Ethics & Behavioral Health

1. Ethics &Behavioral Health PHILIP BOYLE, Ph.D. www.che.org/ethics

2. Goals • Understand uniqueness • Who decides • Advance directives • Treatment Refusal • Boundaries • Resource allocation

3. Uniqueness of behavioral health? • Nature of Mental Illness • Treatment of metal illness • Capacity of the person/patient/client • Providers • Social context • Setting

4. What is unique to behavioral health? • Nature of illness • Medical model  Moral model • Organic Brain disorder   Deviance • Nature of treatment • Psychopharmacology   talk therapy/ transference use of power • Drugs & restraint <- -> Partnering

5. Patient has unique features • Capacity is suspect/ compromised • Forced treatment • Activities of daily living • Confidentiality • Active consumer involvement • Focused on living not illness

6. What is unique to behavioral health? • Providers: • Non-traditional relationships • Long period of involvement • Boundaries • Power relationships • Dual Agency (Psych in war) • Employees not trained in mental health • Patients as volunteers or employees

7. What is unique to behavioral health? • Social context • Stigma • Parity • Coercion • Use of police power • Prisons and mental health care

8. What is unique to behavioral health? • Setting: • In patient • Outpatient • Inner city • Street medicine • Group home • Home • Rural health • Confidentiality • Access

9. What is unique to behavioral health? • Ethical issues Everyday ethics Capacity Advance directives Involuntary treatment Boundary issues Resource allocation Cultural diversity

10. Advance Directives: State Laws • All states have AD • Some exclude mental health from AD • 22 have psychiatric AD • Which shall prevail? • Revocation—”Ulysses Clause”

11. Treatment directive • Options to help avoid or minimize hospitalization • Activities that comfort/reduce distress • Activities that exacerbate symptoms • People who to contact/or visit • Medications—acceptable or not • Effective alternatives to restraint/seclude

12. Treatment preferences • Authority granted to agent • About no termination • Facility • Physician • Medication • ECT • Emergency treatment e.g., restraints • Experimental treatment • Who to notify/Visitors • Duration • Temporary custody of children • Revocation

13. REVOCATION • Patient has capacity • Proxy is unwilling or unable • Cancellation or destruction • Ulysses Clause • Divorce • Not in accord with patient’s wishes • Revocation options • At any time • Only when capacity • Always ask even if incapacitated

14. Case Advance Directive John, 28-yr-old with an 8-year history of schizophrenia & 1 hospitalization. Executed PAD @ religious retreat where he had discussed his feelings of humiliation about his psychiatric hospitalization. Parents petitioned for involuntary commitment due to an exacerbation of his psychosis. Prior to admission, John was functioning well Discontinued his anti-psychotic medication, olanzapine, several weeks prior due to excessive weight gain. became isolated, withdrawn, and paranoid, hyper-religious, grandiose delusion that he was a messenger of God with prophetic powers.

15. Case Advance Directive Hearing voices Cut his wrists and arms & refused all but liquids & medications. During college, preoccupied with a “call to Christ.” Proselytizing on campus, he stopped attending classes and was eventually barred from campus when his public preaching became disruptive. Approximately a month later, he was involuntarily hospitalized. No history of violent or dangerous behavior, suicide attempts, self-injury or substance abuse

16. Case Advance Directive John’s medical records contain an apparently legally executed PAD, which includes an instructional directive as well as healthcare power of attorney. He refuses hospitalization unless admitted to a “Christian hospital” forcibly administered medications and consents to treatment with haloperidol or another “time-honored” medication. Mother is healthcare agent Treating psychiatrist determines that John meets the statutory definition of incapacity in that he “lacks sufficient understanding or capacity to make and communicate mental health treatment decisions.”

17. Case Advance Directives • Did John create the PAD while capable? (2) Is a patient with schizophrenia, who never achieved full remission, capable of executing a valid PAD? (3) Was John’s PAD, including specific decisions about medications, informed by present knowledge of risks and benefits of these decisions? (4) Was John adequately educated about the pros and cons of the treatment he proposed in the PAD and whether it was feasible? (5) Was John’s mother adequately involved in the preparation of the PAD so that she is prepared to act as a proxy decision maker?

18. Cases • Jane, a 36-year-old woman schizoaffective disorder • Frightened because of past trauma • Psychiatrist could hardly speak English. • She explained certain medications tardive dyskinesia, • he either didn't understand her though she was not capable • Prescribed Haldol to her, which was one of the medications she didn't want to take. She describes her hospitalizations as terrifying, dehumanizing experiences. "It's not that I'm opposed to psychiatric treatment", she says. "I know that I need treatment for my brain disorder. But, I'm not willing to accept treatment when I am given no say in how I am going to be treated. I would rather go to jail or become homeless again than to have to go back to the hospital."

19. Cases • Mr. and Mrs. Smith’s son John suffers from schizophrenia • Stopped taking his medication • Know, will lead to decompensation with bad consequences • Suicide / bizarre behavior / survival • Each time, they wait until he so deteriorates until he becomes so ill that he meets the state's criteria for involuntary commitment and forced treatment. • They hate to go to court to involuntarily commit their son. • When he is doing well, has expressed his need for treatment and his appreciation of his parents for intervening • Off medications, he shuns his family, denies his illness and his need for treatment. "There must be a better way," Mrs. Smith sighs. "I can't bear to stand by and watch John suffer this way."

20. Case • 29 year female • History of depression • Boyfriend finds her overdosed • ER she becomes conscious • Refuses gastric levage • Want to sign out AMA

21. Conditions for forced treatment • Serious harm to self or others • Likely to occur • Force is proportionate

22. Case • Mary refuses an amputation • Sister is agent • Diabetes, foot ulcer, schizophrenia • Sister requests amputation • Mary understands she will die eventually without amputation some delusional activity and confusion • Refusing all medication

23. Use of Power Case Ron is in a structures residential program. Hospitalized repeatedly because he stops taking his medications, Agrees to money management and have medications stored in the office of the residential program. 10 weeks after discharge: decompensation. He has been “cheeking” his medications for the past 2-3 weeks. Primary clinician arranges with the money manager to refuse thrice weekly allowance on any day that R.F. doesn’t bring in a note from the residential program  

24. Coercion Case When is it acceptable to use leverage to get voluntary clients to comply with treatment and how do you assure that it is not being done for expediency or other inappropriate reasons associated with the need to control the client? What conflicts do we create by handling the client’s money? Would the situation be altered if R.F.’s money management agreement clearly stipulated the requirement for him to take his medications without “cheeking” them before receiving his daily money allowance?

25. Boundaries Case • Brenda, 29-year-old psych-nurse, on addiction rehabilitation unit. • Caring for Tom, a shy, 33-year-old with bi-polar disease, committed because of several DUI • Clinical director permits Brenda to take Tom to her church and another community event. • During stay Brenda started jogging with Tom after her shift. • 3 months after Tom’s discharge, clinical director hears that Brenda is romantically involved with Tom. • Clear, yet unwritten unit expectation that staff members are not to date current or former patients up to one year after discharge. • Brenda was never officially informed but she was aware that the consequence • How should the director of the unit handle the situation?

26. Boundaries • Where do they come from? • Common human morality • Conflict-of interest • Professional codes • Goal of treatment: do no harm

27. Where do boundaries come from? • Nature of the therapeutic relation • Common human morality • Mission & values • Job descriptions • Professional Codes • Culture

28. Resource Allocation • Who should be given preference of treatment? • Those who could fully recover? • Those with severe and persistent MI who will not recover? • Equality of opportunity? • Weighted dice?