tip the balance back in favour of the competent patient in future situations. The decision represents a landmark for patient autonomy generally.Less

Process of clinical decision making

Fiona Randall and R.S. Downie

in Palliative Care Ethics: A Companion for All Specialties

This chapter begins by examining responsibility for outcomes, and then deals mainly with the process of decision making. It clarifies the moral issues that arise in the traditional methods of ... More

This chapter begins by examining responsibility for outcomes, and then deals mainly with the process of decision making. It clarifies the moral issues that arise in the traditional methods of decision making and explores the moral difficulties inherent in the use of some more recently developed formal systems, such as flow charts and clinical guidelines, which have been proposed as improvements on the traditional process. In palliative care, clinical workers have to make decisions in circumstances that entail factual complexities, uncertainties, and difficult moral choices. Nevertheless, a decision has to be made. Letting someone die is permitted in certain circumstances whereas killing is prohibited. The doctrine of double effect, which relies on a moral distinction between intended and foreseen events, allows the use of measures to relieve suffering even those events carry a significant risk of shortening life.Less

Advance Directives

Gian Domenico Borasio and Raymond Voltz

in Palliative Care in Amyotrophic Lateral Sclerosis: From diagnosis to bereavement, 2nd Edn

This chapter focuses on advance directives wherein the patients are given freedom to indicate their preferences for medical treatment and intervention. In many parts of the world, consideration of ... More

This chapter focuses on advance directives wherein the patients are given freedom to indicate their preferences for medical treatment and intervention. In many parts of the world, consideration of advance directives has been increasing, allowing patients to discuss and clarify their wishes, even if they were not able to express them due to the progression of the disease. Advance directives have been becoming a recognized tool for ensuring patient autonomy at the stage wherein they can no longer be asked directly for their preferences. However, discussing and formulating an advance directive (AD) in ALS can be difficult and time-consuming. More often than not, physicians feel unprepared for this task and fear of the legal consequences that comes with withdrawal of life-sustaining treatments gets the better of them. However difficult and time-consuming ADs are, the role of ADs is indispensable in the medical field particularly with the advent of new therapies and new methods for prolongation of life. A lot of consideration comes with the discussion and implementation of ADs but the sole and final decision must reside with the patient unless they prefer otherwise. Aside from discussing ADs, a checklist for end-of-life planning and advance directives in ALS is included as well.Less

The Caesarean Section Cases and the Supremacy of Autonomy

Jonathan Herring

in Law and Medicine: Current Legal Issues Volume 3

This chapter shows that caesarean section cases have presented a number of difficult issues for the law. The Court of Appeal has suggested the cases can be easily dealt with by referring to the ... More

This chapter shows that caesarean section cases have presented a number of difficult issues for the law. The Court of Appeal has suggested the cases can be easily dealt with by referring to the supremacy of the principle of autonomy. However, it has been argued that the law does not generally accept autonomy as an absolute principle. Nor has the law developed sufficiently to enable the courts to make autonomy paramount. In particular, there is insufficient protection to ensure a patient receives all the information she needs for a decision, and the law has not yet sufficiently developed a way of dealing with a patient who has conflicting desires. It has been argued that the vision of pregnancy that autonomy portrays — namely the rights of autonomy trumping the interests of the foetus — is a vision of conflict which is at odds with most women’s experience of pregnancy. In the light of the enormous sacrifices in pregnancy and the mutual relationship between the woman and the foetus, the law has no basis for seeking to impose legal obligations on pregnant women. This leads us back to listening to the woman’s voice about how her relationship with the foetus should continue through birth. Under the present legal structure it is hard enough for the woman’s voice to be heard, yet alone decide what it is she is saying.Less

The Role of Community

Autumn Alcott Ridenour and Lisa Sowle Cahill

in Dying in the Twenty-First Century: Toward a New Ethical Framework for the Art of Dying Well

Autumn Ridenour and Lisa Cahill address the role of community in the articulation of a contemporary art of dying. They question whether conventional interpretations of patient autonomy best serve the ... More

Autumn Ridenour and Lisa Cahill address the role of community in the articulation of a contemporary art of dying. They question whether conventional interpretations of patient autonomy best serve the dying patient, and argue instead for Kant’s notion of relational autonomy, which, in their view, corrects overly individualistic conceptions of autonomy. They show how current bioethical and philosophical views of personhood both clash with and support their call for a relational autonomy, and they conclude with practical ways in which patients, their communities, and health care professionals can collaborate to promote improved care of the dying.Less

Respecting Patient Autonomy: From Non-Interference to Empathy

Jodi Halpern

in From Detached Concern to Empathy: Humanizing Medical Practice

This chapter discusses the moral implications of implementing empathy versus patient autonomy. Patients' rights have evolved to include, among other things, the right for the patient to refuse ... More

This chapter discusses the moral implications of implementing empathy versus patient autonomy. Patients' rights have evolved to include, among other things, the right for the patient to refuse treatment and the right for increased participation in the medical decision making. Detachment allows for the facilitation of these latter two actions, although the ethics therein come into question when detachment hinders the patient's wellbeing. Patients need emotional support and communication, especially when making difficult medical decisions. A doctor's emphatic presence by itself can present opportunities for healing. There are also times when patients exercise personal freedom in deciding that the doctor should make their decisions for them. All in all, patient autonomy can and should be respected, although it should not mean outright non-interference.Less

Medical Care

Elizabeth Price Foley

in Liberty for All: Reclaiming Individual Privacy in a New Era of Public Morality

One of the fundamental facets of residual individual sovereignty is bodily autonomy, or sovereignty over one's own body, which took root in cases that considered the imposition of unwanted medical ... More

One of the fundamental facets of residual individual sovereignty is bodily autonomy, or sovereignty over one's own body, which took root in cases that considered the imposition of unwanted medical treatment as criminal battery or homicide. This gave rise to a distinct negligence tort in which medical care is provided despite the absence of the patient's fully informed consent. The informed consent doctrine has recently focused more on patient autonomy than beneficence. The notion of patient autonomy to make informed medical decisions is related to the concomitant autonomy to refuse recommended medical treatment once so informed. This chapter examines law and governmental power in relation to medical care, informed consent, forbidden treatments, liberty to refuse treatment, physician-assisted suicide, and euthanasia.Less

The Manipulation of Medical Practice

Vivienne Harpwood

in Law and Medicine: Current Legal Issues Volume 3

Developments during the second half of the 20th century have introduced greater concern for the autonomy of the patient, and the most recent trends threaten to circumscribe the doctor’s traditional ... More

Developments during the second half of the 20th century have introduced greater concern for the autonomy of the patient, and the most recent trends threaten to circumscribe the doctor’s traditional and jealously-guarded freedom to practise with the minimum of external intervention. This chapter presents a broad overview of the ways in which medical practice is being manipulated by extraneous forces, with a view to controlling the level of clinical negligence litigation. It explores recent encroachments on traditional professional freedoms of individual doctors in the UK, pointing to a range of convergent and cumulative pressures for greater accountability and monitoring of medical practice and clinical judgement. Some of these pressures are the product of technological advances in terms of data collection and evaluation; others are the result of the open acknowledgement of financial limitations in the provision of healthcare, a growing climate of empowerment of consumers generally, and powerful media. These elements are examined in the course of the discussion, and likely future developments are considered in the light of the changed political and legal climates which promote intervention in what had for centuries been regarded as a private professional domain.Less

Nurse Education

Lorraine Dixon

in Education in Palliative Care: Building a Culture of Learning

Nurses represent a significant proportion of the health care workforce engaged in providing palliative care for patients with life-threatening illnesses and their families. As palliative care has ... More

Nurses represent a significant proportion of the health care workforce engaged in providing palliative care for patients with life-threatening illnesses and their families. As palliative care has developed and been acknowledged as a specialty, nurse education has been forced to be creative, resourceful, and proactive in providing nurse practitioners with the skills and knowledge that they require to support patients and their families when facing a life-threatening illness. This chapter outlines the trajectory of nurse education in the UK from pre-registration through to advanced nurse practitioners and describes current provision of palliative care education at pre- and post-registration levels. It also considers ways in which palliative nurse education is shaped by policy and explores current and future challenges facing practitioners and educators.Less

Bedside Rationing or Rational Planning: In Search of Perspective on Medical Benefit and Safety

Yechiel Michael Barilan

in Fair Resource Allocation and Rationing at the Bedside

To the extent that rationing involves forgoing of possible benefit, the way benefits are defined is crucial. The definition of benefit should be linked to concepts of flourishing. The chapter ... More

To the extent that rationing involves forgoing of possible benefit, the way benefits are defined is crucial. The definition of benefit should be linked to concepts of flourishing. The chapter explores whether the prerogative of determining what counts as benefit is the province of medical experts or whether defining beneficial health care in specific clinical circumstances is part of a patient’s right of autonomy. Some patients might demand extraordinarily aggressive and expensive care near the end of life, though most physicians and reasonable patients would see that as a net harm. From the perspective of health care justice—fair use of limited health care resources—it seems such patients are demanding something to which they have no just claim on the basis of a highly subjective sense of benefit. This chapter explores when personal judgment of benefit must be respected and when it may be overridden.Less

The Impact of Depression on Health Care Decisions: Autonomy, Capacity, and Competence

Rebecca Saracino, Melissa Masterson, and Barry Rosenfeld

in Depression: Law and Ethics

This chapter examines how depression affects health care decisions, with particular emphasis on patient autonomy, capacity, and competence for decision-making. It first considers the ethical ... More

This chapter examines how depression affects health care decisions, with particular emphasis on patient autonomy, capacity, and competence for decision-making. It first considers the ethical boundaries and psycho-legal criteria for assessing decision-making capacity in the context of medical treatment decisions, attending to issues of autonomy and beneficence as well as the debate over whether paternalistic approaches have a place in our health care system. It then discusses the parameters that help define the debate over paternalism, along with the clinical challenges that accompany the assessment and implementation of these alternative approaches to health care decision-making. The chapter also reviews research exploring the impact of depressive symptoms on decision-making capacity and treatment refusal more specifically. It cites the doctrine of informed consent, the goal of which is to promote patient autonomy and rational decision-making. The chapter concludes with recommendations for a comprehensive approach to decision-making capacity assessment and directions for future research.Less