Ethics and CultureEthics and Culture

● Christopher Gale● Department of Psychological Medicine, Dunedin

School of Medicine

OutlineOutline

● A defence of logical positivism.● Foundations of psychiatric ethics.● The ethics around clinical care with limited funding.● Coercion in psychiatry.● The culture of psychiatry.● Interactions Maori and Mental Health Services.● Transcultural psychiatry.

Logical positivism.Logical positivism.

● Realist: – belief in an external reality.– Belief in reality of other's minds (theory of mind). ”you are not a

hallucination”.● Empirical

– Explanations (hypotheses) can and should be verified.– Use of experimental designs.

● Reductionist.– Tight design trials, minimal variation, often parts of whole.

Alternate positions.Alternate positions.

● Pre-modern.– Our perceptions are masks or metaphors that

underline the forms of true reality (Plato, Augustine).– Reality is an illusion (Gnostics, Buddha).

● Deconstructionism. – The text or narrative of “reality” is a means of

maintaining power.– Madness is a method of rebelling against the

consensual delusion we call reality.

Alternate positions IIAlternate positions II

● Postcolonial.– The narrative of science disavows traditional

knowledge.– Science is a form of colonial oppression, and

traditional methodologies are superior.● Argument from oppression.

– The experience of the (official) oppressed person outweighs any data, and all others should heed this.

Psychiatry is...Psychiatry is...

● Is pragmatic & based, on a logical postivist & utilitarian position, which allows in populations prediction of:– Natural history and prognosis.– Treatment efficacy.– Treatment effectiveness.

● Allows the integration of clinical trials and descriptions of experience: qualitative and quantitative data.

Balance?Balance?

● Pragmatism alone (technocracy) does not consider– Rights– Moral duties

● Argument from theory (theology*) does not look at effectiveness.

● * I am using theology as a description of any closed system, from Christianity to Buddhism or rationalism, from psychoanalysis to marxism.

Classic formulation.Classic formulation.

● Duties:– Respect patient's free choice (autonomy)– Do no harm (non-malfeasance)– Do good (beneficence).– Justice

● When these conflict, resolution should be able to be consistently applied.

● Assumes a fiduciary relationship.

Virtues of professionalismVirtues of professionalism

● Based on fiduciary relationship.– Self denial: work in clients best interests.

● Confidentiality● Conflict of interests.

– Duty to care: care for clients takes priority over all other aspects of life.

● Availability● Continuity of care

– Truth telling.

Conflicts in mental health.Conflicts in mental health.

● Coercion.● Advocacy & access to care.● Confidentiality.● Transcultural approaches.

Coercion.Coercion.

● Adherence to treatment.– By force– By threat of force.

● May or may not involve use of law.– MH law has evolved around law to work around

issues.

Case I: Joe.Case I: Joe.

● A 28 year old single man. ● About a month ago he suddenly experienced a sense that

he needed to isolate himself from the world & meditate.● He usually has no interest in religion. His family are

concerned about him.● He was found in the bush at a campsite, underweight,

with little food. ● It is late autumn: the first snow has occurred at the

campsite.

Issues.Issues.

● Should we treat?● Should we not treat?● How do we justify this?

● Would it be different if Joe was a very religious Buddhist?

Case II: RayCase II: Ray

● 21 year old man. Borderline IQ & Schizophrenia.● Well with treatment.● At home, neglected by mother.

– Takes all benefit money.– Minimal interaction: told to “live in sleep out”. – Occasionally not fed.

● If in supported accomodation, mother pleads him to return home “As I love you”.– Does go home, but says prefers to be elsewhere.

What to do?What to do?

● Can we:– Enforce place of treatment?– Against familial intent?

● Do we have a duty to protect?

● Ray is Maori. Does that change anything?– [it should not].

OutcomeOutcome

● We should not collude with harm.● We have a duty to protect.● The legal options are limited around the mother:

– Question of charge of neglect.– If younger, CYPS would place elsewhere.

● Is unable to care self without support.– Therefore, used second arm MHA and stated place of

care was part of treatment.– Placed in a small, iwi run service. They began slow

liaison with family but made clear would not return home.

Legalities around coercion.Legalities around coercion.

● RANZCP and APA have guidelines MH law.– Require an element of risk (including self neglect).– Require review of restraint, isolation (seclusion)– Specail provision ECT and psychosurgery.– Mandate

● rights and legal review.● “least restrictive environment” and necessity.

● UK is moving towards a generalized law around consent, removing the first arm (the need to have psychiatric phenomena

Act in best interests.Act in best interests.

● Need to suggest treatments in patients best interests.– Not driven by commercial (“big pharma”) or

ideological issues.– Nor skill set.– Nor availability.

● If patient aware options, then need to state what options can be delivered.– “We can offer CBT, but there is a 6-month waiting

list”

Abusive psychiatry.Abusive psychiatry.

● Service driven by model of care.– “Refrigerator mother” (we will allow people with

psychosis to regress and not use medication).– “Trauma model” (As trauma explains everything, you

will disclose your trauma regardless of consequences).

● Ideology filtering care.– Scruples (“you must adhere to my religious beliefs”

eg. refusing referral TOP)– Socail activism (“as society oppresses you, we will

recruit you into the revolution”).

Neglectful psychiatry.Neglectful psychiatry.

● Nihilistic.– “Nothing will work” so discharge | minimise staff.

● Active abuse– Damaging treatments eg. Sleep therapy.– Treatment as punishment.– Sexual and financial exploitation.– Neglect

● Over-staffing● Low proportion trained staff.● Limiting Continuing education and audit.

Consent and research.Consent and research.

● Need informed consent.● Assent is not enough.

– At times need proxy consent from family, but informed consent then needed after event.

● Conflict around payment.– One can reimburse for time and transport– But not an inducement to give consent.

● Department of Statistics works by compulsion. Should they therefore be contracted for epidemiological research?

Research abuses psychiatry.Research abuses psychiatry.

● Tuskagee:– Not treating patients tertiary syphilis despite effective

treatments● Deceit of participants.

– The “prisoner” experiments.– Not telling patients service is publishing audit of their files

● Continuation of trials– After a significant difference found– If one treatment found to be dangerous.

● Use of placebo control (but mandated [US} FDA)– If effective treatments available

Confidentiality.Confidentiality.

● Need to keep secret patient's data.– Allowing for trusting conversation, development of

therapeutic alliance.– Allowing for correct assessment of risks and benefits

of treatment plan.● Need to protect society.

– Infectious (notifiable) diseases.– Risk to others.– Risk to self.

Tarasoff comprimise.Tarasoff comprimise.

● Limited confidentiality.– By risk to others.– Duty to inform patients of this.– Need to communicate to others working to treat

patient eg. GP forwarding notes when move.

● [All discussions of patients are anonymous, and whenever possible patient consent obtained].

Challenges.Challenges.

● Outcome based treatment.– requires more detailed reporting to funders.

● External agencies– [DSW, insurance companies, ACC, coroner, Health and

Disability Commission].– Want access to the entire file to make assessments.

● Issue of coercion: if patient does not consent then they will not be heard or compensated.

● Inter-agency teams:– In health, all employees sign confidentiality agreements and

audited.– This sensitivity may not occur in legal or commercial areas.

Maori.Maori.

● Position has changed over time, and each iwi whanau and person approaches differently.– Integration to rediscovery of culture to separation to a

process of merging two cultures.● Issues have not.

– Respect for religion, culture and elders versus Pakeha secular, skeptical egalitarianism.

– Variation from whanau and iwi being prime importance to rejection same.

– Traditionally, transgressions cultural boundaries led to ultimate sanction.

Mental Health Culture.Mental Health Culture.

● Reflect elite Western Values.– Concerned social justice and environment.– Individualistic.– Relativistic but aggressively secular.– High value placed on education and progression through

career.● Deals poorly with other viewpoints.

– Rhetoric of Appeasement, apologies previous injustices.– Limited adjustment for traditionalists.– Post modern “cone of silence” if dissenting

Conflicts.Conflicts.

● Confidentiality.● Person who makes decisions.● Reason for decisions.

– Attribution of symptoms.● Treatment options.

““New” immigrants.New” immigrants.

● Often from ancient cultures.– Confucian | Buddhist.– Hindu– Islam

● Preconceptions around normative behaviour different.– Sexual behaviour, honour, choice partner, marriage– Education, Discipline– Religious and ethical behaviour.

Universalism vs TransculturalUniversalism vs Transcultural

● Universalism.– People are more the same than different.– Some rights are universal– Culture is devalued.

● Transcultural.– Cultures are more different than the same.– A persons symptoms and behavior are driven by

culture.– Rights only have meaning within a culture.

Notes.Notes.

● Ethical and cultural issues are examined.● Resources are available

– Psychiatric Ethics– Te Iho– Ngai Tahu research unit.

● Providing best and most appropriate care at times limited.– Awareness & discussion this core part of role.