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Faissner M, Braun E. The ethics of coercion in mental healthcare: the role of structural racism. JOURNAL OF MEDICAL ETHICS 2024; 50:476-481. [PMID: 37845011 PMCID: PMC11228209 DOI: 10.1136/jme-2023-108984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 09/28/2023] [Indexed: 10/18/2023]
Abstract
In mental health ethics, it is generally assumed that coercive measures are sometimes justified when persons with mental illness endanger themselves or others. Coercive measures are regarded as ethically justified only when certain criteria are fulfilled: for example, the intervention must be proportional in relation to the potential harm. In this paper, we demonstrate shortcomings of this established ethical framework in cases where people with mental illness experience structural racism. By drawing on a case example from mental healthcare, we first demonstrate that biases in assessing whether the coercive intervention is proportional are likely, for example, due to an overestimation of dangerousness. We then show that even if proportionality is assessed correctly, and the specific coercive intervention would thus be regarded as ethically justified according to the standard framework, coercion may still be ethically problematic. This is because the standard framework does not consider how situations in which coercive measures are applied arise. If structural racism causally contributes to such situations, the use of coercion can compound the prior injustice of racist discrimination. We conclude that the ethical analysis of coercion in mental healthcare should consider the possibility of discriminatory biases and practices and systematically take the influence of structural discrimination into account.
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Affiliation(s)
- Mirjam Faissner
- Department of Psychiatry, Psychotherapy and Preventive Medicine, Ruhr University Bochum, Bochum, Germany
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Esther Braun
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
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Faissner M, Brünig L, Gaillard AS, Jieman AT, Gather J, Hempeler C. Intersectionality as a tool for clinical ethics consultation in mental healthcare. Philos Ethics Humanit Med 2024; 19:6. [PMID: 38693533 PMCID: PMC11064353 DOI: 10.1186/s13010-024-00156-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 03/03/2024] [Indexed: 05/03/2024] Open
Abstract
Bioethics increasingly recognizes the impact of discriminatory practices based on social categories such as race, gender, sexual orientation or ability on clinical practice. Accordingly, major bioethics associations have stressed that identifying and countering structural discrimination in clinical ethics consultations is a professional obligation of clinical ethics consultants. Yet, it is still unclear how clinical ethics consultants can fulfill this obligation. More specifically, clinical ethics needs both theoretical tools to analyze and practical strategies to address structural discrimination within clinical ethics consultations. Intersectionality, a concept developed in Black feminist scholarship, is increasingly considered in bioethical theory. It stresses how social structures and practices determine social positions of privilege and disadvantage in multiple, mutually co-constitutive systems of oppression. This article aims to investigate how intersectionality can contribute to addressing structural discrimination in clinical ethics consultations with a particular focus on mental healthcare. To this end, we critically review existing approaches for clinical ethics consultants to address structural racism in clinical ethics consultations and extend them by intersectional considerations. We argue that intersectionality is a suitable tool to address structural discrimination within clinical ethics consultations and show that it can be practically implemented in two complementary ways: 1) as an analytic approach and 2) as a critical practice.
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Affiliation(s)
- Mirjam Faissner
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany.
- Institute of the History of Medicine and Ethics in Medicine, Charité - Universitätsmedizin Berlin, Thielallee 71, 14195, Berlin, Germany.
| | - Lisa Brünig
- Institute for Ethics, History and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
| | - Anne-Sophie Gaillard
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Anna-Theresa Jieman
- Department of Biological and Experimental Psychology, School of Biological and Behavioural Sciences, Queen Mary University of London, London, UK
| | - Jakov Gather
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Christin Hempeler
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
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Vo H, Campelia GD, Olszewski AE. Addressing Racism in Ethics Consultation: An Expansion of the Four-Box Method. THE JOURNAL OF CLINICAL ETHICS 2023; 34:11-26. [PMID: 36940357 DOI: 10.1086/723322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
Abstract
AbstractRacism is a pervasive issue in patient care and a key social determinant of health. Clinical ethicists, like others involved in patient care, have a duty to recognize and respond to racism on both individual and systems-wide levels to improve patient care. Doing so can be challenging and, like other skills in ethics consultation, may benefit from specialized training, standardized tools and approaches, and practice. Learning from existing frameworks and tools, as well as building new ones, can help guide clinical ethicists to systematically approach racism as it affects clinical cases. Here, we propose an expansion of the commonly used four-box method to clinical ethics consultation, where racism is considered as a potential factor in each of the four boxes. We apply this method to two clinical cases to highlight ethically salient information that might be missed using the standard formulation of the four boxes but captured with the expanded version. We argue that this expansion of an existing clinical ethics consultation tool is ethically justified insofar as it (a) creates a more just approach, (b) supports individual consultants and services, and (c) facilitates communication in contexts where racism impinges on effecting good patient care.
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Bell JAH, Salis M, Tong E, Nekolaichuk E, Barned C, Bianchi A, Buchman DZ, Rodrigues K, Shanker RR, Heesters AM. Clinical ethics consultations: a scoping review of reported outcomes. BMC Med Ethics 2022; 23:99. [PMID: 36167536 PMCID: PMC9513991 DOI: 10.1186/s12910-022-00832-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 08/30/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical ethics consultations (CEC) can be complex interventions, involving multiple methods, stakeholders, and competing ethical values. Despite longstanding calls for rigorous evaluation in the field, progress has been limited. The Medical Research Council (MRC) proposed guidelines for evaluating the effectiveness of complex interventions. The evaluation of CEC may benefit from application of the MRC framework to advance the transparency and methodological rigor of this field. A first step is to understand the outcomes measured in evaluations of CEC in healthcare settings. OBJECTIVE The primary objective of this review was to identify and map the outcomes reported in primary studies of CEC. The secondary objective was to provide a comprehensive overview of CEC structures, processes, and roles to enhance understanding and to inform standardization. METHODS We searched electronic databases to identify primary studies of CEC involving patients, substitute decision-makers and/or family members, clinicians, healthcare staff and leaders. Outcomes were mapped across five conceptual domains as identified a priori based on our clinical ethics experience and preliminary literature searches and revised based on our emerging interpretation of the data. These domains included personal factors, process factors, clinical factors, quality, and resource factors. RESULTS Forty-eight studies were included in the review. Studies were highly heterogeneous and varied considerably regarding format and process of ethical intervention, credentials of interventionist, population of study, outcomes reported, and measures employed. In addition, few studies used validated measurement tools. The top three outcome domains that studies reported on were quality (n = 31), process factors (n = 23), and clinical factors (n = 19). The majority of studies examined multiple outcome domains. All five outcome domains were multidimensional and included a variety of subthemes. CONCLUSIONS This scoping review represents the initial phase of mapping the outcomes reported in primary studies of CEC and identifying gaps in the evidence. The confirmed lack of standardization represents a hindrance to the provision of high quality intervention and CEC scientific progress. Insights gained can inform the development of a core outcome set to standardize outcome measures in CEC evaluation research and enable scientifically rigorous efficacy trials of CEC.
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Affiliation(s)
- Jennifer A H Bell
- Department of Clinical and Organizational Ethics, University Health Network, Toronto, ON, Canada. .,Department of Supportive Care Research, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada. .,The Institute for Education Research, University Health Network, Toronto, ON, Canada. .,Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada. .,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
| | - Marina Salis
- Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada.,Department of Philosophy, University of Toronto, Toronto, ON, Canada.,William Osler Health System, Brampton, ON, Canada
| | - Eryn Tong
- Department of Supportive Care Research, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Erica Nekolaichuk
- Gerstein Science Information Centre, University of Toronto Libraries, University of Toronto, Toronto, ON, Canada
| | - Claudia Barned
- Department of Clinical and Organizational Ethics, University Health Network, Toronto, ON, Canada.,The Institute for Education Research, University Health Network, Toronto, ON, Canada.,Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada.,Pragmatic Health Ethics Research Unit, Institut de Recherches Cliniques de Montreal, Montreal, QC, Canada
| | - Andria Bianchi
- Department of Clinical and Organizational Ethics, University Health Network, Toronto, ON, Canada.,The Institute for Education Research, University Health Network, Toronto, ON, Canada.,Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada.,KITE Research Institute, Toronto Rehabilitation, Toronto, ON, Canada
| | - Daniel Z Buchman
- Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada.,Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Kevin Rodrigues
- Department of Clinical and Organizational Ethics, University Health Network, Toronto, ON, Canada.,The Institute for Education Research, University Health Network, Toronto, ON, Canada.,Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
| | - Ruby R Shanker
- Department of Clinical and Organizational Ethics, University Health Network, Toronto, ON, Canada.,The Institute for Education Research, University Health Network, Toronto, ON, Canada.,Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
| | - Ann M Heesters
- Department of Clinical and Organizational Ethics, University Health Network, Toronto, ON, Canada.,The Institute for Education Research, University Health Network, Toronto, ON, Canada.,Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
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