Ethical issues are pivotal to the practice of psychiatry. Anyone involved in psychiatric practice and mental healthcare has to be aware of the range of ethical issues relevant to their profession. An increased professional commitment to accountability, in parallel with a growing "consumer" movement has paved the way for a creative engagement with the ethical movement. The bestselling 'Psychiatric Ethics' has carved out a niche for itself as the major comprehensive text and core reference in the field, covering a range (...) of complex ethical dilemmas which face clinicians and researchers in their everyday practice. This new edition takes a fresh look at recent trends and developments at the interface between ethics and psychiatric practice. Coming ten years after the third edition, the editors have observed several emerging aspects of psychiatric practice requiring coverage, as a result, 5 new chapters have been added, including cutting edge topics - such as neuroethics. All other chapters have been fully revised and updated. The book will continue to be essential reading for psychiatrists, psychologists, other mental health professionals, and bioethicists, as well as of interest to policy makers, managers and lawyers. (shrink)

In Two Minds is a practical casebook of problem solving in psychiatric ethics. Written in a lively and accessible style, it builds on a series of detailed case histories to illustrate the central place of ethical reasoning as a key competency for clinical work and research in psychiatry. Topics include risk, dangerousness and confidentiality; judgements of responsibility; involuntary treatment and mental health legislation; consent to genetic screening; dual role issues in child and adolescent psychiatry; needs assessment; cross-cultural and gender issues; (...) rational and irrational suicide; shared decision making in multi-agency teams, and the growing role of the user's voice in psychiatry. Key ethical concepts are carefully introduced and explained. The text is richly supported by detailed guides for further reading. There are separate chapters on teaching psychiatric ethics, including a sample seminar, and on writing a research ethics application. Each case history and discussion is followed by a critical commentary from a practitioner with relevant experience. Jim Birley adds a comparative international perspective on psychiatric ethics. Cartoons by Johnny Cowee provide punchy counterpoint! In Two Minds is the sister volume to the third edition of Sidney, Paul Chodoff and Steven Green's highly successful Psychiatric Ethics. In providing a bridge between theory and practice, it will be essential reading for everyone concerned with improving standards in mental health care. (shrink)

Psychiatric ethics as professional and biomedical ethics -- The distinctiveness of the psychiatric setting -- Psychiatric ethics as virtue ethics -- Elements of a gender-sensitive ethics for psychiatry -- Some virtues for psychiatrists -- Character and social role -- Case studies in psychiatric virtues.

The public, mental health consumers, as well as mental health practitioners wonder about what kinds of values mental health professionals hold, and what kinds of values influence psychiatric diagnosis. Are mental disorders socio-political, practical, or scientific concepts? Is psychiatric diagnosis value-neutral? What role does the fundamental philosophical question "How should I live?" play in mental health care? In his carefully nuanced and exhaustively referenced monograph, psychiatrist and philosopher of psychiatry John Z. Sadler describes the manifold kinds of values and value (...) judgements involved in psychiatric diagnosis and classification systems like the DSM. Professor Sadler takes the reader on a fascinating conceptual tour of the inner workings of psychiatric diagnosis, considering the role of science, culture, sexuality, politics, gender, technology, human nature, patienthood, and professions in building his vision of a more humane psychiatric diagnostic process. (shrink)

The aim of this article is to describe the synthesis of the concept of moral stress and to attempt to identify its preconditions. Qualitative data from two independent studies on professional issues in nursing were analysed from a hypothetical-deductive approach. The findings indicate that moral stress is independent of context-given specific preconditions: (1) nurses are morally sensitive to the patient’s vulnerability; (2) nurses experience external factors preventing them from doing what is best for the patient; and (3) nurses feel that (...) they have no control over the specific situation. The findings from this analysis are supported by recent research on stress in the workplace but differ in that the imperatives directing work are moral in nature. Stress researchers have found that persons who experience that they have no control over their work situation and at the same time experience high demands may be prone to cardiovascular diseases. An important question raised by this study is whether moral stress should be recognized as a health risk in nursing. Further research is required in order to generate intervention models to prevent or deal with moral stress. (shrink)

Objectives—While clinical practice is complicated by many ethical dilemmas, clinicians do not often request ethics consultations. We therefore investigated what triggers clinicians' requests for ethics consultation. Design—Cross-sectional telephone survey.Setting—Internal medicine practices throughout the United States.Participants—Randomly selected physicians practising in internal medicine, oncology and critical care.Main measurements—Socio-demographic characteristics, training in medicine and ethics, and practice characteristics; types of ethical problems that prompt requests for consultation, and factors triggering consultation requests. Results—One hundred and ninety of 344 responding physicians (55%) reported requesting ethics (...) consultations. Physicians most commonly reported requesting ethics consultations for ethical dilemmas related to end-of-life decision making, patient autonomy issues, and conflict. The most common triggers that led to consultation requests were: 1) wanting help resolving a conflict; 2) wanting assistance interacting with a difficult family, patient, or surrogate; 3) wanting help making a decision or planning care, and 4) emotional triggers. Physicians who were ethnically in the minority, practised in communities under 500,000 population, or who were trained in the US were more likely to request consultations prompted by conflict. Conclusions—Conflicts and other emotionally charged concerns trigger consultation requests more commonly than other cognitively based concerns. Ethicists need to be prepared to mediate conflicts and handle sometimes difficult emotional situations when consulting. The data suggest that ethics consultants might serve clinicians well by consulting on a more proactive basis to avoid conflicts and by educating clinicians to develop mediation skills. (shrink)

The aim of this study was to explore ethically problematic situations in the long-term nursing care of elderly people. It was assumed that greater awareness of ethical problems in caring for elderly people helps to ensure ethically high standards of nursing care. To obtain a broad perspective on the current situation, the data for this study were collected among elderly patients, their relatives and nurses in one long-term care institution in Finland. The patients (n=10) were interviewed, while the relatives (n=17) (...) and nurses (n=9) wrote an essay. Interpretation of the data was based on qualitative content analysis. Problematic experiences were divided into three categories concerning patients’ psychological, physical and social integrity. In the case of psychological integrity, the problems were seen as being related to treatment, self-determination and obtaining information; for physical integrity, they were related to physical abuse and lack of individualized care; and for social integrity, to loneliness and social isolation. This study provided no information on the prevalence of ethical problems. However, it is clear from the results that patient integrity warrants more attention in the nursing care of elderly patients. (shrink)

Discussion of real cases encountered by medical students has been advocated as a component of medical ethics education. Suggested benefits include: a focus on the actual problems that medical students confront; active learner involvement; and facilitation of an exploration of the meaning of their own values in relation to professional behaviour. However, the approach may also carry risks: students may focus too narrowly on particular clinical topics or show a preference for discussing legal problems that may appear to have clearer (...) solutions. Teaching may therefore omit areas generally considered to be important components of the curriculum. In this paper, the authors present an analysis of the moral problems raised by medical students in response to a request to describe ethically problematic cases they had encountered during two clinical attachments, for the purpose of educational discussion at case-based seminars. We discuss the problems raised and compare the content of the cases to the UK Consensus Statement on core content of learning. The authors also describe the approaches that the students used to undertake an initial analysis of the problems raised, and consider possible implications for the development of medical ethics education. (shrink)

This article describes the results of research that investigated whether student nurses identified the moral aspects of everyday nursing care situations and, if so, how they dealt with them. We intended to elucidate the role of mentoring situations in moral development. Student written documents reflecting discussions during mentoring situations were analysed quantitatively and qualitatively. The students studied in one of the three nursing schools involved in the research. In only a small proportion of cases (.

Internationally, the prevalence of clinical ethics support (CES) in health care has increased over the years. Previous research on CES focused primarily on ethics committees and ethics consultation, mostly within the context of hospital care. The purpose of this article is to investigate the prevalence of different kinds of CES in various Dutch health care domains, including hospital care, mental health care, elderly care and care for people with an intellectual disability. A mixed methods design was used including two survey (...) questionnaires, sent to all health care institutions, two focus groups and 17 interviews with managing directors or ethics support staff. The findings demonstrate that the presence of ethics committees is relatively high, especially in hospitals. Moral case deliberation (MCD) is available in about half of all Dutch health care institutions, and in two-thirds of the mental health care institutions. Ethics consultants are not very prominent. A distinction is made between explicit CES forms, in which the ethical dimension of care is structurally and professionally addressed and implicit CES forms, in which ethical issues are handled indirectly and in an organic way. Explicit CES forms often go together with implicit forms of CES. MCD might function as a bridge between the two. We conclude that explicit and implicit CES are both relevant for clinical ethics in health care. We recommend research regarding how to combine them in an appropriate way. (shrink)

This study presents a qualitative description of situations at work that staff members perceive as giving rise to ethical issues. All staff members working with patients across seven wards were given the opportunity to freely describe ethical considerations in an ethical diary over the course of one week. One hundred and five staff members kept a diary. The diaries were analysed with qualitative content analysis where four dominant themes emerged: good care, order and clarity, loyalty, and inadequacy. These results contain (...) statements in which patients are respected and listened to, as well as statements that express a desire for relatively strict, routine-based care. Relatively few statements were of a reflective or discussing nature which highlights the need for clinical ethical support. There is a need of a visible and supportive leadership which encourages ethical reflection. Reflections on real cases could provide an opportunity to challenge existing practices and thereby promote ethical awareness. (shrink)

A systematic literature review on evaluation of clinical ethics support services in mental healthcare is presented and discussed. The focus was on (a) forms of clinical ethics support services, (b) evaluation of clinical ethics support services, (c) contexts and participants and (d) results. Five studies were included. The ethics support activities described were moral case deliberations and ethics rounds. Different qualitative and quantitative research methods were utilized. The results show that (a) participants felt that they gained an increased insight into (...) moral issues through systematic reflection; (b) there was improved cooperation among multidisciplinary team members; (c) it was uncertain whether clinical ethics support services led to better patient care; (d) the issue of patient and client participation is complex; and (e) the implementation process is challenging. Clinical ethics support services have mainly been studied through the experiences of the participating facilitators and healthcare professionals. Hence, there is limited knowledge of whether and how various types of clinical ethics support services influence the quality of care and how patients and relatives may evaluate clinical ethics support services. Based on the six excluded ‘grey zone articles’, in which there was an implicit focus on ethics reflection, other ways of working with ethical reflection in practice are discussed. Implementing and evaluating clinical ethics support services as approaches to clinical ethics support that are more integrated into the development of good practice are in focus. In order to meet some of the shortcomings of the field of clinical ethics support services, a research project that aims to strengthen ethics support in the mental health services, including patients’ and caregivers’ views on ethical challenges, is presented. (shrink)

In recent years, the attention on the use of coercion in mental health care has increased. The use of coercion is common and controversial, and involves many complex ethical challenges. The research question in this study was: What kind of ethical challenges related to the use of coercion do health care practitioners face in their daily clinical work?

This article describes the results of research that investigated whether student nurses identified the moral aspects of everyday nursing care situations and, if so, how they dealt with them. We intended to elucidate the role of mentoring situations in moral development. Student written documents reflecting discussions during mentoring situations were analysed quantitatively and qualitatively. The students studied in one of the three nursing schools involved in the research. In only a small proportion of cases (<13%) did the students identify the (...) ethical questions in those situations. The results indicate that the nursing students rarely identified moral issues, implying that there was little conscious moral reflection and deliberation in their mentoring situations dealing with their problematic experiences during their internship. Additional competences will be required for session leaders in order to allow mentoring situations to play a more prominent role in moral development. (shrink)

Background Clinical moral case deliberation consists of the systematic reflection on a concrete moral case␣by health care professionals. This paper presents the study of a 4-year moral deliberation project.Objectives The objectives of this paper are to: (a) describe the practice and the theoretical background of moral deliberation, (b) describe the moral deliberation project, (c) present the outcomes of␣the evaluation of the moral case deliberation sessions, and (d) present the implementation process.Methods The implementation process is both monitored and supported by an (...) interactive responsive evaluation design with: (a) in-depth interviews, (b) Maastricht evaluation questionnaires, (c) evaluation survey, and (d) ethnographic participant observation. In accordance with the theory of responsive evaluation, researchers acted both as evaluators and moderators (i.e. ethicists).Results Both qualitative and quantitative results showed that the moral case deliberations, the role of the ethics facilitator, and the train-the-facilitator program were regarded as useful and were evaluated as (very) positive. Health care professionals reported that they improved their moral competencies (i.e. knowledge, attitude and skills). However, the new trained facilitators lacked a clear organisational structure and felt overburdened with the implementation process. The paper ends with both practical and research suggestions for future moral deliberation projects. (shrink)

Ethics support in primary health care has been sparser than in hospitals, the need for ethics support is probably no less. We have, however, limited knowledge about how to develop ethics support that responds to primary health-care workers’ needs. In this article, we present a survey with a mixture of closed- and open-ended questions concerning: How frequent and how distressed various types of ethical challenges make the primary health-care workers feel, how important they think it is to deal with these (...) challenges better and what kind of ethics support they want. Five primary health-care institutions participated. Ethical challenges seem to be prominent and common. Most frequently, the participants experienced ethical challenges related to scarce resources and lack of knowledge and skills. Furthermore, ethical challenges related to communication and decision making were common. The participants welcomed ethics support responding to their challenges and being integrated in their daily practices. (shrink)

Aim: To assess ethical issues in everyday clinical practice among physicians and nurses of the University Hospital Rijeka, Rijeka, Croatia.Subjects and methods: We surveyed the entire population of internal medicine, oncology and intensive care specialists and associated nurses employed at the University Hospital Rijeka, Rijeka, Croatia . An anonymous questionnaire was used to explore the type and frequency of ethical dilemmas, rank of their difficulty, access to and use of ethics support services, training in ethics and confidence about knowledge in (...) ethics. Physicians ranged in age from 27 to 61 years, and nurses , from 20 to 52.Results: The most frequent ethical dilemmas concerned uncertain or impaired decision-making capacity , limitation of treatment at the end of life and disagreements among family members . The most difficult dilemmas concerned euthanasia and physician-assisted suicide and limitation of treatment at the end of life . Only a minority reported ever using any kind of ethics support services or being very confident about knowledge in ethics .Conclusions: Similar ethical difficulties are present in the clinical practice of both physicians and nurses, with important differences in access and use of ethics support services. A need for systematic ethics educational activities was identified. Inclusion of individual ethics consultants in Croatian healthcare ethics support services is strongly advised. (shrink)

Deliberative ways of dealing with ethical issues in health care are expanding. Moral case deliberation is an example, providing group-wise, structured reflection on dilemmas from practice. Although moral case deliberation is well described in literature, aims and results of moral case deliberation sessions are unknown. This research shows (a) why managers introduce moral case deliberation and (b) what moral case deliberation participants experience as moral case deliberation results. A responsive evaluation was conducted, explicating moral case deliberation experiences by analysing aims (...) (N = 78) and harvest (N = 255). A naturalistic data collection included interviews with managers and evaluation questionnaires of moral case deliberation participants (nurses). From the analysis, moral case deliberation appeals for cooperation, team bonding, critical attitude towards routines and nurses’ empowerment. Differences are that managers aim to foster identity of the nursing profession, whereas nurses emphasize learning processes and understanding perspectives. We conclude that moral case deliberation influences team cooperation that cannot be controlled with traditional management tools, but requires time and dialogue. Exchanging aims and harvest between manager and team could result in co-creating (moral) practice in which improvements for daily cooperation result from bringing together perspectives of managers and team members. (shrink)

Next SectionBackground: Physicians face ethical difficulties daily, yet they seek ethics consultation infrequently. To date, no systematic data have been collected on the strategies they use to resolve such difficulties when they do so without the help of ethics consultation. Thus, our understanding of ethical decision making in day to day medical practice is poor. We report findings from the qualitative analysis of 310 ethically difficult situations described to us by physicians who encountered them in their practice. When facing such (...) situations, the physicians sought to avoid conflict, obtain assistance, and protect the integrity of their conscience and reputation, as well as the integrity of the group of people who participated in the decisions. These goals could conflict with each other, or with ethical goals, in problematic ways. Being aware of these potentially conflicting goals may help physicians to resolve ethical difficulties more effectively. This awareness should also contribute to informing the practice of ethics consultation. Objective: To identify strategies used by physicians in dealing with ethical difficulties in their practice. Design, setting, and participants: National survey of internists, oncologists, and intensive care specialists by computer assisted telephone interviews (n = 344, response rate = 64%). As part of this survey, we asked physicians to tell us about a recent ethical dilemma they had encountered in their medical practice. Transcripts of their open-ended responses were analysed using coding and analytical elements of the grounded theory approach. Main measurements: Strategies and approaches reported by respondents as part of their account of a recent ethical difficulty they had encountered in their practice. Results: When faced with ethical difficulties, the physicians avoided conflict and looked for assistance, which contributed to protecting, or attempting to protect, the integrity of their conscience and reputation, as well as the integrity of the group of people who participated in the decisions. These efforts sometimes reinforced ethical goals, such as following patients’ wishes or their best interests, but they sometimes competed with them. The goals of avoiding conflict, obtaining assistance, and protecting the respondent’s integrity and that of the group of decision makers could also compete with each other. Conclusion: In resolving ethical difficulties in medical practice, internists entertained competing goals that they did not always successfully achieve. Additionally, the means employed were not always the most likely to achieve those aims. Understanding these aspects of ethical decision making in medical practice is important both for physicians themselves as they struggle with ethical difficulties and for the ethics consultants who wish to help them in this process. (shrink)

The Norwegian Parliament has decided to give priority to ethics in municipal health services. This priority is supposed to raise competence in ethics within municipal health services. As part of the national project, the participating municipalities were encouraged to develop and carry out local projects. In this article, we present a local ethics project in one of the participating municipalities in central eastern Norway. The local project for raising competence in ethics was carried out in cooperation with researchers at the (...) Centre for Medical Ethics (CME) at the University of Oslo. Most people agree that ethics are important in health services. However, there are many ways to increase competence in ethics and to stimulate ethical reflection. In this article we present a broad overview of this local ethics project, but special focus will be put on presenting the actions that have been used for increasing the level of ethical competence and stimulating ethical reflection among the participants. We describe our evaluation of the project and the research we carried out. Explanations will be given for the thought process behind the decisions that were made. (shrink)