Joshua Galyon
The primary ethical principles in healthcare include respect for autonomy, confidentiality, and justice. However, like every field, mental healthcare has many unique complexities. Due to the nature of many mental health conditions, psychiatric care, unlike general medical care, may demand coercive measures to alleviate a patient’s suffering.
A study by BMC Nursing, where twelve experienced psychiatric mental health nurses were interviewed, revealed a duality in the matter. The study found that it was clear that there is a high level of ethical awareness among the clinical staff, but there is still much more that could be implemented to counter the rising obstacles.
Ethics in a mental healthcare environment are arguably more complex than in other healthcare spaces. because patient autonomy is at stake. This article will go in-depth into the ethical considerations in mental healthcare:
Confidentiality
Confidentiality in mental healthcare dictates that professionals should not share anything you tell them. This vital element of the code of ethics was created with the understanding that a lot of private information is shared during psychiatric sessions, and the patient needs to feel safe and comfortable enough to reveal this kind of information. They should not have concerns about the information leaving the room. Mental healthcare staff are mandated to accord patient privacy by keeping their names, contact details, and details of medication, treatments, and care plans private.
Do minors have a right to confidentiality?
Much consideration is required regarding the duty of confidentiality to children and young people. In this case, confidentiality is the key to trust that minors must have to open up to their doctors. However, the laws regarding the confidentiality of children may vary. While confidentiality should be treated as a human right, complexities between the healthcare system and the law creates challenges regarding the inaccessibility of confidential care for adolescent patients in the United States.
Nevertheless, HIPAA grants parents access to their children’s medical records unless they:
- agree to a confidential relationship between the medical practitioner and the minor,
- the minor gets into care at the direction of a court of law, or
- the applicable law does not require the minor’s consent or care and an adult’s consent.
It is worth noting that various states have different consent laws, usually enacted based on the status of the minor, including their maturity and any emancipated children laws. Consent guidelines for mental health care, like substance abuse, depend on various factors, including the patient’s age, clinical competence, and whether or not they are victims of child abuse or incest. The scope for mental healthcare decisions is vast, given the long list of each state’s legal provisions.
When is disclosure without consent allowed?
A comprehensive justification must back any decision concerning disclosure without consent. It gets even more complicated when the minor refuses disclosure; thus, the conflict arises between the patient’s right to autonomy and confidentiality.
Sometimes disclosure of the information is necessary to ensure the minor’s safety; however, it is advisable to keep a detailed record of decisions and reasons. Disclosure without consent is allowed when:
- the disclosure is for the subject’s best interest, or they do not have the understanding or maturity to decide on disclosure,
- private information or disclosure is ordered by a court, or
- public interest in a case overrides confidentiality.
Disclosure, even with consent, may limit the amount of information revealed. Mental healthcare staff must only disclose the minimum necessary information to the appropriate authority or persons.
Right to autonomy
Most psychiatric patients acknowledge that autonomy over their mental health care is a significant driving force behind their recovery. While the law facilitates coercion measures such as involuntary admissions and cares without consent in special circumstances, generally, patients are entitled to autonomy. Coercion measures or practices often dehumanize the patient, ultimately hindering the recovery process due to long-term effects. Common assumptions are that autonomous personal disability is associated with the patient’s quality of life which manifests as suffering. Diminished autonomy is central to mental health care but often overlooked due to the generalization of mental illnesses. The relationship between autonomy and mental illnesses remains up for discussion as each disorder affects the patient’s autonomous ability differently.
Although it is vital for everyone to enjoy the right to autonomy, some mental illnesses can affect autonomy. Mental health disorders can affect how people relate with themselves and those around them, and they may affect the patient’s ability to make the right decision concerning their health, occasionally deeming them a threat to themselves and the world around them.
Autonomy can be interpreted in various ways due to the absence of a consensus between fields such as political philosophy, legal, moral, and practical ethics. Regardless, two dimensions of autonomy remain undoubtedly critical to the discussion- authenticity, and competence.
Authenticity refers to how an individual relates to their commitments, beliefs, and values that motivate rationality in their decision-making. A conflict between two or more motivations is common and may lead to self-doubt, indecisiveness, or inappropriate responses. This, however, should not always indicate diminishing autonomy. For example, when you get a job in another country but are also engaged in a relationship, you may find yourself stuck as these two motivations are significant parts of your life, and in opposition with each other. The ambivalence should not weaken one’s autonomous ability. Similarly, mental illnesses such as schizophrenia may interfere with authenticity, where behavior, thoughts, and feelings are impacted, causing the victim to lose sight of their motivations in life, thus making them lose a sense of themselves.
Competence refers to one’s ability to form ambitions, goals, preferences, and intentions. Mental illness may interfere with this ability and affect a person’s self-control, consequently affecting their ability to act on their choices and achieve set goals. For example, a person struggling with obsessive-compulsive disorder may get the urge to clean their home even when it is spotless. Although they may realize there is no point in doing so, they feel the need to continue.
Duty of care
Duty of care is a legal requirement that ensures healthcare professionals act in the best interest of the patient by providing the most reasonable standard of care and taking actions that protect their safety. Duty of care is especially important in cases where it is decided that the patient’s action or failure to act appropriately could be consequential—usually causing harm to themselves or others.
This legal obligation is essential in ensuring professionals maintain standards of proficiency, performance, conduct, and ethics during their practice. Since the duty of care is legally binding, professionals can be accused of breach by omission or action if they fail to attain the specified standard of care.
Also, the duty of care is not optional; thus, it significantly helps enforce accountability and responsibility in mental health care. The obligation is subject to change according to the situation. This means that although the duty of care sets expectations on the quality and boundaries of reasonable practice, deviating from the standard should not automatically imply a breach of the standard or negligence.
Nevertheless, an unexpected action requires thorough justification hence the need for a more articulate decision-recording process to keep clear information about what can and cannot be done. The process should prompt further guidance over concerns to a superior in the facility.
Balancing confidentiality, autonomy, and duty of care
The primary roles of a mental healthcare practitioner are to safeguard a patient’s welfare and foster legal justice. With this in mind, ethical dilemmas may arise in situations where one or two ethical consideration conflict with each other. Ethical guidelines may only provide the next step of action for some situations but not all; thus, professionals may rely on ethical theories and models and often be misguided, thus leading to unethical action.
A conflict between ethical considerations causes ethical dilemmas. Take the example of a patient suffering from severe illness who declines treatment. In such a case, the professional’s moral obligation to respect their patient’s decision primarily depends on the severity of the case and the consequences of lack of treatment. Without the patient’s consent, the medical professional may be forced to resort to coercive measures, including mechanical constraint, seclusion, physical restraint, and forced medication. Several jurisdictions give the psychiatrist or any licensed mental healthcare practitioner the power to override a person’s will or preference, allowing them to admit or commit the patient involuntarily to a facility for treatment.
In this situation, there is a significant conflict between autonomy and duty of care, where the professional must disregard the patient’s unwillingness to get treatment for their safety. While the psychiatrist must respect the patient’s rights, they must also deliver the best standard of care when preserving and restoring a patient’s mental and physical health. Additionally, the practitioner may be forced to disclose confidential information; thus, the patient is seemingly stripped of their right to privacy and to make their own choices and choose their preferences.
With such complexities, it is vital to have a system or method of resolving ethical dilemmas. The concept of dialectical principlism is relevant here, as it includes guidelines and theories for professional organizations regarding ethical dilemmas.
Professionals can advance their abilities to make ethical decisions by constantly reviewing existing resources. Promoting your skills in the area and the wider psychiatric field is vital to empower better patient outcomes. St. Bonaventure University offers an extensive Online Mental Health Counseling Master’s Degree to help professionals overcome daily challenges, including ethical dilemmas. The program is designed to promote collaborative learning, with learners participating and speaking up on various challenges in the field. You should expect extensive discussions, proper guidance, and abundant resources on ethical considerations and theories to help you find a balance in arising conflicts and encourage the creation of innovative solutions for the same in your career.
What is dialectical principlism?
The dialectical principlism approach is a method designed to lay out, prioritize and find a balance between conflicting ethical considerations. This method was designed to help practitioners make the most ethical decisions, and it works by creating a hierarchical model of ethical considerations where each is specified according to the practitioner’s role.
In this case, the word dialectical is all about creating a balance between competing principles to arrive at the best and most ethical decision. Forensic psychiatrists often face moral dilemmas where they must implement the most ethical action in unclear circumstances. Their primary responsibility is to foster justice, but other secondary duties usually drawn from biomedical ethics and personal values, such as maintaining security or protecting children, may outweigh their primary responsibility. For example, a forensic psychiatrist may decline a party who wishes to hire him despite the strength of evidence in their favor if the perceived outcome may harm the better side. Accepting cases only for one side is ethical, and a professional may choose to only take cases from one side to prioritize their principles, societal values, and duties.
Although dialectical principlism seemingly leans toward prioritizing one ethical consideration over the other, it does not mean there is a standard blueprint to follow. The aim of the approach is always to help keep mental health practitioners make the right ethical choices. There can never be a sound equilibrium; thus, no ethical considerations can be regarded as the most or least important.
The dialectical process attempts to reach a morally correct decision and forces the parties involved to reflect on their beliefs and continuously review moral arguments. As a result of this, in some cases, the approach makes some decisions harder to make. For example, in the case of a forensic psychiatrist, one would reason that their primary duty is to prioritize their duty of care to society, but technically, their sole responsibility remains to deliver their services to whoever hires them. While one forensic psychiatrist may choose to avoid a case in which they would be helping an ethically questionable party altogether, another may pursue it because they have to make a living, thus making the approach challenging.
Ultimately, however, following dialectical principlism is about reducing or avoiding conflict between ethical considerations; thus, the ideal decision would be to avoid cases that bring up such complications. All in all, finding a balance between ethical dilemmas is a work in progress for even the most experienced professionals in the mental healthcare field.
