Advocates of physician-assisted suicide often argue that, although the provision of PAS is morally permissible for persons with terminal, somatic illnesses, it is impermissible for patients suffering from psychiatric conditions. This claim is justified on the basis that psychiatric illnesses have certain morally relevant characteristics and/or implications that distinguish them from their somatic counterparts. In this paper, I address three arguments of this sort. First, that psychiatric conditions compromise a person’s decision-making capacity. Second, that we cannot (...) have sufficient certainty that a person’s psychiatric condition is untreatable. Third, that the institutionalisation of PAS for mental illnesses presents morally unacceptable risks. I argue that, if we accept that PAS is permissible for patients with somatic conditions, then none of these three arguments are strong enough to demonstrate that the exclusion of psychiatric patients from access to PAS is justifiable. (shrink)

Informed consent is reviewed as it applies to psychiatric patients. Although new legislation, such as the Mental Health Act 1983, provides a useful safeguard for the protection of the civil rights of patients, it could actually reduce their humane care unless applied with sensitivity for the nature of their unique difficulties. In order to guard against this possibility, we suggest that legal requirements should be considered in light of the ethical principles which underlie them. Three principles are (...) considered: those of autonomy (freedom); beneficence (paternalism); and the fiduciary principle (partnership). Psychotherapy is offered as a model for informed consent, which might be generalised to other clinical situations. (shrink)

In this paper some of the general issues surrounding recently published guidelines for the practice of research ethics committees are outlined, concentrating in particular on the difficulties raised by research with psychiatric patients. Research is distinguished from ordinary clinical practice by the intention to advance knowledge. So defined, research with psychiatric patients should be governed by the same four principles as research with any other group--knowledge, necessity, benefit and consent. In applying these principles, however, particularly the (...) principle of consent, many acute difficulties are raised by psychiatric patients. A number of proposals for addressing these difficulties are discussed. It is suggested that, notwithstanding the value of published guidelines, and the help that may be available from research ethics committees, the primary responsibility for maintaining high standards of practice in research rests with research workers themselves. (shrink)

The AIDS epidemic calls for an ethical analysis of conflicting obligations surrounding HIV-infected psychiatric patients and confidentiality, as well as issues that go beyond confidentiality. Although laws pertaining to HIV infection have been enacted in a number of states, these statutes leave much discretion to health professionals. The ethical principle known as "the harm principle" can permit disclosure of confidential information and detention or isolation of psychiatric patients who pose a threat of infecting other patients. (...) From an ethical point of view, however, the circumstances under which traditional protections may be weakened or abandoned remain limited. (shrink)

Advances in neurobiological knowledge and neuroimaging technology have contributed greatly to our investigations into the nature of self-awareness.

This article presents the findings of an empirical research project on how psychiatrists in a secular country (Denmark) approach the religious patients, and how the individual worldview of the psychiatrist influences this approach. The study is based on 22 interviews with certified psychiatrists or physicians in psychiatric residency. The article presents the theoretical and methodical grounding and introduces the analytical construct “subalternalizing,” derived from subaltern studies. “Subalternalizing” designates a process where a trait in one worldview (patient) is marginalized (...) as a consequence of another worldview’s (psychiatrist) “disinterest.” The analysis located four categories: (a) religion as a negative part of the patient story, (b) religion as a positive part of the patient story, (c) religion in relation to radicalization, and (d) there are no religious patients. The discussion shows that the approach is influenced by the psychiatrist worldview. Examples of “subalternalizing” are given and how this excludes “positive religious coping” and “existential and spiritual care” from treatment. (shrink)

Some jurisdictions that have decriminalized assisted dying exclude psychiatric patients on the grounds that their condition cannot be determined to be irremediable, that they are vulnerable and in need of protection, or that they cannot be determined to be competent. We review each of these claims and find that none have been sufficiently well-supported to justify the differential treatment psychiatric patients experience with respect to assisted dying. We find bans on psychiatric patients’ access to (...) this service amount to arbitrary discrimination. Proponents of banning the practice ignore or overlook alternatives to their proposal, like an assisted dying regime with additional safeguards. Some authors have further criticized assisted dying for psychiatric patients by highlighting allegedly problematic practices in those countries which allow it. We address recent evidence from the Netherlands, showing that these problems are either misrepresented or have straightforward solutions. Even if one finds such evidence troubling despite our analysis, other jurisdictions need not adopt every feature of the Dutch system. (shrink)

In their insightful article, Brent Kious and Margaret Battin (2019) correctly identify an inconsistency between an involuntary psychiatric commitment for suicide prevention and physician aid in dying (PAD). They declare that it may be possible to resolve the problem by articulating “objective standards for evaluating the severity of others’ suffering,” but ultimately they admit that this task is beyond the scope of their article since the solution depends on “a deep and difficult” question about comparing the worseness of two (...) possible scenarios: letting someone die (who could have been helped) with not letting someone die (whose suffering could only be alleviated by death). In our commentary, we argue that creating such standards is more difficult than the authors assume because of the many types of deep uncertainties we have to deal with: (1) diagnostic, (2) motivational, and (3) existential. (shrink)

Some jurisdictions that have decriminalized assisted dying exclude psychiatric patients on the grounds that their condition cannot be determined to be irremediable, that they are vulnerable and in need of protection, or that they cannot be determined to be competent. We review each of these claims and find that none have been sufficiently well-supported to justify the differential treatment psychiatric patients experience with respect to assisted dying. We find bans on psychiatric patients’ access to (...) this service amount to arbitrary discrimination. Proponents of banning the practice ignore or overlook alternatives to their proposal, like an assisted dying regime with additional safeguards. Some authors have further criticized assisted dying for psychiatric patients by highlighting allegedly problematic practices in those countries which allow it. We address recent evidence from the Netherlands, showing that these problems are either misrepresented or have straightforward solutions. Even if one finds such evidence troubling despite our analysis, other jurisdictions need not adopt every feature of the Dutch system. (shrink)

This article investigates “impaired insight,” a controversial psychiatric category describing a mad person unable to know his or her madness. Like “moral insanity” and other concepts before it, impaired insight offers a way to link the disparate logics of human responsibility in psychiatry and the law. I attribute its development to changes wrought by deinstitutionalization, the rise of antipsychotic medication, and patient incarceration in penal settings. In a system that aims to govern psychiatric patients through their freedom, (...) the logic of impaired insight introduces a wrinkle: can a person make an informed choice to refuse treatment if madness itself impairs awareness of illness? Drawing on tools from the sociology of science, I trace the process by which researchers recast psychodynamic “denial” as a neurological and therefore non-volitional “impairment” in the 1990s. I then show how social movement actors mobilized the materialized form in the legal and policy fields in the 2000s, bringing insight science to bear upon the very questions of custodial management and patient rights that gave birth to it. At stake is this dilemma: how can societies that simultaneously privilege individual responsibility and somatic accounts of behavior govern those at the border of legal capacity, and with what justification? (shrink)

This article looks at the relevance of the concept of self-determination to psychiatric patients by studying the existence, importance and manifestations of self-determination. The data were collected by interviewing long-term patients (n = 72) in one mental health care organization, which included a psychiatric hospital and an outpatient department. Self-determination was defined in terms of the right to decision-making, the right to information, the right of consent, the right to refuse treatment, and the right to be (...) heard and taken into account. It was found that, with the exception of the right to refuse and consent, these rights are indeed present in the practice of psychiatric nursing and that they are relevant and important to psychiatric patients. The patients typically gave ethical, practical and legal reasons for a psychiatric patient's right to self-determination. The main reasons why psychiatric patients said they lacked the right to self-determination were illness and staff authority. Recommendations for educational, clinical and methodological implications for the future in nursing are discussed. (shrink)

Several authors have recently suggested that the suffering caused by mental illness could provide moral grounds for physician-assisted dying. Yet they typically require that psychiatric-assisted dying could come to question in the cases of autonomous, or rational, psychiatric patients only. Given that also non-autonomous psychiatric patients can sometimes suffer unbearably, this limitation appears questionable. In this article, I maintain that restricting psychiatric-assisted dying to autonomous, or rational, psychiatric patients would not be compatible (...) with endorsing certain end-of-life practices commonly accepted in current medical ethics and law, practices often referred to as ‘passive euthanasia’. (shrink)

Objective: To investigate the prevalence of and risk factors associated with mental health symptoms in psychiatric outpatients and their family members in China during the COVID-19 pandemic.Methods: This cross-sectional, survey-based, region-stratified study collected demographic data and mental health measurements for depression, anxiety and acute stress from 269 psychiatric patients and 231 family members in the Second Xiangya Hospital in China from April 27, 2020 to May 8, 2020. Binary logistic regression analysis was performed to identify risk factors (...) associated with mental health outcomes.Result: The results of this survey revealed that symptoms of depression, anxiety, and acute stress were highly prevalent symptoms in the psychiatric patient group. Respondents who were female, unmarried or highly educated were significantly more likely to have the above symptoms. In the family member group, more than half of them felt that the burden of nursing had increased during the epidemic. Subjects with a high degree of burden of care were significantly more likely to exhibit the above mental health symptoms, while females were significantly more likely to have acute stress.Conclusions: The results of this survey revealed a high prevalence of mental health disorder symptoms among psychiatric patients and an increased burden of nursing among their family members after the COVID-19 outbreak in China. Understanding the risk factors in those particular groups of people help improve the public health service system for mental health problems during public health events. For further study, exploration of the needs of mental health services and dynamic change tracking will be needed. (shrink)

This essay argues that the Chinese Mental Health Act of 2013 is overly individualistic and fails to give proper moral weight to the role of Chinese families in directing the process of decision-making for hospitalizing and treating the mentally ill patients. We present three types of reactions within the medical community to the Act, each illustrated with a case and discussion. In the first two types of cases, we argue that these reactions are problematic either because they comply with (...) the law but undermine the patient’s interests by refusing the family’s request to have the patient hospitalized, or violate the law by hospitalizing patients in response to the real concerns of their families. In the third type of situation, psychiatrists inappropriately encourage families to produce evidence of the patient’s behavior that is harmful to self or others in order legally to commit the patient. Each of these problems, we conclude, should be tackled by supplementing Article 30 of the Act with the stipulation that a psychiatrist may authorize the involuntary hospitalization of a patient, who is not at risk of causing physical harm to self or others, with the consent of all major family members. Drawing on the deeply culturally embedded moral traditions of Confucian medical familism, this proposal would facilitate the proper treatment of a significant number of Chinese mentally ill patients under the care of their families. (shrink)

Limitations on reproductive decision making, including forced sterilization and involuntary birth control, raise significant ethical challenges. In the United States, these issues are further complicated by a disturbing history of the abuse and victimization of vulnerable populations. One particularly fraught challenge is the risk of teratogenicity posed by moodstabilizing psychiatric medications in patients who are incapable of appreciating such dangers. Long-acting reversible contraception (LARC) offers an intervention to prevent pregnancy among individuals who receive such treatments, but at a (...) cost to their reproductive autonomy. This article examines the ethical issues involved in the use of involuntary LARC for patients on teratogenic psychiatric medications (TPMs) and argues that such an approach can only be justified as a last resort after a careful consideration of the alternatives and an assessment of potential risks and benefits. (shrink)

Volume 19, Issue 10, October 2019, Page 1-2.

This article delves into a problem that is still seldom addressed by historians—namely, the use of medical records testifying to the implementation of a psychoanalytically inspired treatment within a psychiatric institution for historical research. Based on publications, a broad spectrum of medical patient records, and interviews with former practitioners, it more broadly addresses issues related to the attention to patients’ voices at the University Psychiatric Clinic of Strasbourg, a central institution of psychiatric care in Northeastern France (...) that was once considered a bastion of French Freudianism. Eventually, it contends with the fundamentally elusive nature of medical patient records when it comes to talking cures, highlighting the challenges and limitations inherent in the historical exploitation of this type of source. (shrink)

How patients and nurses experience the acute care psychiatric environment The concept of the therapeutic milieu was developed when patients’ hospitalizations were long, medications were few, and one‐to‐one nurse–patient interactions were the norm. However, it is not clear how the notion of ‘therapeutic milieu’ is experienced in American acute psychiatric environments today. This phenomenological study explored the experience of patients and nurses in an acute care psychiatric unit in the USA, by asking them, ‘What (...) stands out to you about this psychiatric hospital environment?’ Three figural themes emerged, contextualized by time, which was a source of stress to both groups: for patients there was boredom, and for nurses, pressure and chaos. Although they shared some themes, nurses and patients experienced them differently. For instance, nurses felt caged‐in by the Plexiglas‐enclosed nursing station, and patients felt caged‐in by the locked doors of the unit. The findings from this US study do not support the existence of the therapeutic milieu as described in the literature. Furthermore, although the nurse–patient relationship was yearned for by nurses, it was nearly absent from patients’ descriptions. The caring experienced by patients was mainly derived from interactions with other patients. (shrink)

Background: Advocacy is an important role of psychiatric nurses because their patients are ethically, socially, and legally vulnerable. This study of Japanese expert psychiatric nurses’ judgments of interventions for patient advocacy will show effective strategies for ethical nursing practice and their relationship with Japanese culture. Objectives: This article explores Japanese psychiatric nurses’ decision to intervene as a patient advocate and examine their ethical, cultural, and social implications. Research design: Using semi-structured interviews verbatim, themes of the problems (...) that required interventions were inductively summarized by a qualitative analysis and their contexts and nursing judgments were examined. Participants and research context: The participants were 21 nurses with 5 or more years of experience in psychiatric nursing. Ethical considerations: The research was approved by Institutional Review Board of research site and study facilities. The participants gave written informed consent. Findings: Analysis of 45 cases showed that nurses decided to intervene when surrounding people’s opinions impeded patients’ safety, healthcare professionals’ policies impeded patients’ decision-making, own violent behaviors impeded treatment and welfare services for patients, own or families’ low acceptance of illness impeded patients’ self-actualization, inappropriate treatment or care impeded patients’ liberty, and their families abused patients’ property. Discussion: To solve conflicts between patients and their surrounding people, the nurses sought reconciliation between them, which is in accordance with Japanese cultural norms respecting harmony. When necessary, however, they protected patients’ rights against cultural norms. Therefore, their judgments cannot be explained by cultural norms alone. Conclusion: The findings indicate that the nurses’ judgments were based on respect for patients’ rights apart from cultural norms, and they first sought solutions fitting the cultural norms before other solutions. This seems to be an ethical, effective strategy if advocates know the culture in depth. (shrink)

In August 2001, the Israeli Ministry of Health issued its Limitation of Smoking in Public Places Order, categorically forbidding smoking in hospitals. This forced the mental health system to cope with the issue of smoking inside psychiatric hospitals. The main problem was smoking by compulsorily hospitalized psychiatric patients in closed wards. An attempt by a psychiatric hospital to implement the tobacco smoking restraint instruction by banning the sale of cigarettes inside the hospital led to the development (...) of a black market and cases of patient exploitation in return for cigarettes. This article surveys the literature dealing with smoking among psychiatric patients, the role of smoking in patients and the moral dilemmas of taking steps to prevent smoking in psychiatric hospitals. It addresses the need for public discussion on professional caregivers’ dilemmas between their commitment to uphold the law and their duty to act as advocates for their patients’ rights and welfare. (shrink)

Patients with mental illness, and depression in particular, present clinicians and surrogate decision-makers with complex ethical dilemmas when they refuse life-sustaining non-psychiatric treatment. When treatment rejection is at variance with the beliefs and preferences that could be expected based on their premorbid or “authentic” self, their capacity to make these decisions may be called into question. If capacity cannot be demonstrated, medical decisions fall to surrogates who are usually advised to decide based on a substituted judgment standard or, (...) when that is not possible, best interest. We propose that in cases where the patient meets the widely accepted cognitive criteria for capacity but is making decisions that appear inauthentic, the surrogate may best uphold patient autonomy by following a “restorative representation” model. We see restorative representation as a subset of substituted judgement in which the decision-maker retains responsibility for deciding as the patient would have, but discerns the decision their “truest self” would make, rather than inferring their current wishes, which are directly influenced by illness. Here we present a case in which the patient’s treatment refusal and previously undiagnosed depression led to difficulty determining the patient’s authentic wishes and placed a distressing burden on the surrogate decision-maker. We use this case to examine how clinicians and ethicists might better advise surrogates who find themselves making these clinically and emotionally challenging decisions. (shrink)

Deprivation of liberty in psychiatric hospitals is common world-wide. The aim of this study was to find out whether patients had experienced deprivation of their liberty during psychiatric hospitalization and to explore their views about it. Patients (n = 51) in two acute psychiatric inpatient wards were interviewed in 2001. They were asked to describe in their own words their experiences of being deprived of their liberty. The data were analysed by inductive content analysis. The (...) types of deprivation of liberty in psychiatric hospital care reported by these patients were: restrictions on leaving the ward and on communication, confiscation of property, and various coercive measures. The patients' experiences of being deprived of their liberty were negative, although some saw the rationale for using these interventions, considering them as part of hospital care. (shrink)

Background Maintaining the dignity of patients who attempted suicide is one of the caregivers’ main ethical duties. Yet, in many cases, these patients are not treated with dignity. The concept of dignity is abstract, and there is no research on the dignity of suicidal patients. So, the present study is done to investigate psychiatric nurses’ perception of dignity in patients who attempted suicide. Objective The present study explores the concept of dignity in patients who (...) attempted suicide from the perspective of psychiatric nurses. Research design The present study is a qualitative, descriptive work of research Participants and research context A total of 20 psychiatric nurses from 2 hospitals affiliated with a university of medical sciences in the southeast of Iran were selected via purposeful sampling. Ethical considerations The Research Ethics Committee of the Hamadan University of Medical Sciences approved the study’s protocol, and ethical principles were followed in general. Findings From the findings of the study, three main themes, namely “ respect for personal; identity,” “management of psychological tension,” and “compassion-focused therapy,” with 12 sub-themes were extracted. Discussion and conclusion In the perspective of caregivers, patients who attempted suicide need to be cared for in supportive environments with compassionate and respectful behaviors to control their psychological tensions. These conditions would maintain such patients’ dignity and result in appropriate behavioral outcomes. Policy-makers and administrators can use the present study’s findings to create an appropriate clinical environment in which the dignity of patients who attempted suicide is properly maintained. (shrink)

Volume 20, Issue 6, June 2020, Page 82-84.

Adherence to ethical principles in clinical research and practice is becoming topical issue in China, where the prevalence of mental illness is rising, but treatment facilities remain underdeveloped. This paper reports on a study aiming to understand the ethical knowledge and attitudes of Chinese mental health professionals in relation to the process of diagnosis and treatment, informed consent, and privacy protection in clinical trials.