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Whittington R, Aluh DO, Caldas-de-Almeida JM. Zero Tolerance for Coercion? Historical, Cultural and Organisational Contexts for Effective Implementation of Coercion-Free Mental Health Services around the World. Healthcare (Basel) 2023; 11:2834. [PMID: 37957978 PMCID: PMC10650021 DOI: 10.3390/healthcare11212834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 10/10/2023] [Accepted: 10/19/2023] [Indexed: 11/15/2023] Open
Abstract
Coercion of service users/patients when receiving care and treatment has been a serious dilemma for mental health services since at least the 18th century, and the debate about how best to minimise or even eradicate compulsion remains intense. Coercion is now, once again and rightly, at the top of the international policy agenda and the COST Action 'FOSTREN' is one example of a renewed commitment by service user advocates, practitioners and researchers to move forward in seriously addressing this problem. The focus of service improvement efforts has moved from pure innovation to practical implementation of effective interventions based on an understanding of the historical, cultural and political realities in which mental health services operate. These realities and their impact on the potential for change vary between countries across Europe and beyond. This article provides a novel overview by focusing on the historical, cultural and political contexts which relate to successful implementation primarily in Europe, North America and Australasia so that policy and practice in these and other regions can be adopted with an awareness of these potentially relevant factors. It also outlines some key aspects of current knowledge about the leading coercion-reduction interventions which might be considered when redesigning mental health services.
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Affiliation(s)
- Richard Whittington
- Centre for Research & Education in Security, Prisons and Forensic Psychiatry, Forensic Department Østmarka, St. Olav’s Hospital, 7030 Trondheim, Norway
- Department of Mental Health, Norwegian University of Science & Technology (NTNU), 7034 Trondheim, Norway
- Department of Public Health, Policy & Systems, University of Liverpool, Liverpool L69 3BX, UK
| | - Deborah Oyine Aluh
- Lisbon Institute of Global Mental Health, Comprehensive Health Research Centre, Nova Medical School, 1169-056 Lisbon, Portugal
- Department of Clinical Pharmacy and Pharmacy Management, University of Nigeria Nsukka, Nsukka 410105, Nigeria
| | - Jose-Miguel Caldas-de-Almeida
- Lisbon Institute of Global Mental Health, Comprehensive Health Research Centre, Nova Medical School, 1169-056 Lisbon, Portugal
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Perry J. Challenges of anticipation of future decisions in dementia and dementia research. HISTORY AND PHILOSOPHY OF THE LIFE SCIENCES 2022; 44:62. [PMID: 36376514 PMCID: PMC9663374 DOI: 10.1007/s40656-022-00541-8] [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: 10/15/2021] [Accepted: 09/27/2022] [Indexed: 06/16/2023]
Abstract
Anticipation of future decisions can be important for individuals at risk for diseases to maintain autonomy over time. For future treatment and care decisions, advance care planning is accepted as a useful anticipation tool. As research with persons with dementia seems imperative to develop disease-modifying interventions, and with changing regulations regarding research participation in Germany, advance research directives (ARDs) are considered a solution to include persons with dementia in research in an ethically sound manner. However, little is known about what affected people deem anticipatable.This contribution provides a critical reflection of the literature on anticipation and of a qualitative study on the assessment of ARDs with persons with cognitive impairment in Germany. It combines theoretical and empirical reflections to inform the ethical-legal discourse.Anticipation involves the conceptual separation of the past, the present, and the future. Including dimensions such as preparedness, injunction, and optimization helps in establishing a framework for anticipatory decision-making. While dementia may offer a window of time to consider future decisions, individual beliefs about dementia including fears about stigma, loss of personhood, and solitude strongly impact anticipating sentiments. Concepts of anticipation can be useful for the examination of uncertainty, changing values, needs, and preferences interconnected with the dementia trajectory and can serve as a means to make an uncertain future more concrete. However, fears of losing one's autonomy in the process of dementia also apply to possibilities of anticipation as these require cognitive assessment and reassessment of an imagined future with dementia.
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Affiliation(s)
- Julia Perry
- Department of Medical Ethics and History of Medicine, University Medical Center Göttingen, Humboldtallee 36, 37073, Göttingen, Germany.
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Starke G, De Clercq E, Borgwardt S, Elger BS. Why educating for clinical machine learning still requires attention to history: a rejoinder to Gauld et al. Psychol Med 2021; 51:2512-2513. [PMID: 33308336 DOI: 10.1017/s0033291720004766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Georg Starke
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - Eva De Clercq
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - Stefan Borgwardt
- Department of Psychiatry, University of Basel, Basel, Switzerland
- Department of Psychiatry and Psychotherapy, University of Lübeck, Lübeck, Germany
| | - Bernice Simone Elger
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
- University Center of Legal Medicine, University of Geneva, Geneva, Switzerland
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Gillies RD, Lim I. Psychiatry in Nazi Germany: an ethical analysis and relevance to psychiatry today. Australas Psychiatry 2021; 29:406-408. [PMID: 33626308 DOI: 10.1177/1039856221992639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To investigate the war crimes committed by psychiatrists during the German Nazi regime in the twentieth century and better understand the moral arguments used to justify them. METHOD This article provides a historical review of the crimes committed by psychiatrists in Nazi Germany and ethical analysis from the perspectives of consequentialism and deontology. RESULTS Nazi psychiatrists oversaw the death of more than 200,000 people with mental illnesses and inflicted harm on many more. Consequentialist reasoning may have been used to justify these atrocities. Deontological reasoning proved impervious to exploitation by the Nazi regime, but without codification it was too easily abandoned and thus failed to protect patients. CONCLUSIONS A duty-based code of ethics that enshrines universal respect for the humanity, dignity and autonomy of all persons, and condemns the misuse of professional knowledge and skills, may be a safeguard against the future political abuse of psychiatry.
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Affiliation(s)
| | - Izaak Lim
- Department of Psychiatry, School of Clinical Sciences, Monash University, Clayton, VIC, Australia.,Early in Life Mental Health Service, Monash Health, Clayton, VIC, Australia
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Freudenreich O, Kontos N, Querques J. Ethics in Public and Community Psychiatry. Psychiatr Ann 2021. [DOI: 10.3928/00485713-20210511-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Chivilgina O, Elger BS, Jotterand F. Digital Technologies for Schizophrenia Management: A Descriptive Review. SCIENCE AND ENGINEERING ETHICS 2021; 27:25. [PMID: 33835287 PMCID: PMC8035115 DOI: 10.1007/s11948-021-00302-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 03/23/2021] [Indexed: 05/05/2023]
Abstract
While the implementation of digital technology in psychiatry appears promising, there is an urgent need to address the implications of the absence of ethical design in the early development of such technologies. Some authors have noted the gap between technology development and ethical analysis and have called for an upstream examination of the ethical issues raised by digital technologies. In this paper, we address this suggestion, particularly in relation to digital healthcare technologies for patients with schizophrenia spectrum disorders. The introduction of digital technologies in psychiatry offers a broad spectrum of diagnostic and treatment options tailored to the health needs and goals of patients' care. These technologies include wearable devices, smartphone applications for high-immersive virtual realities, smart homes, telepsychiatry and messaging systems for patients in rural areas. The availability of these technologies could increase access to mental health services and improve the diagnostics of mental disorders. In this descriptive review, we systematize ethical concerns about digital technologies for mental health with a particular focus on individuals suffering from schizophrenia. There are many unsolved dilemmas and conflicts of interest in the implementation of these technologies, such as (1) the lack of evidence on efficacy and impact on self-perception; (2) the lack of clear standards for the safety of their daily implementation; (3) unclear roles of technology and a shift in the responsibilities of all parties; (4) no guarantee of data confidentiality; and (5) the lack of a user-centered design that meets the particular needs of patients with schizophrenia. mHealth can improve care in psychiatry and make mental healthcare services more efficient and personalized while destigmatizing mental health disorders. To ensure that these technologies will benefit people with mental health disorders, we need to heighten sensitivity to ethical issues among mental healthcare specialists, health policy makers, software developers, patients themselves and their proxies. Additionally, we need to develop frameworks for furthering sustainable development in the digital technologies industry and for the responsible usage of such technologies for patients with schizophrenia in the clinical setting. We suggest that digital technology in psychiatry, particularly for schizophrenia and other serious mental health disorders, should be integrated into treatment with professional supervision rather than as a self-treatment tool.
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Affiliation(s)
- Olga Chivilgina
- Institute of Biomedical Ethics, University of Basel, Basel, Switzerland.
| | - Bernice S Elger
- Institute of Biomedical Ethics, University of Basel, Basel, Switzerland
- Unit of Health Law & Humanitarian Medicine At the Institute for Legal Medicine, University of Geneva, Geneva, Switzerland
| | - Fabrice Jotterand
- Institute of Biomedical Ethics, University of Basel, Basel, Switzerland
- Center for Bioethics and Medical Humanities, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, USA
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How Stigma Distorts Justice: the Exile and Isolation of Leprosy Patients in Hawai`i. Asian Bioeth Rev 2018; 10:53-66. [PMID: 33717275 DOI: 10.1007/s41649-018-0042-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 02/17/2018] [Indexed: 10/26/2022] Open
Abstract
Leprosy has taken on many names throughout human history. But none of its nomenclature has adequately captured the essence of what it has historically meant to live with the disease like the Hawaiian term ma`i ho`oka`awale, or "the separating sickness." The appropriateness of this term is twofold: on the one hand, it accurately reflects the physical isolation imposed on leprosy patients as a result of stigmatization and quarantine policies; on the other, it seems fitting to use the language of the culture and race that leprosy so disproportionately affected in nineteenth and twentieth century Hawai`i. This essay offers an ethical analysis of the treatment of leprosy patients in Hawai`i to identify mistakes made in the sphere of public health to better guide the management of infectious diseases today. It provides an historical overview of leprosy in order to contextualize its journey to the Hawaiian Islands, with a particular focus on the horrific century-long isolation of leprosy patients to the remote Kalaupapa settlement. It then presents two contrasting normative claims about the banishment and isolation practices by using two different theories of justice: utilitarianism and Rawls' justice as fairness. In doing so, this essay illustrates the ways in which stigmatization and racism could likely affect the abhorrent treatment of leprosy patients by disproportionately appealing to the "greater good." However, I contend that this dichotomization of justice brings us to a moral impasse in the context of public health. Rather, considering infectious diseases with a "patient as victim and vector" (PVV) approach may prove more beneficial, especially in tandem with a schema of justice that promotes self-respect as a primary good to combat the deleterious effects of stigma. This historical reflection may thus allow medical professionals and policy makers alike to draw upon valuable ethical lessons for contemporary initiatives in public health.
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Campo-Arias A, Herazo E. Innovations, Reviews and Proposals on the DSM-5: the Case of Sexual Dysfunctions, Gender Dysphoria and Paraphilic Disorders. ACTA ACUST UNITED AC 2018; 47:56-64. [PMID: 29428123 DOI: 10.1016/j.rcp.2016.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 08/25/2016] [Indexed: 11/18/2022]
Abstract
Human behaviours have different meanings according to the historical moment and context. In this article sexual behaviours are taken as a category in order to analyse how psychiatric nosology is structured, as manifested in texts such as the DSM-5. The development of these diagnostic manuals are tools that are far from being free of subjectivities and interference of elements of power, expressed in the way health, illness, mental health, and mental disorders, are assumed; in short, the normal and pathological. Each new diagnosis, or even its elimination, and the recomposing of the different diagnostic criteria, especially in the field of sexual behaviour, present visions of how individual and collective human life is conceived, as well as an expression of accurate attempts to control human sexualities through the medicalisation of behaviour, coupled with moral, religious, and even legal considerations. Categories such as gender dysphoria, paraphilia or paraphilic disorders are examples of how the limits intended to establish a biomedical perspective are also incomplete and imprecise. These violate individual and social construction of sexualities and the conception of mental health, showing persistent difficulties and controversies that are evident in the way psychiatric classifications are made.
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Affiliation(s)
- Adalberto Campo-Arias
- Instituto de Investigación del Comportamiento Humano (Human Behavioral Research Institute), Bogotá, Colombia; Programa de Medicina, Facultad de Ciencias de la Salud, Universidad del Magdalena, Santa Marta, Colombia.
| | - Edwin Herazo
- Instituto de Investigación del Comportamiento Humano (Human Behavioral Research Institute), Bogotá, Colombia
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Abstract
In 1943, Leo Kanner published the first systematic description of early infantile autism. He concluded that this was a neurodevelopmental disorder and that 'these children have come into the world with an innate inability to form the usual, biologically provided contact with people'. Moreover, his astute descriptions of parental behavior in his first publications were prescient and underlie later recognition of the importance of genetics. Our understanding has grown over the ensuing years with revisions in diagnostic classification, recognition of the broader autism phenotype in families, appreciation of the importance of developmental models, advances in genetic methodology, better understanding of the relationship to intellectual deficits, recognition of syndromic autism in neurogenetic sydromes, advances in neuroimaging, and advances in animal models, both mutant mouse models and transgenic non human primate models. Kanner recognized diagnostic heterogeneity and opined that the children had not read those diagnostic manuals and did not easily fall into clear cut categories. Such heterogeneity continues to confound our diagnostic efforts. Always an advocate for children, when reviewing the DSM III criteria in 1980, Kanner emphasized that no matter how well developed our criteria each child must be treated as a unique person.
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Affiliation(s)
- James Harris
- a Department of Psychiatry and Behavioral Sciences , The Johns Hopkins University School of Medicine , Baltimore , MD , USA
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de Silva P. How to improve psychiatric services: a perspective from critical psychiatry. Br J Hosp Med (Lond) 2017; 78:503-507. [DOI: 10.12968/hmed.2017.78.9.503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Damulin IV. Eponyms related to Nazism neurosciences. Zh Nevrol Psikhiatr Im S S Korsakova 2017; 117:174-177. [DOI: 10.17116/jnevro201711721174-177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Maltreatment of people with serious mental illness in the early 20th century: a focus on Nazi Germany and eugenics in America. J Nerv Ment Dis 2012. [PMID: 23197125 DOI: 10.1097/nmd.0b013e318275d391] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Prejudice and stigma against people with mental illness can be seen throughout history. The worst instance of this prejudice was connected to the rise of the eugenics movement in the early 20th century. Although the Nazi German T-4 program of killing people with mental illness was the most egregious culmination of this philosophy, the United States has its own dark eugenics history-nearing a slippery slope all too similar to that of the Nazis. Mental health care clinicians need to examine this period to honor the memory of the victims of eugenics and to guarantee that nothing like this will ever happen again.
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Psychiatric Ethics — A Complicated Challenge. Psychiatr Ann 2007. [DOI: 10.3928/00485713-20071201-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Robertson M, Morris K, Walter G. Overview of psychiatric ethics V: utilitarianism and the ethics of duty. Australas Psychiatry 2007; 15:402-10. [PMID: 17828638 DOI: 10.1080/10398560701439640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The aim of this paper is to describe the ethical theories of utilitarianism and the ethics of duty (Kant's ethics) and to evaluate their value as theoretical bases of psychiatric ethics. CONCLUSIONS Utilitarianism is a well-established moral philosophy and has significant instrumental value in dealing with common ethical problems faced by psychiatrists. Despite its capacity to generate solutions to ethical problems, utilitarianism requires a process of what Rawls described as 'reflective equilibrium' to avoid morally repugnant choices, based on utility. The criticisms of utilitarianism, such as the problems of quantifying utility and the responsibility for consequences, are very relevant for psychiatry. Singer's model of utilitarian thinking is particularly problematic for our profession. Kant's ethics provides the pretext for duty bound codes of ethics for psychiatrists, but suffers from problems of flawed claims to the universalizability prescribed by Kant's 'categorical imperative'. Kant's valorization of reason as the core of the autonomy of persons is a valuable insight in understanding psychiatrists' ethical obligations to their patients.
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Affiliation(s)
- Michael Robertson
- Royal Prince Alfred Hospital and Sydney South West Area Health Service (Eastern Sector), NSW, Australia.
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Abstract
OBJECTIVE The aim of this paper is to describe the current status of psychiatric ethics as a form of professional ethics and apply this approach to a common clinical situation. CONCLUSION Psychiatry is a profession and, like all professions, comprises a set of specific skills and knowledge that are applied for the 'common good' of society. Such a proposition places the psychiatrist in a position of tension between contractarian and Hippocratic ideals of ethical conduct, in that there is an assumption of moral equivalence between the law and ethics. The supposition that legally defensible behaviours are the same as ethically defensible behaviours is integral to the definition of professional ethics. This frequently places psychiatrists at odds with the 'do no harm' principle.
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Affiliation(s)
- Michael Robertson
- Royal Prince Alfred Hospital and Sydney South West Area Health Service (Eastern Sector), Sydney, NSW, Australia.
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