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Applied Ethics in Mental Health Care

Applied Ethics in Mental Health Care: An Interdisciplinary Reader

Dominic A. Sisti
Arthur L. Caplan
Hila Rimon-Greenspan
foreword by Paul S. Appelbaum
Series: Basic Bioethics
Copyright Date: 2013
Published by: MIT Press
Pages: 392
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  • Book Info
    Applied Ethics in Mental Health Care
    Book Description:

    This book discusses some of the most critical ethical issues in mental health care today, including the moral dimensions of addiction, patient autonomy and compulsory treatment, privacy and confidentiality, and the definition of mental illness itself. Although debates over these issues are ongoing, there are few comprehensive resources for addressing such dilemmas in the practice of psychology, psychiatry, social work, and other behavioral and mental health care professions. This book meets that need, providing foundational background for undergraduate, graduate, and professional courses.Topics include central questions such as evolving views of the morality and pathology of deviant behavior; patient competence and the decision to refuse treatment; recognizing and treating people who have suffered trauma; addiction as illness; the therapist's responsibility to report dangerousness despite patient confidentiality; and boundaries for the therapist's interaction with patients outside of therapy, whether in the form of tennis games, gift-giving, or social media contact. For the most part the selections address contemporary issues in contemporary terms, but the book also offers a few historic or classic essays, including Thomas S. Szasz's controversial 1971 article "The Ethics of Addiction." Contributors include Laura Weiss Roberts, Frederic G. Reamer, Charles P. O'Brien, and Thomas McLellan.

    eISBN: 978-0-262-31724-5
    Subjects: Health Sciences

Table of Contents

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  1. Front Matter
    (pp. i-iv)
  2. Table of Contents
    (pp. v-viii)
  3. Series Foreword
    (pp. ix-x)
    Arthur Caplan

    I am pleased to present the thirty-eighth book in the Basic Bioethics series. The series makes innovative works in bioethics available to a broad audience and introduces seminal scholarly manuscripts, state-of-the-art reference works, and textbooks. Topics engaged include the philosophy of medicine, advancing genetics and biotechnology, end-of-life care, health and social policy, and the empirical study of biomedical life. Interdisciplinary work is encouraged....

  4. Foreword
    (pp. xi-xvi)
    Paul S. Appelbaum

    For mental health professionals, there is no scarcity of ethical challenges. Some of the conundra that arise in everyday mental health work derive from the nature of the disorders and conditions that mental health professionals evaluate and treat. A second set of ethical issues originates in the treatments we use. Additional layers of moral complexity are contributed by the settings in which mental health professionals work. Taken together, it can safely be said that ethical challenges inhere in every aspect of mental health practice.

    Mental disorders themselves create a variety of dilemmas. Severe conditions such as schizophrenia or bipolar disorder,...

  5. Acknowledgments
    (pp. xvii-xviii)
  6. I Foundational Questions

    • [I Introduction]
      (pp. 1-4)

      Unlike other areas of medicine, psychiatry and the behavioral sciences involved in the diagnosis and treatment of mental illness are the subjects of great contention about the reality of what it is that they diagnose and treat. Practitioners do not always agree on how to draw the boundaries between illness and health. Nor do members of the general public agree with the determinations that those expert in mental health offer. Many core public policy questions hinge on how these foundational questions are answered from simple issues such as the number of persons who have a mental illness, which determines how...

    • 1 Contested Boundaries: Psychiatry, Disease, and Diagnosis
      (pp. 5-24)
      Charles E. Rosenberg

      Some years ago, theNew York Timesfront page reported the outcome of a much-discussed courtroom drama, the Andrew Goldstein murder trial. Previously diagnosed and treated—or more often not treated—as a chronic schizophrenic, Goldstein had killed a random young woman by pushing her in front of a subway train. Despite his unchallenged diagnosis, the jury convicted Goldstein of second-degree murder. “He seemed to know what he was doing,” one juror said after the trial. “He picked her up and threw her. That was not a psychotic jerk, an involuntary movement.” Another juror explained that they had thought the...

    • 2 Moot Questions in Psychiatric Ethics
      (pp. 25-34)
      Ralph B. Little and Edward A. Strecker

      Medicine is a science blessed with the magnificent heritage of many great men. Men such as Pasteur, Osler, and Harvey are known to laypeople as well as to doctors.

      Medicine is the concern of everyone. It is our opinion that of all the men who have contributed to medicine, no one has been more intimately reflected in its actual practice than Hippocrates.

      Hippocrates, who lived over 2,000 years ago, is considered the Father of Medicine. He initiated many fine principles, including the scientific method,¹ but none has surpassed his ethical values recorded in his well-known oath, which from its inception...

    • 3 The Ethics of Psychotherapy
      (pp. 35-58)
      Toksoz B. Karasu

      In 1978 Spiegel (1) suggested that we have evolved from an Age of Anxiety to an Age of Ethical Crises. Progressive loss of faith in traditional institutions and the erosion of authority are now being met with the increasing challenge of existing standards and widespread concern for safeguarding human values and rights. Today’s growing climate of antiestablishment, antiprofessional, and antirational sentiment has direct implications for the roles and responsibilities of the psychotherapist. Growing skepticism about the sanctity of science, medicine, and psychiatry means that these fields are no longer above rebuke or exempt from active moral review by their recipients,...

    • 4 Character Virtues in Psychiatric Practice
      (pp. 59-74)
      Jennifer Radden and John Z. Sadler

      The character-focused approach known asvirtue ethicsis especially well suited, we believe, for understanding and promoting ethical psychiatric practice. Virtues are the personal qualities, such as integrity, honesty, and compassion, that we attribute to character.1–3They are traits—stable dispositions and responses rather than more passing and temporary states. For this reason, they are often used in describing people. “She is a courageous person,” we say, or, “He is compassionate.” A virtue-based ethics, then, is one in which people’s selves or characters, rather than their actions or the consequences that flow from those actions, are at the center...

  7. II Capacity, Coercion, and Consent

    • [II Introduction]
      (pp. 75-78)

      One of the key tasks that mental health care professionals are asked to perform is to assess the capacity of persons to be autonomous. Do those in their care have the ability to make decisions about their health care, finances, and day-to-day decisions about accepting specific treatments?

      Competence is determined relative to one’s ability to perform a given set of tasks. To refuse or consent to treatment, a person must understand what she is refusing and the consequences of refusing. She must be mentally capable of making a rational decision that takes these understandings into account. The patient cannot be...

    • 5 Psychiatric Advance Directives and the Treatment of Committed Patients
      (pp. 79-84)
      Paul S. Appelbaum

      Advance directives have been one of the more promising innovations in recent years to give patients a greater voice in their psychiatric treatment (1). Completed when patients are competent, advance directives allow patients to appoint proxy decision makers and to make choices about particular treatments, all to take effect should patients later become incompetent to make decisions for themselves. Advance directives have been hailed as a way of encouraging patients and treaters to discuss future contingencies and to negotiate mutually acceptable approaches to care (2,3). All states have statutes that govern the use of advance directives, which can be applied...

    • 6 Denying Autonomy in Order to Create It: The Paradox of Forcing Treatment upon Addicts
      (pp. 85-90)
      Arthur L. Caplan

      American bioethics affords extraordinary respect to the values of personal autonomy and patient self-determination [1]. Many would argue that the most significant achievement deriving from bioethics in the past forty years has been to replace a paternalistic model of health provider-patient relationships with one that sees patient self-determination as the normative foundation for practice. This shift away from paternalism toward respect for self-determination has been ongoing in behavioral and mental health as well, especially as it is reflected in the “recovery movement” [2–4].

      As a result of the emphasis placed on patient autonomy, arguments in favor of mandatory treatment...

    • 7 End-Stage Anorexia: Criteria for Competence to Refuse Treatment
      (pp. 91-114)
      Margery Gans and Willam B. Gunn Jr.

      Anorexia nervosa is a complex disorder that primarily afflicts women. It can be fatal; the mortality rate is thought to be between 6 and 20 percent (Griffiths & Russell, 1998; Mitchell, Pomeroy, & Adson, 1997). A central symptom of anorexia nervosa is the patient’s conviction that, no matter how emaciated she becomes, she is “fat.” To be “fat” is to be “bad.” She therefore severely restricts her food intake, even to the point of starvation. Unless she is “thin,” her life is meaningless and she is worthless or bad (Orbach, 1986; Shelley, 1997). Even when a patient’s health deteriorates to the degree...

    • 8 “Personality Disorder” and Capacity to Make Treatment Decisions
      (pp. 115-122)
      George Szmukler

      Can patients with a personality disorder, by virtue of that condition alone, lack decision-making capacity? This question has been posed in discussions considering the practicability of an impaired capacity (or decision-making) criterion in mental health legislation1,2and recently in an interesting case report,³ in which a patient with a personality disorder was refusing treatment despite having a dangerously low hemoglobin level as a result of self-cutting. The problem arises most acutely when patients with a personality disorder present in crisis with threats of selfharm, especially suicide, or of harming others.

      In their case report, Winburn and Mullen consider the capacity...

  8. III Violence, Trauma, and Treatment

    • [III Introduction]
      (pp. 123-124)

      Sadly, violence is the new normal. The twenty-four-hour news cycle often includes coverage of the unremitting violence of mass shootings, child rape at the hands of men in authority, and inner-city gang violence. It is well known that violence and trauma are both a cause and an effect of mental illness. We must be careful not to oversimplify this connection. More often it is the mentally ill who are or have been the victims of violence; they are usually not the perpetrators as is so often depicted in the popular press and media. And as victims of violence, mentally ill...

    • 9 Sanctity of Human Life in War: Ethics and Post-traumatic Stress Disorder
      (pp. 125-134)
      James A. Beshai and Richard J. Tushup

      Perhaps only those willing to wrestle with human anguish and unanswered moral and ethical questions, raised by those who have been splattered by the blood of war and lived to tell of it, unequivocally accept the existential reality of combat-related post-traumatic stress disorder (PTSD). This medical disorder acquired identification first in the Civil War as a “soldier’s heart” and as “shell shock” in World War I. World War II and Korea gave us “combat fatigue.” There were attempts to dismiss this disorder as a disease related to combat situations as an artificial construct that is politically motivated (Foucault, 1970, 1975)....

    • 10 The Experience of Violent Injury for Young African American Men: The Meaning of Being a “Sucker”
      (pp. 135-148)
      John A. Rich and David A. Stone

      The problem of interpersonal violence continues to grow in the United States. Every day in the United States, on average, sixty-five people die from, and six thousand people are physically injured by, interpersonal violence.¹ Homicide is the leading cause of death for African Americans fifteen to thirty-four years old and the third leading cause of death for all persons fifteen to twenty-four years old. In 1989, the lifetime probability of an African American male being murdered was 1 in 27, while for a white male it was 1 in 205.² Homicide rates, however, are only a small part of this...

    • 11 The Psychological Impact of Rape Victims’ Experiences with the Legal, Medical, and Mental Health Systems
      (pp. 149-178)
      Rebecca Campbell

      Sexual violence is a pervasive social problem: National epidemiological data indicate that 17 percent to 25 percent of women are raped in their adult lifetimes (Fisher, Cullen, & Turner, 2000; Koss, Gidycz, & Wisniewski, 1987; Tjaden & Thoennes, 1998). Rape is one of the most severe of all traumas, causing multiple, long-term negative outcomes, such as post-traumatic stress disorder (PTSD), depression, substance abuse, suicidality, repeated sexual victimization, and chronic physical health problems (Kilpatrick & Acierno, 2003; Koss, Bailey, Yuan, Herrera, & Lichter, 2003).¹ Rape victims have extensive postassault needs and may turn to multiple social systems for assistance. Approximately 26 percent to 40 percent of...

  9. IV Addiction

    • [IV Introduction]
      (pp. 179-180)

      The following four contributions on addiction wrestle with one of the toughest challenges those in mental health care face. Addiction is not only devastating for those in its grasp, but addiction to alcohol and drugs also exacts a staggering toll on families, friends, coworkers, and societies. The costs of addiction extend to the crime associated with some addictive behavior; attempts to prevent access to addictive substances such as heroin, cocaine, or prescription pain medications; and the cost of dealing with the physical and mental toll that addiction takes.

      Craig Reinerman begins by reminding us that the addiction model is a...

    • 12 Addiction as Accomplishment: The Discursive Construction of Disease
      (pp. 181-200)
      Craig Reinarman

      In the United States and many other Western industrialized societies at the start of the twenty-first century, “addiction” is said to be a “disease.” Virtually everyone in the treatment industry embraces the notion that “addiction” is a “disease,” as do nearly all people who understand themselves to be “in recovery” from it. Officials of the U.S. National Institute of Drug Abuse have adopted the claim that “addiction is a brain disease” as a kind of mantra (e.g., Enos, 2004; Leshner, 1997, 2001; Volkow, 2003). Even the drug policy reform movement, which advocates decriminalization of drugs, invokes the disease concept of...

    • 13 The Ethics of Addiction
      (pp. 201-210)
      Thomas S. Szasz

      Much of my work during the past fifteen years has been devoted to showing that for the most part, psychiatric problems are not medical but moral problems (1–3). Almost nowhere is this now more obvious than in the case of addiction, yet almost nowhere is the moral perspective now more vehemently rejected and the medical perspective more ardently embraced.

      Lest we take for granted that we know what “drug addiction” or “drug abuse” is, let me begin with a definition of it.

      Webster’s Third New International Dictionary(unabridged) defines addiction as “the compulsory uncontrolled use of habit-forming drugs beyond...

    • 14 Myths about the Treatment of Addiction
      (pp. 211-222)
      Charles P. O’Brien and A. Thomas McLellan

      Although addictions are chronic disorders, there is a tendency for most physicians and for the general public to perceive them as being acute conditions such as a broken leg or pneumococcal pneumonia. In this context, the acute-care procedure of detoxification has been thought of as appropriate “treatment.” When the patient relapses, as most do sooner or later, the treatment is regarded as a failure. However, contrary to commonly held beliefs, addiction does not end when the drug is removed from the body (detoxification) or when the acute post-drug-taking illness dissipates (withdrawal). Rather, the underlying addictive disorder persists, and this persistence...

    • 15 Ethical Considerations in Caring for People Living with Addictions
      (pp. 223-228)
      Laura Weiss Roberts and Kim Bullock

      The care of people living with addiction is ethically complex work. Addiction is stigmatized in our society (1,2), and clinical services for addiction-related conditions are underdeveloped, raising many ethical issues related to respect, confidentiality, and justice. Addictions of all kinds are associated, by definition, with a lack of personal control over the addictive behavior and are often linked with intermittent or enduring cognitive deficits, creating concerns about affected individuals’ capacities for autonomy and shared decision-making with caregivers (3–6). Some addictions are associated with risky and/or illegal activities, introducing very difficult considerations related to dangerousness, self-neglect, or self-injury and potential...

  10. V Mental Illness and the Courts

    • [V Introduction]
      (pp. 229-232)

      This part offers a sampling of articles that highlight ethical questions emerging at the intersection of law and mental health care. The first three articles coalesce around conflicts that mental health care practitioners face, and the fourth illustrates how legal systems may in fact reinforce bias against mentally ill persons. We turn to the paradigmatic case ofTarasoff v. Regents of the University of California, in which a young man murdered Tatiana Tarasoff, completing a plan he had described to his therapist.

      The invocation ofTarasoffhas become somewhat of an ethical clarion for the so-called duty to warn. Across...

    • 16 Confidentiality and the Prediction of Dangerousness in Psychiatry
      (pp. 233-236)
      William J. Curran

      The California Supreme Court continues to make financial awards to patients in suits against physicians with seemingly little regard for the effect of these awards and decisions upon the practice of medicine and the availability of insurance to cover this largesse of the judiciary, and without regard for the social consequences of this “money-for-everything” attitude.

      The particular case,Tarasoff v. Regents of the University of Californiahas already become infamous among mental health programs in California and among college and university student medical programs all over the country as it has taken its course through the various levels of trial...

    • 17 Madness versus Badness: The Ethical Tension between the Recovery Movement and Forensic Psychiatry
      (pp. 237-254)
      Claire L. Pouncey and Jonathan M. Lukens

      With its consistent message that persons with severe mental illness can and should be responsible for their own life choices, the recovery movement in the United States has made progress in overcoming the stigma of mental illness, advancing the civil rights of persons with severe mental illness, and providing better and more accessible treatment for mental illness. However, in deliberately emphasizing the capabilities of persons with mental illness for self-determination, recovery advocates leave unaddressed important questions about how, when, and to what extent mental illness can limit a person’s capacity to make sound choices, or even her moral accountability. Although...

    • 18 Ethical Considerations of Multiple Roles in Forensic Services
      (pp. 255-266)
      Robert Henley Woody

      Over the past few decades, the practice of forensic psychology has ad vanced rapidly along an ambiguous pathway (Otto & Heilbrun, 2002): “The purview of forensic psychology continues to expand, demonstrating the breadth and differentiating scope of practice in this specialty field” (Craig, 2005, p. 3). Being in a “professional” specialty necessitates that a code of ethics provide a framework for provision of services to consumers (Brint, 1994). Alignment with behavioral science opens the door for mental health practitioners of every ilk to enter into the courtroom to provide forensic services (Daubert v.Merrell Dow Pharmaceuticals,Inc.,1993).

      The recent vicissitudes...

    • 19 Watch Your Language: A Review of the Use of Stigmatizing Language by Canadian Judges
      (pp. 267-282)
      Michelle Black and Jocelyn Downie

      It might be expected that with more knowledge about the causes and consequences of psychological disorders, we would see a reduction in stigmatizing behaviors toward those who have mental illness. However, according to a U.S. Surgeon General’s Report and other, more recent research, there is actually even more stigma now than there was forty years ago.² The history of mental illness can be captured by Kale’s description of the history of epilepsy: “4000 years of ignorance, superstition, and stigma followed by 100 years of knowledge, superstition, and stigma.”³ This is troubling because stigmatization may lead to a person being stereotyped...

  11. VI Therapeutic Boundaries

    • [VI Introduction]
      (pp. 283-286)

      The proper bounds of the therapeutic relationship have long been the subject of ethical inquiry. InThe Oath, Hippocrates identifies and proscribes certain boundary breaches:

      Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further from the seduction of females or males, of freemen and slaves.

      From graft to sex, Hippocrates recognizes the range of potential boundary issues. Indeed, volumes have been produced pertaining to the ethics of sexual boundary violations in both medicine generally and mental health care specifically. In...

    • 20 Boundary Violation Ethics: Some Conceptual Clarifications
      (pp. 287-302)
      Jennifer Radden

      Boundary-violation discourse may be said to be thelingua francaof psychiatric and other psychotherapeutic ethics today. Informal discussions about unacceptable behavior are rarely characterized in any but these terms. Although this language is perhaps overused, psychotherapeutic practice places more stringent restrictions on boundary transgressions than are found in other areas of medical practice.

      Boundary-violation discourse is integral to forensic psychiatry, in which boundary-violating behavior is evaluated as impermissible or in other ways legally actionable. Here, behavior judged to be boundary-violating leads to professional censure. It also gives rise to malpractice charges because of its damaging effects, such as suicide...

    • 21 The Price of a Gift: An Approach to Receiving Gifts from Patients in Psychiatric Practice
      (pp. 303-320)
      David H. Brendel, James Chu, Jennifer Radden, Howard Leeper, Harrison G. Pope, Jacqueline Samson, Gail Tsimprea and J. Alexander Bodkin

      No professional relationship is more complex than the one between a patient and a psychiatrist (psychiatristhere is used as a proxy formental health clinician). This relationship is defined in large measure by the respective roles that they both play in their multifaceted interactions. Patients come for help with the hope and expectation that they will be treated with respect, compassion, and competence. Psychiatrists, meanwhile, expect that patients will strive to tell the truth about their conditions, adhere to treatment recommendations, and pay their bills. Treatment relationships in psychiatry conform, for the most part, to the typical conventions of...

    • 22 How Certain Boundaries and Ethics Diminish Therapeutic Effectiveness
      (pp. 321-328)
      Arnold A. Lazarus

      Civilized interactions depend heavily on recognizing and respecting boundaries. To violate a boundary, whether of an entire nation or one individual, is to usurp someone’s legitimate territory and invade his or her privacy by disregarding tacit or explicit limits. In quality relationships, people honor one another’s rights and sensibilities and are careful not to intrude into the other’s psychological space. It is therefore not surprising that the literature on psychotherapy continues to dwell on this important issue from many different perspectives.

      Ethicalconsiderations are closely related to matters of personal and interpersonal boundaries. The recently revised ethical principles of psychologists...

    • 23 Boundary Issues in Social Work: Managing Dual Relationships
      (pp. 329-350)
      Frederic G. Reamer

      Particularly since the early 1980s, social workers have developed an increasingly mature grasp of ethical issues. During the past two decades, social work’s literature has expanded markedly with respect to identifying ethical conflicts and dilemmas in practice, developing conceptual frameworks and protocols for ethical decision making when professional duties conflict, and formulating risk management strategies to prevent ethics-related negligence and ethical misconduct (Berliner, 1989; Besharov, 1985; Levy, 1993; Linzer, 1999; Loewenberg & Dolgoff, 1996; Reamer, 1982, 1990, 1994, 1995a, 1998b, 1999; Rhodes, 1986).

      As the social work literature clearly demonstrates, ethical issues related to professional boundaries are among the most problematic...

    • 24 Patient-Targeted Googling: The Ethics of Searching Online for Patient Information
      (pp. 351-370)
      Brian K. Clinton, Benjamin C. Silverman and David H. Brendel

      The Internet has changed the way that medicine and psychiatry are practiced, as patients and physicians now routinely search online for medical and personal information. In the literature, physicians have considered the pros and cons of online searches for information regarding diagnosis, treatment, and research.1–7Recently, others have considered the complexities of patients’ searching online for information, both professional or personal, about physicians.8–10Little consideration has been given, however, to the converse situation—namely, to physicians’ searching online for information about patients. We believe that this practice—which we callpatient-targeted Googling(PTG)—is widespread and deserving of...

    • 25 Professional Boundaries in the Era of the Internet
      (pp. 371-384)
      Glen O. Gabbard, Kristin A. Kassaw and Gonzalo Perez-Garcia

      In a previous communication (1), we identified the emerging clinical and ethical problems in the era of electronic communication. We now turn to the novel ethical and clinical dilemmas involved in defining professional boundaries in light of the expanded dimensions of the Internet. Over the past decade, the capacity to search for information quickly and accurately has grown through search engines such as Google, Yahoo, and Bing. Also, individuals have greater ability to share personal information through blogs and social networking sites such as Facebook and MySpace. The availability of personal and professional details to be had with a click...

  12. Contributors
    (pp. 385-388)
  13. Permissions and Credits
    (pp. 389-392)
  14. Index
    (pp. 393-400)
  15. Series List
    (pp. 401-402)