Ethical dilemmas in psychiatry

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Ethical dilemmas in psychiatry

• Prof. Guy Widdershoven
• Department of Health, Ethics and Society

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Outline

• The story of a patient
• Coercion and interference, the current situation
• Autonomy
• Care ethics
• A deliberative approach to coercion and
  interference

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The story of a patient

• Kay Redfield Jamison studies psychology, and
  starts working in psychiatry

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The story of a patient

• She becomes manic and later depressed
• She takes medication (lithium), which is
  effective but leads to lack of emotions and loss
  of motivation to work
• She wants to stop tretament, but her psychiatrist
  forces her to continue
• With support of her psychiatrist, she experiments
  with the dose, and becomes more herself
• I was more sensitive to beauty, but also to
  sadness

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Coercion and interference, the current situation

• Under which conditions is coercion in psychiatry
  allowed in The Netherlands
• .....
• Which types of coercion exist in psychiatry
• .....
• Which type of coercion is regarded as most invase
  in NL 1, 2, 3
• What is the legal status of interference
• ....

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Coercion and interference, the current situation

• Strict legal rules coercion as last resort
• Only in case of danger to self or others
• (In)competence does not play a role
• Three types seclusion, fixation, medication
• In The Netherlands, seclusion is regarded as less
  invasive compared to forced medication
• Interference is less invasive than coercion, but
  also problematic

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Jamison

• Involuntarily admitted to the hospital
• Enforced medication
• Danger to self (and others)
• Psychiatrist does not allow stopping of
  medication
• He keeps interfering (allowing reduction of
  medication under strict conditions)
• Interference is valued positively by Jamison

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Autonomy

• Negative freedom
• Right to be left alone
• Competence as limiting condition (not in
  psychiatry)
• Positive freedom
• Ability to develop ones life
• Competence as crucial aspect and goal

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Jamison

• Negative freedom
• Involuntary admission and treatment because of
  danger
• Positive freedom
• Reducing the dose in order to work
• Self-understanding (including sadness)

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Care ethics (J. Tronto)

• Care is an activity of the species which
  includes everything we do in order to maintain
  our world, to continue and repair it, in order
  to live in it as well as possible

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Phases of care

• Caring about (attentiveness)
• Taking care of (responsibility)
• Care giving (competence)
• Care receiving (responsiveness)

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Jamison

• Attention when things go wrong (or too well)
• Psychiatrist remains firm about medication,
  arranges possibility of experiment
• Psychiatrist keeps her under supervision
• Life has more quality after change of the dose

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A deliberative approach to coercion in psychiatry

• Focus on autonomy as self-development
• (Fostering) competence
• Deliberation about options for care
• Care as a process, attention for prevention and
  evaluation
• Coercion as the extreme of a spectrum of
  interference

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Conclusion

• Autonomy negative freedom dominant in
  psychiatric law, positive freedom needs more
  attention competence should be central
• Care ethics interference is positive, but should
  be evaluated as part of a process of care,
• A deliberative approach deliberation is needed
  about the goal of coercion (self-development,
  working life), as well as the means (seclusion vs
  medication)