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Ethical Decision-Making in Mental Health
Kim Jameson, MA, PhD CandidateEthicist, Vancouver Coastal Health
Co-Author: Bethan Everett, MBA, Ph.D.Ethicist, Vancouver Coastal Health
Objectivesu Introduction to VCH Ethics Servicesu Name ethical principlesu Overview of the ethical decision-making processu Present a case scenariou Describe concepts of risk and capacityu Name the factors that help determine when and
how to interveneu Discussion
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Ethical Decision-making
Virtually all health care decisions have an ethical component
i.e. What is the right thingto do given the circumstances?
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VCH Ethics ServicesRole: ØTo provide support to those confronting difficult
ethical concerns, questions and/or issues related to health care.
Primary Functions:ØCase ConsultationØEducation and capacity buildingØ Input to guidelines/policies
Top Ethical Issues in Mental Health
• Refusal of life-sustaining/saving medical treatment when mental health issues are present
• Disagreement over appropriate psychiatric care• Discharging at risk• Confidentiality and family involvement • Addressing requests for Medical Aid in Dying
(MAID)
Ethical Principles
Non-maleficence
Beneficence
Autonomy
Justice
Phase 3Proposing Options and applying principles
Phase 2Gathering Facts
Phase 1Planning & Framing
the IssuesPhase 5Implementing & Evaluating
Phase 4Decision- making
* Team Members *Client
Family & friendsCare providers
Health Professionals
w Why are we here?w Who should be here?w What are the issues?w What are our values and biases?
w What does the client want? w What could we do?w What other options are available?w What ethical principles apply to the various options?
wWhat criteria are we using to make decision?w What’s the ‘best choice’ available? w What’s our back up plan?
w Who’s responsible for what?w Does anyone need debriefing?w Can we live with this?w Have we documented the process?
w What are the facts?w What are the risks?
ETHICAL DECISION-MAKING FRAMEWORK
Medical health issuesHealth care needsDiagnosis/prognosisRisks/benefits of interventionGoals of interventions
Client/surrogate wishesWhat does client wantIs there a substitute decision maker (SDM)What does SDM wantIs client informed/is consent needed
Quality of life
How will intervention change quality of lifeWho defines qualityWhat is the harm/benefit ratio Is this a holistic approach
Contextual featuresWho else is affectedWhat costs are involvedProfessional practice/legal implicationsSocietal considerationsAre there risks? (How probable, severe, and who is at risk?)
Ethical Process• All parties should be involved• All parties should have the information needed
to come to a decision• Communication should be open, honest,
transparent• Relationships should be respectful• Promises should be kept• There should be an awareness and
accommodation for differences in power
Case ScenarioChao-xing has schizophrenia and has been diagnosed with early-stage breast cancer. She is being held in hospital under the Mental Health Act, and the Public Guardian and Trustee (PGT) is her health care decision-maker. The client has refused further testing and treatment for breast cancer because she does not believe she is ill. Despite having received consent from the PGT to undertake testing, Chao-xing’s oncologist refuses to proceed.(J. Young & B. Everett (2015). “Cause of Death: Schizophrenia?” BC Medical Journal, 57 (10), 434-437)
Capability
• How do we know if a person is capable?
• What does capable mean?
Client
Specific decision/choice
Capablei.e. understands and appreciates
Client is Decision Maker
Not capable
Substitute decision maker Advance Directive
WHO MAKES THE DECISION
Substituted decision Best interest decision
RiskThe chance or probability of a negative outcome or consequence of an action, inaction, behavior or decision
6 elements of intolerable risk• A change that impairs one’s ability to protect oneself
or others from harm• Evidence of current decline /severe change in
condition• High probability that decline or severe change will
occur• Severity of anticipated harm• Imposition of risks on others• Inability to choose to be at risk
Ethical analysis of risk• Which principles are in
conflict?
• Risk to who?
• Is the Client capable
• What is nature of risk?
• Can the risk be brought to acceptable level?
Autonomy/ Non Maleficence/ Beneficence/ Justice
Self? Others?
Capable or Incapable (ethical and legal)How serious/ probable/ Evidence vs Speculation
Yes or No?
When do we intervene?• Encumbered- decreased capacity for whatever
reason and autonomy may be compromised
Mental illnessEmotional stateUndue influence
Lack of Information
risk capability/competence
mental illness
emotional state
undue influence
information interference
not permanentor serious orprobable(tolerable)
client can understand & appreciate risks, outcomes, consequences
none absent absent client has full information
explain
argue
permanent, & serious & probable(intolerable)
understands
does not understand
mild
significantseriously impairing
seriously impairing
client has little or no information
pressure
physically coerce
5 Ethical Criteria
• Interfere only if it will be– Effective– Benefits >harm– Non-discriminatory– Least intrusive– If at all possible, thought justified by person upon
whom it is imposed
Case Discussion
• Client’s refusal (autonomy) vs duty to promote well-being (beneficence) and do no harm/ reduce harms (non-maleficence) through safe and effective care– Client’s decisional capacity– Consent to mental and physical health care– Risk and benefits in immediate and long term
Thank You!
Ethics Service Contact Information
Ø If an ethicist is not available please call anyone on this list:
Ø Bethan Everett: First on call for Acute - VGH and UBC Hospitals, Vancouver Community, GF Strong Rehab Centre and George Pearson Centre ~ 604-266-6264 (office); 778-870-2805 (cell) [email protected]
Ø Terry Anderson: First on call for Richmond, Bella Coola and Bella Bella ~ 604-538-8180
Ø Kim Jameson : First on call for Coastal (North Shore, Sea-to-Sky, Sunshine Coast and Powell River ~ 778-877-7208 [email protected]
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