Clinical Ethics Support Services Are Not as Well-Established in Forensic Psychiatry as in General Psychiatry

[Theoretical foundations of clinical ethics consultation in psychiatry]

BACKGROUND

Clinical ethics consultants support mental health professionals in identifying and analyzing moral problems in clinical practice.

OBJECTIVE

Presentation of key ethical concepts and normative theories that are relevant for clinical ethics consultation in mental healthcare.

MATERIAL AND METHODS

Conceptual and ethical analyses.

RESULTS

After distinguishing between morality, ethics and law, moral problems are differentiated from other types of problems encountered in clinical practice. Subsequently, key ethical concepts and the concept of moral distress are clarified. In relation to the normative framework a distinction is made between philosophical ethical theories and medical ethical theories, such as principlism and the ethics of care. Finally, justification tests for ethical decision-making in situations of danger to self or others based on the harm principle and soft paternalism are proposed.

CONCLUSION

Knowledge of key ethical concepts and normative theories is important for the identification and analysis of moral problems in mental healthcare and should be given greater weight in the training of clinical ethics consultants.

[The Basel model of principle-oriented clinical ethics consultation 2.0 : An introduction for psychiatry]

BACKGROUND

The effectiveness of clinical ethics counselling in medicine in terms of satisfaction of the participants, support of ethical decision-making, perceived impact on clinical care, moral competence and quality of communication is now empirically well validated. In psychiatry, more and more institutions have structures for clinical ethics consultation as well; however, there is still a lack of evaluative accompanying research on the benefits and differential indications of the various forms and models of clinical ethics counselling in psychiatry.

AIM OF THE WORK

The article presents the principles and the step by step application of the principle-oriented clinical ethics consultation according to the Basel model 2.0.

MATERIAL AND METHODS

The article is based on material and procedures developed at the Clinical Ethics Unit of the University Hospital Basel and the University Psychiatric Clinics Basel for the principle-oriented clinical ethics consultation according to the Basel model 2.0.

RESULTS AND DISCUSSION

Principle-oriented clinical ethics consultation according to the Basel model 2.0 is suitable for dealing with moral issues and conflicts in psychiatric practice and for their ethical reflection; however, further evaluative accompanying research is needed on the benefits and differential indications of this and other models of clinical ethics support in psychiatry.

Intersectionality as a tool for clinical ethics consultation in mental healthcare

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.

Clinical ethics problems in psychiatry and the need for clinical ethics consultation in Japan: A cross-sectional study

Aim

Psychiatrists often encounter ethical dilemmas in their daily clinical practice. Clinical ethics consultations (CECs) have been recently increasing, especially in general hospitals. However, the current situation in the psychiatric field is unclear. This study clarifies clinical ethics problems in psychiatry and determines the need for CECs.

Methods

We conducted an anonymous self-administered questionnaire survey in February 2022, which targeted directors and supervisors of psychiatric specialty training programs at 1224 psychiatry facilities.

Results

Responses were received from 311 facilities (response rate: 25.4%). CEC systems existed in 223 (72.2%) facilities, and medical safety committees were the most common. Clinical ethics problems occurred at 248 (80.3%) facilities; the most common method for managing the problems was discussions at case conferences without using CECs. The top four reasons for psychiatrists to solicit advice were conflicts with patients' relatives, treating a patient with cognitive impairment, discontinuation of treatment, and suicide/attempted suicide. Most respondents (89.9%) considered CECs necessary.

Conclusion

Although CECs exist in psychiatry, they may not meet the needs of clients. Future studies are needed to investigate client satisfaction and CEC evaluation methods in facilities where psychiatric CECs are provided.

Predicting crime during or after psychiatric care: Evaluating machine learning for risk assessment using the Danish patient registries

BACKGROUND

Structural changes in psychiatric systems have altered treatment opportunities for patients in need of mental healthcare. These changes are possibly associated with an increase in post-discharge crime, reported in the increase of forensic psychiatric populations. As current risk-assessment tools are time-consuming to administer and offer limited accuracy, this study aims to develop a predictive model designed to identify psychiatric patients at risk of committing crime leading to a future forensic psychiatric treatment course.

METHOD

We utilized the longitudinal quality of the Danish patient registries, identifying the 45.720 adult patients who had contact with the psychiatric system in 2014, of which 474 committed crime leading to a forensic psychiatric treatment course after discharge. Four machine learning models (Logistic Regression, Random Forest, XGBoost and LightGBM) were applied over a range of sociodemographic, judicial, and psychiatric variables.

RESULTS

This study achieves a F1-macro score of 76%, with precision = 57% and recall = 47% reported by the LightGBM algorithm. Our model was therefore able to identify 47% of future forensic psychiatric patients, while making correct predictions in 57% of cases.

CONCLUSION

The study demonstrates how a clinically useful initial risk-assessment can be achieved using machine learning on data from patient registries. The proposed approach offers the opportunity to flag potential future forensic psychiatric patients, while in contact with the general psychiatric system, hereby allowing early-intervention initiatives to be activated.

Types of Ethical Problems and Expertise in Clinical Ethics Consultation in Psychiatry - Insights From a Qualitative Empirical Ethics Study

Background: Ethics consultation has been advocated as a valuable tool in ethically challenging clinical situations in healthcare. It is paramount for the development and implementation of clinical ethics support services (CESS) in psychiatry that interventions can address the moral needs of mental health professionals adequately and communicate the nature of the services clearly. This study explores types of ethical problems and concepts of ethical expertise as core elements of CESS in mental healthcare with the aim of contributing to the further development of ethical support in psychiatry. Methods: We conducted 13 semi-structured interviews with mental health professionals and CESS members and triangulated them with four non-participant observations of ethical case consultations in psychiatry. Data were analyzed according to principles of grounded theory and are discussed from a normative perspective. Results: The analysis of the empirical data reveals a typology of three different ethical problems professionals want to refer to CESS: (1) Dyadic problems based on the relationship between patients and professionals, (2) triangular problems, where a third party is involved and affected as a side effect, and (3) problems on a systemic level. However, CESS members focus largely on types (1) and (2), while the third remains unrecognized or members do not feel responsible for these problems. Furthermore, they reflect a strong inner tension connected to their role as ethical experts which can be depicted as a dilemma. On the one hand, as ethically trained people, they reject the idea that their judgments have expert status. On the other hand, they feel that mental health professionals reach out for them to obtain guidance and that it is their responsibility to offer it. Conclusion: CESS members and professionals in mental healthcare have different ideas of the scope of responsibility of CESS. This contains the risk of misunderstandings and misconceptions and may affect the quality of consultations. It is necessary to adapt concepts of problem solving to practitioners' needs to overcome these problems. Secondly, CESS members struggle with their role as ethical experts. CESS members in psychiatry need to develop a stable professional identity. Theoretical clarification and practical training are needed.

Moral Dilemmas in Contact-Based Care: The Relevance of Moral Case Deliberation for Forensic Psychiatry

Currently, forensic psychiatry shows a shift from a control-based to a contact-based approach. Working from contact may, however, entail new moral questions and dilemmas. How to secure safety when focusing on contact? Does contact imply being physically close to the patient, or should one refrain from intimate relations? In order to help care professionals to deal with these moral issues, clinical ethics support can be useful. A specific approach in clinical ethics support is moral case deliberation (MCD). An MCD is a structured dialogue between professionals on a moral issue they experience in practice, structured by a conversation method and guided by a facilitator. In this article, we describe the background and procedures of MCD. Furthermore, we present a case example in which care professionals reflect on the moral question of whether provision of care in forensic psychiatry may entail physical closeness. The MCD shows that an open conversation results in a better understanding of different perspectives and creates the basis for finding a joint way to proceed in the case. We conclude that MCD can enable professionals to reflect on moral issues and develop shared values in forensic psychiatry.