By Stacey Kusterbeck
Mental health issues are coming up more frequently during ethics consults, according to ethicists interviewed by Medical Ethics Advisor. Here are some ethical questions involving mental health that ethicists are helping to resolve:
• Ethicists are being consulted on how to address combative behaviors that disrupt the patient’s own care or the care of other patients.
Clinicians are seeing patients who refuse essential care or refuse to leave clinical facilities when treatment or care no longer is necessary. “These are growing issues in hospitals, clinics, and community-based settings,” reports Julie M. Aultman, PhD, director of the medical ethics and humanities program at Northeast Ohio Medical University in Rootstown.
Aultman regularly receives phone calls and consultation requests from physician groups whose staff are experiencing low morale and burnout because of having to address negative behaviors. “This can lead to poor patient care, disruptions, and poor patient satisfaction,” warns Aultman.
Ethicists can guide healthcare teams in recognizing the underlying issues among patients with challenging behaviors. For example, difficult social situations or undiagnosed mental illness may contribute to combative behavior. Ethicists also can help to develop institutional policies that absolve care obligations to patients who are combative. “An ethics consult can help everyone concerned get to the root of these issues, while determining whether to enforce policies on restrictions on care,” says Aultman.
• Ethicists are addressing issues involving privacy and confidentiality.
“These issues are coming up in informal discussions, formal ethics consultations, grand rounds, or because of complaints directed to hospital administration,” says Aultman. Ethicists are hearing concerns about disclosure of private information in group therapy sessions, for example. To help prevent breaches, ethicists can emphasize the importance of confidentiality to patients attending group sessions, suggests Aultman. Ethicists also can work with healthcare teams to weigh potential consequences when breaches of confidentiality do occur among professionals (such as it being a factor during performance reviews) and patients (such as restricted access to group therapy sessions).
• Clinicians want help determining which unit patients with medical needs and severe mental illness should be admitted to.
Some patients have a psychiatric disorder with medical manifestations, such as treatment-refractory anorexia nervosa.
“As with many ethics issues, it is difficult to find a one-size-fits-all solution, particularly given the wide variety of mental health disorders, their symptomology, and their impact on patient behavior,” observes Joanna Smolenski, PhD, assistant professor at Baylor College of Medicine’s Center for Medical Ethics and Health Policy and a clinical ethicist at Houston Methodist Hospital.
Ethicists usually get involved after the patient already has been admitted, typically to an intensive care unit (ICU) when the medical unit is unable to adequately address the patient’s psychiatric needs. However, because the patient continues to have ICU-level medical requirements, such as vasopressors, it is not clear that transfer to a psychiatric unit is appropriate. “So, the patient ends up stuck. Either they sacrifice some aspect of medical care or some aspect of psychiatric care,” says Smolenski.
Where a patient is appropriately housed is a clinical determination to be made by a treating team and not a clinical ethicist. “However, this is an issue that contributes to the challenging nature of care for these patients. Ethicists are often involved as part of the interdisciplinary treatment team for patients like these,” says Smolenski.
• Ethicists are asked about the best ways to promote patient autonomy and independence for patients who are involuntarily hospitalized.
“We are seeing an ethical and legal shift from surrogate and substituted decision-making,” reports Aultman. Traditionally, a guardian or conservator makes the decisions on behalf of the patient. There is a movement toward a supported decision-making approach. In that model, patients with limited capacity can make decisions with added support from families or others. Patients can be involved in decisions on who within the family unit is permitted to visit, for instance.
“This shift has been prompted by several factors. Unfortunately, there are challenges to implementing a supported decision-making approach,” says Aultman. Mental and physical disability rights emphasize the importance of dignity and a person’s self-determination in decision-making, regardless of limited capacities or capabilities. However, there may be inadequate resources to support the patient.
Some patients lack capacity to such a degree that they cannot even participate in decision-making even with assistance. “Determining this can itself be a challenge for healthcare professionals, legal teams, and others,” says Aultman.
• Ethicists are seeing frequent consult requests involving patients diagnosed with a serious mental illness who decline a medical intervention.
Some patients refuse any kind of care whatsoever. At times, the interventions they decline have serious implications for their health, including death. Clinicians want help understanding issues of decisional capacity and, especially in dire clinical situations, to understand whether they can treat the patient over the patient’s rejection.
“Broadly, these cases can be characterized by the ethical dilemma of beneficence vs. respect for autonomy,” says Ryan J. Dougherty, PhD, MSW, HEC-C, an assistant professor in the Center for Medical Ethics and Health Policy at Baylor College of Medicine, and a clinical ethics consultant at Houston Methodist Hospital.
In addition to clarifying how to balance these principles, ethicists can aid teams in understanding what autonomy is in clinical decision-making. “However, social biases concerning mental illness can lead to underestimating, and ultimately, undermining autonomy,” observes Dougherty.
• Clinicians wrongly assume that patients lack decision-making capacity by default, simply by virtue of having mental health disorders.
“One of the most common elements of ethics consults, in my experience, is education around capacity. Many practitioners continue to see a psychiatric diagnosis as an automatic indicator of incapacity. That is simply not the case,” says Smolenski.
Ethicists can clarify that having a mental illness does not indicate a patient lacks capacity and encourage the use of decisional capacity assessments. Some patients with mental health disorders have full decision-making capacity. Others are capable of making some medical decisions. “Many patients without decisional capacity can still highlight what’s important to them or are willing to share the conditions under which they would agree to treatment,” says Dougherty.
Ethicists can encourage clinicians to maximize patient participation in their own healthcare, to the extent possible. “Decision-making capacity is always both time- and decision-specific. For this reason, it is essential that a proper capacity assessment be performed in this patient population,” says Smolenski.
• Some patients who refuse treatment are incapacitated, but reject the involvement of their surrogate decision-maker.
“This creates a problem of representation, where it’s unclear who should be making decisions on behalf of the incapable patient,” says Smolenski.
The fact that a patient lacks decision-making capacity is not, on its own, grounds to provide treatment over the patient’s objections. Even if the patient lacks decision-making capacity, their preferences still are ethically relevant to treatment decisions. “When considering whether it is ethically permissible to authorize a treatment that an incapable patient is refusing, we must consider why they are refusing, and what impact the treatment will have on the patient’s emotional and psychological well-being,” advises Smolenski.
Some conditions are transient, causing patients to lose decision-making capacity episodically. For patients with intermittent delusions or severe depressive episodes, for example, decision-making capacity can be restored after acute symptoms subside. In some cases, treatment can restore the patient’s capacity.
“When that is the case, treating the condition, even if over the patient’s objection, can actually be autonomy-promoting,” says Smolenski. Deferring treatments also can be an ethically appropriate option if the patient’s psychiatric symptoms are known to be intermittent, episodic, and self-resolving.
• Clinicians may want to know if using restraints is ethically justifiable.
“Many providers are understandably uncomfortable utilizing restraints at all,” says Smolenski. At times, restraint is necessary to safely provide treatment, however.
“Restraints must be a matter of last resort, in the patient’s overall best interest, and used for as brief a duration as possible,” emphasizes Smolenski.1 Well-meaning clinicians sometimes take the view that any treatment over objection is automatically a violation of autonomy, simply because the patient has expressed a contrary preference. However, when patients lack decision-making capacity, it already has been determined that the patient is not a fully autonomous agent. In such cases, respecting their preferences is potentially failing to protect a particularly vulnerable patient.
“Restraint may be necessary in order to safely provide the treatment that is necessary to protect the patient — and about which the patient is not able to autonomously decide,” Smolenski explains.
- Dougherty R, Smolenski J, Smith JN. The lived realities of chemical restraint: Prioritizing patient experience. AJOB Neurosci 2024;15:29-31.
