Clinical Ethics Discussion: Should a physician be allowed to prescribe psychotropic drugs for a delusional patient without explicit explanation regarding diagnosis and treatments?
Eubios Journal of Asian and International Bioethics 12 (2002), 21-26.
A patient B in his forties visited Dr. A's clinic. B complained that one of his neighbors intruded his house every night and gave him an injection including poison while he was sleeping and the poison caused his serious general fatigue and insomnia. He was concerned that his organs and his skin (injection sites) were damaged due to venomous injections, resulting in general fatigue. He requested Dr. A to check up on his medical condition and investigate the extent of damages caused by poisonous chemicals.
B looked uneasy and anxious. Physical examination revealed, however, nothing but mosquito bites and mild skin rashes. Dr. A told B that his conditions required blood and urine test to judge whether or not and to what extent the "poison" damage his organs and skin. B agreed to have these tests. Dr. A thought that B's problem was psychiatric and the patient was suffering from a kind of delusional diseases, but did not tell B his impression. After B left Dr. A's clinic, Dr. A personally consulted with a fellow psychiatrist who was working at the same clinic about B's problem. The psychiatrist told Dr. A that the patient was likely to suffer from paranoia and it would be the best method to refer him to a mental clinic. If B refused to see a psychiatrist, it would be necessary to contact with B's family. In the case where the patient's family was unavailable, the fellow psychiatrist suggested, one of alternatives might include prescribing a small amount of psychotropic drugs for B without telling the nature of the drugs.
When B revisited Dr. A's clinic a week later, the patient's condition seemed to get worse. He was restless and looked upset. As soon as he entered the clinic, he started repeating his complaints about an intruder and venom again. He also mentioned that he had changed a place to live several times to run away from the intruder and that local police had ignored his request to arrest the intruder. After listening to the complaints, Dr. A explained that the test results were completely normal and his skin got almost normal. Nothing actually suggested organ damage brought about by poisons injected. Dr. A told B that it might be possible that some sort of mental stress could make B believe what did not really happen to him and recommend B to see a psychiatrist. Dr. A's remark infuriated B and he severely berated Dr. A by saying "You call me a liar. No one believes me, but I am not crazy."
Dr. A gave up persuading B to see a psychiatrist and accepted B's complaints as "true" for the time being. Inquiry about his relative revealed that he got divorced long time ago and had been living alone. No contact address of any family member was available. Dr. A told B that he seemed to be exhausted by a variety of stress and lack of sleep and that it would be a good idea to take a pill for relaxation and good sleep. By saying so indeed, Dr. A attempted to prescribe a small dose of a certain psychotropic drug to alleviate B's delusion without explaining his diagnosis and the nature of treatments. This is because Dr. A was quite sure that B could not understand what his problem really was and would refuse to take any kind of drugs for mental illnesses. Dr. A sincerely wished to alleviate B's suffering and genuinely hope that B could make a comeback to normal life. Is Dr. A allowed to, however, prescribe psychotropic drugs for B without explicit explanation regarding diagnosis and treatments?
Commentary by Koichiro Itai
Department of Philosophy & Ethics, Miyazaki Medical College
5200 Kihara, Kiyotake-cho, Miyazaki-gun, Miyazaki 889-1692 Japan
Any attempt to resolve the ethical dilemma with which we are confronted in this case would always brings about serious antagonism between the principle of respect for autonomy and the principle of beneficence, i.e. doing good for a patient. If Dr. A tried to respect the patient's autonomy he should not prescribe psychotropic drugs to the patient without explicit explanation. On the other hand, if Dr. A thought that it is likely that psychotropic drugs can remove delusions that annoy the patient, the principle of beneficence would suggest or allow the doctor to give the drugs to his suffering patient.
What is an issue here is who, if any, can tell us what the patient's best interest is. In this case, the patient cannot judge what is the best for him. We do not know that the best interest judgment made by others, Dr. A in the case in question, is really consistent to what the patient regard as the best interest for himself. Furthermore, psychotropic drugs have serious and sometime irreversible adverse effects. Prescribing the drugs for B without disclosing such side effects would be against the principle of nonmaleficence, i.e., doing no harm to others. Moreover, psycho education has been given attention in mental health care and the significance of informed consent in psychiatry has been well recognized recently. For instance, in the Ethical Principles of Psychologists and Code of Conduct (APA, 1992), psychologists are required to obtain appropriate informed consent to therapy and related procedures, using language that is reasonably understandable to patients, and to make reasonable efforts to answer patients' questions and to avoid misunderstandings about treatments (1). Not to mention, there are situations that administration of psychotropic drugs to patients with mental illness is justified. In the Declaration on the Rights of Mentally Retarded Persons adapted by the General Assembly of the United Nations (1991), two requirements are given when a proxy decides to commit a mentally ill patient without his or her consent: 1) he or she is incompetent, and 2) an imminent danger to self or others (2). In this case we discuss now, however, the patient is not threatening himself or other persons. Regarding the patient's competency, it is not certain that Dr. A' s judgment about B's capacity is reliable. Our arguments so far seem to lead us to the conclusion that Dr. A should not prescribe any psychotropic agents for B.
Is it really a right answer though? Discussion given above is certainly a logical and rational one and may be a plausible ethical argument, but this case is an actual one and the patient B's suffering is real, not hypothetical. Does the patient have to wait his delusion for improving spontaneously? Should we let the delusion to continue suffering the patient endlessly? As the case suggests, B apparently got worse when he came back to Dr. A's clinic a week later. A history of medicine tells us that many unethical conducts have been done on many patients in the name of medical progress, the best interest of patients themselves, and public welfare, and respect for patient autonomy, i.e., informed consent in this case, is therefore, indispensable in medical care. Nevertheless, I would argue, many of us may be caught in "autonomism" (excessively autonomy-centered justification) for fear of infringement of patient's rights in situation where such infringement is ethically justifiable or even preferable. Such trends should be regarded as protective. In the following, I would like to argue for giving B the psychotropic drugs without explicit explanation regarding diagnosis and treatments.
An issue of mental patients' right to refuse treatment with psychotropic medication is primarily a legal one and the decision by the New York State Court of Appeals in Rivers v. Katz is now accepted as definitive (3). According to the decision, a court may override a patients' right to refuse medication in order to avoid danger to the patient or others. Posing a danger to self or others is almost universally used to justify hospitalizing the patient against his or her will. As refusal of psychiatric treatment is concerned, the primary consideration is usually given to whether or not the patient is competent. Under the laws of the state of California, for example, patients are given a document informing them that they have a right to refuse treatment with psychotropic medication. The document continues:
However, you may be treated with psychotropic drugs over your objection in the case of an emergency or upon a determination that you do not have the capacity to refuse treatment, in a capacity hearing held for this purpose. The hearing officer will determine whether you have the capacity to refuse medication as a form of treatment. You may appeal the determination of the capacity hearing to the superior court of the court of appeal (4).
It is very questionable that the very patient who is handed this form over can really understand the content of the document. Generally speaking, "parens patriae" or "police power", which is a legal concept referred in attempt to justify medical or psychiatric interventions without a patient's consent, may be aimed at maintaining social safety and security. Such concepts tend to protect interests of society as a whole from harms caused by "dangerous individuals" rather than protecting the interests of patients with mental disorders. Therefore, once the two conditions including dangerousness to self or others and mental incompetence are met and involuntary interventions are officially recommended and administered, such forced treatments are supposed to implemented persistently and constantly, not temporary. On the other hand, there should be an another goal and justification of involuntary interventions. I would argue that involuntary psychiatric treatments should be given to a patient who loses mental capacity, aiming at restoring his or her mental capacity by making use of minimal and safe doses of medication. That is to say, similarly paternalistic, what I propose here is primarily to aim at materializing the patient's best interests, not public welfare, through the recovery of patient autonomy.
I am aware that it is possible to refute my proposal by arguing that no one can certainly know what the best interest of an individual is except the individual. However, such an argument is not clinical, not productive, or practical, although it might be interesting from the academic standpoint. It is also possible that slippery slope arguments can be used to object my recommendation. But saying that giving the delusional patient some drugs in order to recover his or her mental capacity will launch the rest of us and other patients down a slippery slope is equivalent to declaring that practical guidelines to prevent it from occurring is useless and futile in the first place. What is important is to establish a safety device to keep unethical conduct from happening at the other end of the slope, not do nothing for fear that something wrong might happen in the future. It should be addressed again that paternalistic interventions in order to restore patient's mental capacity have to be temporary. As soon as the patient becomes competent enough to understand his or her own medical conditions and problems, medication stared without sufficient disclosure should be stopped immediately and informed consent about psychiatric treatments should be obtained from the patient. The main point of my strategy is that a period of medication is strictly limited. It follows that administration of psychotropic agents should be given up when a delusional patient becomes competent. And when the patient refuses to take the pills on the basis of sufficient understanding about benefits and harms of the recommended treatment, then administration of the drugs ought to be discontinued.
Judgment of mental capacity or competency should not be done on the dichotomous basis, i.e., all or none, and the scale to measure patient's capacity must be continuous. We need to set a certain cut-off point to determine whether or not the patient is competent enough to understand what is going on and to calculate benefit/risk ratio from his or her personal standpoint. What is most crucial is that we recognize the nature of mental capacity such as continuity and variability and that we not miss the timing to obtain informed consent from the patient. In the following, I will enumerate conditions required to justify prescribing psychotropic drugs for mentally incompetent psychiatric patients without sufficient explanation regarding diagnosis and treatments.
1. A psychiatrist as well as Dr. A has to agree that the patient B is incompetent. On purpose to keep the procedure due and transparent, guidelines or systematic checking mechanism has to be developed. 2. Drugs given to B should have a minimal side effect and when any of adverse effects develops medication must be stopped immediately. Duration of medication should also be minimal. The primal goal of our medication should be limited to restore the minimal level of capacity, neither to cure the patient nor take his delusion away completely. Therefore, additional drugs should not easily be prescribed. 3. Informed consent should be obtained when it is judged that the patient restores the minimal capacity to agree or disagree the recommended interventions. 4. When the patient refuses to take any sorts of drugs, alternatives should be discussed between B and Dr. A. Only when these conditions are met, and only when psychotropic medication can be expected with a high degree of certainty to be beneficial and can avoid potentially undesirable side effects, involuntary medication without patient's informed consent should be considered ethically justifiable. I believe that this procedure can avoid the risk of slippery slope.
Finally, I would like to add one more thing. As previously mentioned, what is crucial is to establish a safety device to keep unethical conducts from happening at the other end of the slippery slope, but not do nothing for fear that something wrong might happen. However, I want to make it clear that "do something" does not necessarily mean giving psychotropic pills. Confronting with the case where the patient is apparently incapable and suffering and a possibility to improve the patient's condition seems considerable exists, I argued for prescribing drugs for B without informed consent and tried to list essential prerequisite conditions. However, I want to say with special emphasis that "let us give the patient a pill first" is not a good attitude for medical professions to have. Doing something to the patient may include actively and carefully listening to the patient. Although, at a glance, just listening to the patient look like doing nothing, but, in really, the physician's listening actively to the patient's suffering, complaints, and distress should be regarded as useful "interventions." Listening to the patient just passively literally means doing nothing, but considering what they are saying, raising questions, and responding thoughtfully can constitute doing something significant (5). If this active listening was considered ethically and medically more appropriate than temporary administration of psychotropic drugs on purpose to restore the patient capacity, spending with patients without mental capacity, observing them in order to judge their competency in the constant attempt of dialogic reciprocity may be the one we should choose to prescribe.
1. Ethical Principles of Psychologists and Code of Conduct (American Psychological Association, 1992), 4.02 Informed Consent to Therapy. http://www.apa.org/ethics/code.html
2. Declaration on the Rights of Mentally Retarded Persons adapted by the General Assembly of the United Nations(1991), Principle11-6,7,8,13, and 15.
3. Rivers v.Katz, 67 N.Y. 2d 485, 492, 495; N.E. 2d 337, 341, 504; N.Y.S. 2d 74, 78(1986).
4. Ellen Wright Clayton, "Rights of the Mentally Ill to Refuse Medication," American Journal of Law and Medicine 13, No.1(1987): 45-46.
5 Beth J. Singer, Mental Illness: Rights, Competence, and Communication, Glenn McGee(ed.), Pragmatic Bioethics, Vanderbilt University Press, 1999, 141-151.
Commentary by Atsushi Asai
- Atsushi Asai, MD, Mbioeth., DMsc.
Department of Biomedical Ethics, School of Public Health,
Kyoto University Graduate School of Medicine
Konoe-cho, Yoshida, Sakyo-ku, Kyoto 606-8501 Japan
First, I will discuss several arguments for a physician's prescribing psychotropic drugs for a delusional patient without sufficient explanation regarding diagnosis and treatment, i.e. the nature of the drugs. Then, I will argue that the physician ought not to do so for various reasons. Finally, however, the limitations and problems of my conclusion will also be mentioned. I have to admit that, in the outset, I would just be able to defend my conclusion only by a score of 51-49. Important issues to consider in this case are enumerated in the Table.
Arguments for physician's prescribing psychotropic drugs for a delusional patient without sufficient explanation regarding diagnosis and treatment
First, what a good-natured physician thinks is "What I can do in order to help this suffering patient B?" This patient is apparently and seriously suffering by mental illness and his medical conditions undoubtedly require immediate medical and psychiatric interventions. The right of competent patient to refuse medical treatments or procedures has been well and firmly established, but it is doubtful whether such right can be extended to a patient whose capacity, i.e. ability to understand what is going on is impaired. It can be argued that the right to be protected from threats of mental illnesses should be prioritized over the right to self-determination of the patient who cannot do proper self-determination. Birley claimed, when he discussed about compulsory treatment and commitment, that " Every citizen should have the right to be admitted against his or her will, to be treated without loss of dignity, in a first class psychiatric service (1)." Many medical professions would agree that their fundamental mission is to serve the best interest of their patients in need.
Second, the principle of respect for patient autonomy instruct physicians to prescribing psychotropic drugs for a delusional patient without sufficient explanation regarding diagnosis and treatment and defend such act (2). In this case, the very delusion deprives the patient of his capacity of self-determination and his abnormal state of mind let him to refuse appropriate and useful treatment. Therefore, by treating his delusion, it is very likely that he can recover his autonomy. In a sense, temporary overriding of his refusal by deception and manipulative wording can make him truly autonomous in the long run. Therefore, preferable consequence can justify the physician's not saying that he was going to give the patient a psychotropic drug. Deception and manipulations should not be regarded absolutely wrong when such acts can benefit those who are deceived or manipulated.
Third, like the significance of patient autonomy, individual freedom has an inestimable value. It is undoubtedly right to say that freedom should not be restricted without justifiable reasons and due process regardless of his or her psychiatric condition. In this case, however, the quality of freedom should be considered. Is the patient really free under the influence of dreadful delusional thoughts? Does his liberty contribute to his overall happiness? It would be fair to argue that claiming that we should respect one's freedom at any cost is too extreme and a one-sided way of looking at things. In real clinical setting, words and phrases such as autonomy and free will are sometimes far from the reality (3). Therefore, to let the patient really free, the physician's paternalistic intervention is justified.
Fourth, many rational persons would want involuntary treatments for themselves when it is necessary to treat their mental disorders in the event that they were to become non-complaint (4). It might not be unfair to claim that rational preferences and common views of people would support this sort of compulsory interventions if it were done for their best interest. Many people would appreciate such paternalistic treatments once they regain their rationality.
Fifth, many guidelines and jurisdictions regarding involuntary commitment allowed a psychiatrist to commit patients with mental illness in the event there exist dangerousness to self or others. However, this criterion seems insufficient to protect the interests of patients in question discussed here. The patient in question is unlikely to harm self or others at least at this moment. However, should a physician want for the deterioration of the patient? Should the physician stand by and watch his or her patient getting worse and worse? This is objectionable. This is because there is no difficulty to anticipate that the patient loses lots of valuable things and relationship in the progress of deterioration. It may be possible that he loses his job and important personal relationship including marriage and friendship. Can respect for individual liberty and freedom with questionable quality compensate such significant losses that cannot be recovered? Again, the primary goal of medicine is serving the best interest of patients and physician's mission directs him or her therapeutic interventions. Furthermore, without timely treatments, the patient will actually harm self or others in the future.
Arguments against physician's prescribing psychotropic drugs for a delusional patient without sufficient explanation regarding diagnosis and treatment
In the following, I would argue that the physician should not prescribe psychotropic drugs for a delusional patient without sufficient explanation regarding diagnosis and treatment.
First, although it is reasonable to claim that the primary goal of medicine is benefiting suffering patients in need and physicians of virtue feel compelled to help patients like the one in question. Nevertheless, there exist many factual questions: Does a chosen psychotropic drug or any other psychotropic drugs really work to remove the delusion? Can the patient really recover his autonomy? To what extent does the delusion of the patient damage his capacity to understand? How serious is he troubled with the delusion? How likely will he deteriorate resulting in harming self or others? It is suspicious that the physician precisely estimates the possibilities. These are problems that require highly specialized psychiatric training, experiences and skills. Even if the physician in the case in question can do such estimations and prediction, many others may not do so. Especially, deciding patient's capacity is very difficult and controversial issue. Therefore, the good will to help cannot solely justify the prescription of psychotropic drugs for a delusional patient without relevant explanation. In addition, serious adverse effects can occur to the patient and harms caused by the medication can overwhelm the benefit that gives. Side effects of psychotropic drug are disturbing and sometime irreversible. That is why we need serious consideration in this regard. Lo claimed, "The ethical guideline of preventing harm is generally regarded as having more moral force than the guideline of doing good. Thus, the obligation to prevent harms to nonautonomous psychiatric patients or to their parties is stronger than the duty to do good by helping psychiatric patients recover from their diseases (5)." We are required stronger reasons to do something to others than to do nothing.
Second, an individual physician cannot judge what is a good life for others or determine the quality of freedom. No one can do so. It would be fair to claim that respect for one's freedom at any cost is too extreme and a one-sided way of looking at things. However, granting physicians a special privilege to decide other's quality of freedom, happiness, and ideal life are more problematic and dangerous than respect for freedom at any cost. The abuse or misuse of the privilege is likely to happen. For example, suppose one physician believes in one religion. He conscientiously thinks that those who cannot believe the religion are unhappy and need psychiatric treatment; also imagine that he also regards homosexual people as sick and abnormal. In such cases, the physician might give his patients psychotropic drugs without informed consent. This kind of "good deeds" needs no malice. It is also suggested that a boundary between being normal and being abnormal is sometimes difficult and may be under the influence of personal or religious beliefs. Furthermore, the risk of ill-intended abuse of privilege to determine other's quality of freedom, happiness, and ideal life should not be neglected.
Third, the risk of slippery slope should not also be forgotten. In the case in question, we are thinking about the ethical permissibility of prescribing psychotropic drugs for a delusional patient without sufficient explanation regarding diagnosis and treatment. However, once this kind of act is accepted, what can follow? For example, some physicians might try to administer a large amount of psychotropic drugs to their patients without sufficient disclosure and consent. Others could give their patients major tranquilizers by explaining that they are medication for stomach. In the name of the best interest of the patient, even lobotomy can be performed in the worst scenario. Therefore, it would be better to stick to protection of freedom as a fundamental human right and we should stand the criteria of dangerousness to themselves or others as the ground of compulsory or manipulative treatments.
Fourth, the claim that rational preferences and common views of people would support compulsory interventions if they were done for their best interest is not plausible. This ignores differences in preferences and values among people. Not to mention, people living with mental illness have their own desires, goals, or personal projects and it would be arrogant to assume that psychiatric patients cannot have personal wishes or perspective as we can. We are all different and it might be prudent to say that one should not do what one would not have others behave oneself to others. Of course, the Golden Rule teaches us that one should behave toward others as one would have others behave toward oneself and we can learn a lot from this lesson (6). If the physician followed this rule and gave the patient sufficient explanation and dialogue at the same time, it would be morally praiseworthy. In any case, that I would want others to do for me cannot be sufficient reasons to do something to others without their permission.
Fifth, an attempt to prescribe psychotropic drugs for a delusional patient without sufficient explanation regarding diagnosis and treatment can be regarded impractical as well as futile. Most psychotropic drugs have significant side effects and most uninformed patients would discontinue taking the pills sooner or later because of discomfort caused by the medication. Even the informed patients would stop taking drugs. For example, mildly depressive patients who understand benefits and side effects of antidepressants sometimes cannot tolerate adverse effects of medication. Especially in ambulatory settings like the case in question, no one could impose the patient to swallow the pill. It should also be noted that the attempt resulting in giving the patient serious side effects would destroy a chance of establishing physician-patient relationship. It is possible that if the patient trusted the physician well enough, the former might change obstinate attitudes and try to listen to physician's recommendation even under the influence of his delusion.
Conclusions and problems
In conclusions, I would argue that it is not preferable for us to live in a society where an individual physician is allowed to deprive patients with mental illnesses of their freedom without disclosing the truth regarding diagnosis and the nature of treatments. A current list of "human rights" includes a lot of rights and the right of liberty or freedom should be regarded as the most fundamental one. The protection of individual right to liberty is the last resort to guarantee free, safe, and happy life. Unless there exists high likelihood of dangerousness to themselves and others, we should insist on the protection of this basic right. I would admit, at the same time however, my conclusion may deprive a conscientious physician of a chance to help patients in need and a society might fail to prevent patients with mental disorders from leading a life of agony. Therefore, as a physician, ambivalence towards my own conclusion exists in my mind. That is why I wrote in the beginning that I could support my conclusion only by a score of 51-49. All we can do is to choose the lesser evil. It should also be added that the problem discussed here is not uncommon in the clinical setting and medical professions are often confronted with a serious ethical dilemma. I dare say that those who can come to one conclusion with no difficulty may not be well informed of the seriousness of the ethical dilemma involved in this case.
Finally, I would comment on two more issues. First, a slippery slope argument was used against physician's prescribing psychotropic drugs for a delusional patient without sufficient explanation regarding diagnosis and treatment. However, this kind of the argument has an apparent weak point. Discussing the opposition against active euthanasia for severely suffering and disable new born infants based on the slippery slope argument, one physician correctly argued that "Slippery slope arguments against euthanasia in such cases appear to many to be especially unjust. Such arguments appear to say to the baby, "As far as your interests are concerned it would be morally best if we induced a quick and painless death. But if we do, it will launch the rest of us down a slippery slope. So put up with your distress, and save us all from slippery slopes (7)." This criticism can perfectly apply to the case in question. Second, one alternative solution may be the establishment of ethical guidelines or holding a hospital ethical committee to deal with this sort of dilemma. Due process and collective evaluation about facts and informed decisions is clearly better than one physician's individual decision. Nevertheless, even it is true that the decision made is well balanced and more considerate, what is to happen to the delusional patient in question is the same from his own perspective. His freedom and wishes not to have psychiatric treatments is to be overridden. What the patient thinks is good is ignored. Therefore, it is still uncertain whether or not such due procedure can really be regarded as due.
J. L. T. Birley Psychiatrist and Citizens. Brit. J. Psychiatry 1991; 159: 1-6.
Heather Sones The Right to Refuse Psychotropic Drugs. The Canadian Nurse 1993; 89: 27-30.
Yuval Melamed, Dafna Fromer, Ziomna Kemelman, Yoram Barak Working with mentally ill homelss persons: should we respect their quest for anonymity? JME 2000;26:175-178.
Allen E. Buchanan, Dan W. Brock Deciding or Others The Ethics of Surrogate Decision Making. Cambridge University Press, 1990, Cambridge, 311-325.
Bernard Lo.: Resolving Ethical Dilemmas: A Guide for Clinicians. Williams and Wilkins, Baltimore, 1995, 243-250.
The American Heritage_ Dictionary of the English Language, Third Edition, 1992, Houghton Mifflin Company. Electronic version licensed from INSO Corporation.
Neil Cambpell When Care Cannot Cure: Medical Problems in Seriously Ill Babies. F.K. BELLER and R. F. WEIR (ed), The Beginning of Human Life, 327-44, Kluwer Academic Publishers, 1994.
Table: Issues to Consider
Patient's suffering, a need of treatments, and physician's basic mission
The right to self-determination and autonomy and the right to be protected
Doubts about the right of incompetent patient to refuse treatments
Recovery of autonomy and paternalism
Foreseeable undesirable consequences
Judgments about patient's capacity
Freedom as fundamental human rights and the quality of freedom
A boundary of normality and abnormality
Abuse and misuse
Risk of slippery slope
Physician's ability to diagnose mental illness and evaluate patient's capacity
Practical and clinical problems
Priority of non-maleficence over beneficence and harms inflicted by treatments
Ethicality of lying and deception
The Need For Due Process in Psychiatric Ethics: Commentary on Itai & Asai
- Frank (Yeruham) Leavitt, Ph.D.
Chairman, The Centre for International Bioethics
Faculty of Health Sciences
Ben Gurion University of the Negev, Beer Sheva, Israel
I've been looking for good material on psychiatric ethics to use in my teaching. I'll certainly use Itai and Asai's article as assigned reading in my courses. It is in psychiatric, paediatric and geriatric medicine that the question of autonomy becomes most problematic. We have patients who are not clearly capable of autonomous decisions. But they are not totally incapable either.
Itai and Asai argue for their positions so persuasively that it is hard to decide who is right. Obviously real life situations are much more complex than one can sum up in a bioethics article. And maybe we could make a more confident decision if we really met the patient. But even there, it is doubtful that any one physician could be quite sure of making the right decision, or of doing any better than what Asai calls a "51-49" situation. It is for this reason that I think that Asai's last word is the right one: He suggests calling an ethics committee meeting for a problem of this sort, saying: "Due process and collective evaluation about facts and informed decisions is clearly better than one physician's individual decision".
I would say in general that some kinds of clinical decisions are simply too weighty and complex, with too far-reaching consequences, for one physician, even the most learned and experience professor, to make the decision. I would like to suggest three kinds of decisions, which should be made by groups, and not individuals:
In all of these cases, the group might be a hospital ethics committee. Or it might (in my opinion, most preferably) be the ward staff meeting, including physicians, nurses and social workers, and perhaps preceded by consultation with the patient's family. Or it might be an impromptu staff discussion in the coffee room. The exact forum is not crucial. What is crucial is the physician's humility to admit that we are dealing with issues, which are too big for one person to handle alone.
Although the Israeli Patient's Rights Law of 1996 requires that all hospitals have clinical ethics committees, a number of hospitals have still not established committees. This is true at least as of September 2001, which was the last time I looked into the matter. I think that this situation is not totally unjustified. Physicians, including psychiatrists, may have good reason to suspect that an ethics committee would be too "autonomistic" in its ideology, thereby hampering beneficence towards patients. And as we have learned from Itai and Asai, dogmatically insisting on autonomy is not always clinically appropriate. If the institutions of ethics committees and ethicists are going to work, much needs to be done to develop an atmosphere in which physicians will be able to trust ethicists to consider the detailed nuances of each case, without insisting dogmatically upon principles like autonomy.
- Decisions to withhold information about treatment (as in the present case).
- DNR decisions (even if the patient has requested or assented).
- Decisions to disconnect a ventilator from a terminal patient.
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