Psychiatric practice is often faced with complex situations that seem to pose serious moral dilemmas for practitioners. Methods for solving these dilemmas have included the development of more objective rules to guide the practitioner such as utilitarianism and deontology. A more modern variant on this objective model has been 'Principlism' where 4 mid level rules are used to help solve these complex problems. In opposition to this, there has recently been a focus on more subjective criteria for resolving complex moral (...) dilemmas. In particular, virtue ethics has been posited as a more sensitive method for helping doctors to reason their way through difficult ethical issues. Here the focus is on the character traits of the practitioner. Bloch and Green advocated another way whereby more objective methods such as Principlism and virtue ethics are combined to produce what they considered sound moral reasoning in psychiatrists. This paper points out some difficulties with this approach and instead suggests that a better model of ethical judgment could be developed through the use of narratives or stories. This idea puts equal prima facie value on the patient's and the psychiatrist's version of the dilemma they are faced with. It has the potential to lead to a more genuine empathy and reflective decision-making. (shrink)

Introduction: The decision of “do not attempt resuscitation” in the event of cardiopulmonary arrest is usually made when the patients are critically ill and cannot make an informed choice. Although, various professional bodies have published guidelines, little is know about the patients’ own views regarding DNAR discussion.Aim: The aim of this study was to determine patients’ attitudes regarding discussing DNAR before they are critically ill.Methods: A prospective study was performed in a general out patients department. A questionnaire was distributed to (...) consecutive outpatients along with an explanatory leaflet in the adult outpatient clinic.Results: 364 patients completed the questionnaire . 90% of respondents wanted all patients to be asked regarding DNAR decision at some point during a hospital admission. The majority would not find a DNAR discussion distressing. Only 10% would find it upsetting, however, 48% of these still wanted a discussion. 37% of respondents wanted to discuss DNAR decisions on admission; 32% in outpatients; 17% at consent for surgery, 14% when they are critically ill. 87% of respondents would not object to their relatives being involved in making decisions about their resuscitation status. However, only 12% of the subjects in the study had been involved in discussing the resuscitation status of a relative and 21% would not be comfortable to discuss a relative’s resuscitation status. Although 33% of patients preferred their resuscitation status to simply be documented within their clinical notes, 77% wanted it to be more easily accessible.Conclusions: This study suggests that contrary to current practice most patients want to discuss their DNAR status prior to becoming critically ill. This includes half of the small number that find it distressing to discuss. Although most patients are comfortable with relatives being involved in discussing DNAR, a significant proportion do not want their relatives to be asked. Furthermore, once a decision has been made, the majority of patients want it to be more accessible than current practice allows. (shrink)

Introduction: The decision of “do not attempt resuscitation” in the event of cardiopulmonary arrest is usually made when the patients are critically ill and cannot make an informed choice. Although, various professional bodies have published guidelines, little is know about the patients’ own views regarding DNAR discussion.Aim: The aim of this study was to determine patients’ attitudes regarding discussing DNAR before they are critically ill.Methods: A prospective study was performed in a general out patients department. A questionnaire was distributed to (...) consecutive outpatients along with an explanatory leaflet in the adult outpatient clinic.Results: 364 patients completed the questionnaire . 90% of respondents wanted all patients to be asked regarding DNAR decision at some point during a hospital admission. The majority would not find a DNAR discussion distressing. Only 10% would find it upsetting, however, 48% of these still wanted a discussion. 37% of respondents wanted to discuss DNAR decisions on admission; 32% in outpatients; 17% at consent for surgery, 14% when they are critically ill. 87% of respondents would not object to their relatives being involved in making decisions about their resuscitation status. However, only 12% of the subjects in the study had been involved in discussing the resuscitation status of a relative and 21% would not be comfortable to discuss a relative’s resuscitation status. Although 33% of patients preferred their resuscitation status to simply be documented within their clinical notes, 77% wanted it to be more easily accessible.Conclusions: This study suggests that contrary to current practice most patients want to discuss their DNAR status prior to becoming critically ill. This includes half of the small number that find it distressing to discuss. Although most patients are comfortable with relatives being involved in discussing DNAR, a significant proportion do not want their relatives to be asked. Furthermore, once a decision has been made, the majority of patients want it to be more accessible than current practice allows. (shrink)

Objectives: To identify ethical attitudes about involuntary admission (known in Great Britain as formal admission) in mental health professionals and lay-people in England and Germany, especially looking at possible differences between Mental Health Professionals who are directly involved in the involuntary admission process and those who are not.Method: Three scenarios of potentially certifiable patients (known in Great Britain as sectionable patients) were presented to identify attitudes. A questionnaire asked about attitudes towards involuntary admission as well as treatment. A questionnaire analysis (...) was then performed.Results: There were similar attitudes towards involuntary admission between laypeople and mental health professionals involved in the involuntary admission process with the exception of professionals not actively involved in the involuntary admission process. Neither personal or professional experience with mental illness nor the different legal frameworks between Germany and England influenced attitudes much. Support for involuntary admission broadly increased with age.Conclusions: Psychiatrists and other mental health workers are in tune with society with regards to attitudes to involuntary admission. People involved with mentally ill patients but not in the involuntary admission process have negative attitudes towards involuntary admission. This may influence Mental Health Tribunals suggested in the new draft Mental Health Bill (2002) for England and Wales, because these Tribunals will potentially lack any involvement of professionals involved in the involuntary admission process. (shrink)

The Mental Health Act 2007 introduced Deprivation of Liberty safeguards into the Mental Capacity Act 2005 with potentially far reaching resource implications. There appears to be no scientific data regarding the prevalence of deprivation of liberty in clinical settings such as hospitals and nursing homes. We examined how many patients across a whole Trust area in Wales were subject to some lack of capacity, how well documented this was and how many were potentially deprived of their liberty. We found that (...) no patient was deprived of their liberty, but 8% lacked capacity to make either basic or complex decisions; another 5% lacked capacity to make complex decisions. Documentation was good in mental health and community directorates, but there were gaps in documentation (not practice) in the medical and surgical directorates. Routine collection of data improved documentation regarding deprivation of liberty criteria. There is a high likelihood that senior nursing staff underestimate the number of patients who lack capacity. (shrink)

This paper ethically analyses arising out the proposed changes to the Mental Health Act for England and Wales. It looks in particular at thea shift in philosophy that the author claims has occurred with the proposals away from rights-focused principles to more utilitarian or outcome-focused principles. It gives examples of these changes and explores itstheir consequences.