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Summary Week 5 - Severe Mental Illness in Urban Context
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Module 5: Reflection on the Role of thePsychologist
Ch 5: Ethical Rationale
The consumer is in general better placed than the mental health professional to identify what
is in their best interests
- Care should normally be provided on the basis of the consumer’s goals and
preferences
The two ethical justifications for compulsion – are (1) the interests of society and (2) the best
interests of the patient
- Best interests are better defined by the patient – or their nominated proxy
decision-maker – than by mental health professionals
Working with the Consumer
A guiding ethical principle – states that mental health services should as far as possible be
oriented towards supporting the individual to achieve personally valued goals
- Rather than towards the goals professionals may have for them
Unfortunately – the emergent properties of the MHS are not always consistent with this
principle:
Care plans typically focused on (1) amelioration of deficits, (2) resolution of symptoms, (3)
avoidance of hospitalization and relapse, and (4) restoration of social functioning
- These are based on clinical goals rather than life goals
Personal Recovery
An orientation towards giving primacy to consumer-defined goals means the primary job of
MHS is to support the person to progress towards their own life goals
- Not provide treatment to meet clinical goals
,Professional expertise is a resource to be offered to the consumer
This principle is the ethical justification for a focus on personal recovery
- However – there are obligations conferred on MH professionals that require things
to be done which are not based on patient’s life goals – and with which patient
may not agree
There are two justifications for doing things to people against their will
Compulsion Justification (1) – Benefit to Society
Societies have values – and these reflect the relative importance attached at a given point in
time to individual freedom and group freedom
- i.e., the Apollonian-Dionysian spectrum
Societal values change over time – but at any one time they are invariant
1. They are expressed as mandated behavioral constraints
Most commonly in relation to mental health – these constraints are that (1) no one will be left
to die – or (2) allowed to harm others
- These constraints are non-negotiable
One obligation placed on MH professionals – is to constrain behavior in order to uphold these
societal values
This obligation is conferred either (1) directly via mental health legislation or (2) indirectly
via codes of conduct and mental health policy
These socially imposed, non-negotiable constraints on behavior – provide one ethical
justification for compulsion
- The justification for intervening is to uphold societal rules – rather than for the
benefit of the patient
, Compulsion Justification (2) – Best Interests
The other ethical justification – concerns intervening in situations where there is a risk of
damage to one’s life, health and well-being
The right to autonomy is reasonably over-ridden for some people at some points in their life –
by considerations of best interests
- This is recognized in mental health legislation
The ethical justification for compulsion is paternalism – i.e., a clinician is acting
paternalistically towards a patient when:
(1) His action benefits the patient
(2) His action involves violating a moral rule with regard to the patient
(3) His action does not have the patient’s past, present, or immediately forthcoming
consent
(4) The clinician believes they can make their own decision
The more acceptable ethical principle of beneficence – i.e., doing things to a person on the
basis of professional beliefs about what is in their best interests
This approach arises from a world-view that (1) treatments are effective – and (2) the
privileged access of health professionals to these effective interventions places an ethical
requirement on those practitioners to provide treatment
- Resulting in the assumption that – best interests are necessarily defined by
professionals
Challenges to the Assumption
There are four challenges to this assumption:
First – this ethical imperative is increasingly out of step with wider societal values – which
instead emphasize (1) personal responsibility, (2) informed choice, and (3) the right to self-
determination
In other areas of life – there is a recognition that the goals, aspirations, and values of the
individual should take primacy over those of the professional
, Second – health professionals no longer have sole access to information about treatments
An implicit dichotomy developed during the Enlightenment – between (1) the knowledge
held by professionals and (2) belief held by lay people
- The implication of this dichotomy is that professional knowledge is more highly
valued than lay beliefs
This distinction is challenged in a constructivist epistemology – in which all forms of
knowing are positioned as belief
- There is no true, unchanging knowledge
Third – an awareness that the interests of people with mental illness have not been well
served when responsibility for their well-being is assumed by others
An example would be the asylums
Fourth – giving primacy to professional perspective on best interests is inconsistent with
modern capacity-based legislation
The Mental Capacity Act defines best interests as – what the patient would have chosen for
themselves in a situation if they had capacity
- This requires attention to the person’s goals, values and preferences
Main Arguments
The main arguments are that:
(1) Best interests are a justification for compulsion
(2) In a recovery-focused system – the closer to the individual’s view of their own best
interests the compulsion is – the more it can be ethically justified
The two justifications for compulsion are (1) non-negotiable behavioral constraints –
mandated by society – and (2) the best interests of the patient
- Best interests are best defined by the patient – or their nominated proxy decision-
maker
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