Mentally Disabled and Mentally Ill Persons: I. Healthcare Issues

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I. HEALTHCARE ISSUES

Primary healthcare providers for patients with mental illnesses bear the same ethical obligations as providers who serve patients with physical illnesses, yet they face special challenges in upholding those obligations. When mental illness causes a patient to be violent or suicidal, clinicians may confront situations in which their duties to the patient conflict with other ethical duties. At times, the decision about which duty to obey involves careful moral consideration. Additionally, because mentally ill persons are particularly vulnerable to abuse, the clinician has a special obligation to protect such patients against abuses.

For example, in the case of a patient who has attempted suicide, the duty to respect the patient's autonomy may conflict with the duty to protect the patient from harm. The patient may wish to go home, yet the clinician—who may be a physician in a hospital emergency room, a psychiatrist, or the patient's therapist—may decide to hospitalize the patient. At this point, the patient's fundamental right to refuse care has been denied. The moral justification may seem clear: The patient is not thinking rationally, so he or she should not be permitted to function autonomously. The patient deserves an explanation about why he or she is being hospitalized and has a right to information about the legal routes for challenging the decision.

It's true that in some cases, suicide may be a carefully reasoned choice. Far more often, though, planning or attempting to harm oneself results from a clinical depression or other psychiatric disorder. Discerning whether a patient's suicide reflects a rational decision is typically not possible in an emergency room setting. It would be ethical to hospitalize a patient to prevent suicide until a more thorough assessment could take place, including discussions with family members and or with healthcare providers who have known the patient over a long period of time.

Even when the clinician's overriding moral duties are clear, actual situations are complicated. There is often disagreement among patients, clinicians, families, and the courts about whether a patient's rights may be denied. This article explores common moral dilemmas in the medical and psychiatric care of individuals who are experiencing a major mental illness, such as schizophrenia or clinical depression, and those who suffer from the serious deficits in memory and intellectual functioning seen in dementia or mental retardation. Health professionals caring for such patients are likely to face one or more of the following questions and ethical concerns:

Does the person with mental illness have the capacity to decide about suggested treatments (informed consent for treatment)?
When is it ethical to hospitalize mentally ill persons against their will (commitment)?
Is it ethical to treat mentally ill persons against their will with psychiatric medications (coerced treatment)?
Is it ethical to use coercive methods to encourage a mentally ill person to comply with prescribed treatments (coerced compliance)?
When is it ethical to withhold information from a person because that person has a history of serious mental illness (truth-telling)?
When is it ethical to breach the confidentiality of a mentally ill patient (confidentiality)?
Under what circumstances is it ethical to withhold scarce health resources from a person because that person is seriously mentally ill (allocation of scarce resources)?

Informed Consent for Treatment

No patient should be treated by a doctor without first being informed about the nature of the treatment and then consenting to have the treatment. When a person with a history of serious mental illness is being treated for a medical condition, his or her doctors may consult a psychiatrist about the patient's capacity to make medical decisions.

Assessing the capacity to make medical decisions need not involve a comprehensive evaluation of intellectual functioning. A straightforward discussion regarding a patient's understanding of a specific medical decision is usually sufficient. The psychiatrist asks questions about the nature of the illness and possible treatments and determines from the responses if the patient understands the problem, the treatment choices, and the likely consequences of a given decision. A formal judgment of medical competence can only be made in court (Appelbaum and Grisso). However, the psychiatrist's informal evaluation can guide treatment in most clinical situations.

A person whose mental abilities are partly impaired may be competent to make certain decisions about medical care. This situation can arise with an elderly person who suffers from mild dementia or a younger person affected by mild mental retardation (Kaplan, Strang, and Ahmed). For this reason, decision-making capacity must be assessed on a case-by-case basis.

Also, a person who is incompetent at one time may be competent at another. Delirium and depression, conditions seen frequently among patients hospitalized for medical reasons, are examples of conditions that temporarily disrupt clear thinking. A person who is delirious or depressed may be found incompetent to refuse treatment, yet when the delirium clears or the depression lifts, that person is considered competent.

Consider the case of a thirty-five-year-old man with kidney failure (Shuchman and Wilkes). Doctors told him that he required dialysis to take over the function of his kidneys. The man refused dialysis, saying he would rather die. A psychiatrist determined that the man suffered from a severe depression that was interfering with his ability to think rationally, and the man was deemed lacking in the capacity to make medical decisions. Over time, and with treatment, including antidepressant medication, the depression resolved. Eventually, the man's doctors judged him capable of making treatment decisions. However, the man's uplifted spirits did not alter his desire to stop dialysis. The lifesaving technology was discontinued and he died within a few days. Though the outcome may be death, respect for patient autonomy requires that competent patients be allowed to refuse therapies (Angell; Hebert and Weingarten).

Commitment

Though involuntary confinement of mental patients decreased markedly over the last three decades of the twentieth century, it is still an essential tool used to protect patients who are potentially dangerous due to a mental illness. Since hospitalizing a patient against his or her will necessarily denies the patient's autonomy, it is essential that the act be morally justified. Yet, what qualifies as such justification is controversial.

During the 1960s, a person in need of treatment due to mental disorder met the criteria for involuntary admission to a psychiatric hospital in most states and provinces; in the 2000s, the criteria are significantly narrower. Individuals may be involuntarily hospitalized if they are deemed a danger to themselves (for example, if they are about to attempt suicide), a danger to others, or are unable to care for themselves due to mental illness. Typically, the assessment leading to involuntary hospitalization is done by a mental health professional, though such requirements vary in different states and provinces. Once confined, the person may be hospitalized for up to a few days. If commitment extends beyond a specified brief period, a court hearing generally must be held to determine whether further involuntary confinement is appropriate. The courts have also encouraged treatment of psychiatric patients in less restrictive settings than inpatient hospital wards when possible. Other treatment options include "day hospital" programs that allow patients to return home at night, and case management programs that ensure daily checks on outpatients.

In practical terms, the decision to hospitalize someone involuntarily is often a difficult one. Consider a woman who is depressed and has attempted suicide. She might be safest in a hospital, since there is a risk of her making a second suicide attempt while she remains depressed. But safety alone cannot be a reason for hospitalization, as very few of those who attempt suicide will go on to successfully complete suicides in the future. This woman might be safe outside a hospital if she is engaged in frequent outpatient counseling. Commonly, psychiatrists making a decision about committing a patient consider factors known to raise the risk that the person will be harmed or will harm themselves. For example, an individual who has made a serious suicide attempt in the past is at higher risk.

During the late 1980s, psychiatrists and patients' families began objecting to the narrowed commitment criteria, arguing that the rights of people with mental illness were being protected at the expense of their mental health (Appelbaum). These objections resulted in the grounds for commitment being broadened in some areas. The outpatient commitment system, in which outpatients are given courtordered treatment or returned to the hospital in certain situations, is an example of the broadening of commitment laws to include individuals who are not clearly dangerous to themselves or others (Geller). This system, also referred to as supervised discharge or community treatment orders has been introduced in Australia, Canada, the United Kingdom, and Europe as well as the United States. Though not problem-free, it appears to be an effective means of offering mental patients increased care with greater freedom than inpatient commitment provides (Swanson, Swartz, and Borum, et al. and Swartz, Swanson, and Wagner et al.).

Coerced Treatment

Ethics demands that a competent mental patient's refusal of treatment must be respected. Even a patient confined to a mental institution cannot be treated against his or her will, unless the patient poses an imminent threat of harm to others. This concept received extensive legal backing from court rulings during the 1980s. Courts in Massachusetts, New York, and California ruled that unless a patient was found incapable of making treatment decisions, he or she could not be treated involuntarily with antipsychotic medications. The rulings were motivated by reports that psychiatric medications were overused at mental hospitals and staff were often indifferent to patients' risks of drug side effects.

In many states and provinces, psychiatric medications have since evolved into a special legal category of treatment. Forcibly giving a patient psychiatric medication is only permissible if the patient is behaving in a violent manner or is actively threatening to do so. As a result, clinicians treating mental patients typically cannot medicate a refusing patient without involving the courts. By contrast, physicians do not need to consult a judge in order to commit mental patients to involuntary hospitalization. The result is that mentally ill and psychotic patients may be hospitalized against their will but cannot be medicated against their will (Appelbaum). In these situations, psychiatrists often seek permission from the courts to medicate the patient, arguing that the patient has benefited from medication before or is judged highly likely to benefit from medication.

The courts often grant the permission and treatment proceeds in a practice sometimes known as medication over objection. Studies suggest that once a court ruling in favor of treatment is issued, patients often accept oral antipsychotic medications under duress, thereby avoiding forced injections of medication (Greenberg, Moore-Duncan and Herron).

The more stringent criteria for involuntary medication became a focus of controversy on similar grounds as the controversy over narrower commitment criteria. Psychiatrists described mental patients who refuse medication as 'rotting with their rights on,' conveying the image of a person who is not thinking rationally and whose condition is steadily worsening, yet who cannot be treated appropriately or faces delays in treatment because of judicial restraints (Appelbaum and Gutheil).

The mid- to late 1990s saw the start of a movement towards the use of psychiatric advance directives. These are treatment guides prepared by chronically mentally ill patients who are capable of making decisions about their psychiatric treatment when they are functioning well but experience repeated episodes of impaired decision-making during relapses. Most states accept advance psychiatric directives in some form but a survey suggests that psychiatric advance directives are easily ignored in crisis situations (Backlar, McFarland, Bentson, Swanson and Mahler).

Another area of care in which doctors may seek legal opinions regarding involuntary medication involves severely mentally ill female patients who decline birth-control treatments. Some authors suggest that there are situations in which it would be ethical to act to prevent pregnancy in patients who are incompetent to make medical decisions (McCullough, Coverdale, Bayer, et al.). The courts have held that when a mentally incompetent woman is pregnant, decisions about her obstetric care should involve a determination about what the woman would want if she were competent (Curran). In practice, when a severely mentally ill woman becomes a mother, child-welfare agencies are asked to evaluate the woman's ability to care for her child. In extreme cases, this evaluation may lead to court proceedings that can result in the woman's losing custody of her child.

Coerced Compliance

The idea that a patient's decisions must be voluntary is central to the concepts of patient autonomy and informed consent. Exceptions to the idea of voluntariness, such as commitment and involuntary medication, have been viewed as last resorts for patients considered incapable of making rational decisions. Occasionally, however, coercive methods are used to encourage mentally ill individuals to comply with treatments, even when these individuals' decision-making capacities are not in question. Substance-abusing pregnant women comprise one group that is increasingly coerced into treatment, either via incarceration or via compulsory addiction treatment programs (Abel and Kruger). This use of coerced compliance has been supported by state courts as a means of protecting the woman's future child. Yet the practice is controversial because the potential protection it affords the fetus requires overriding a competent adult's treatment decisions (Chavkin and Paltrow).

The coercive methods used with chronic mental patients are more subtle. An example is a man with a chronic mental illness who received disability payments from the government because of his mental condition. The man's government check was sent to the mental-health clinic where he was treated. To receive his check, the man was required to show up for his therapy session. The therapist believed this was a useful technique for encouraging adherence to treatment in a patient with disorganized thinking.

Mental-health practitioners justify such paternalistic strategies as a means of preventing deterioration in a patient's condition but such clinical justifications may not stand up to moral scrutiny. Yet these kinds of practices would be ethical if they were discussed openly with the patient and the patient consented.

Truth-Telling

A physician or therapist who shields a patient from the truth about his or her illness may unwittingly cause mistrust of care providers and of the medical system in a patient who needs to depend on that system (Sheldon). Yet clinicians caring for seriously mentally ill individuals sometimes do withhold information.

In one example, a physician withheld a diagnosis of cancer from a patient with a history of depression and suicide attempts (Lo). The physician feared that disclosing to the patient that she had a terminal illness could precipitate a suicide attempt. His intention was to protect the patient from harm, but the patient probably should have been informed about her diagnosis.

Though patients in general are likely to be told their diagnoses, studies of patients in psychiatric hospitals from the 1980s found that important information was frequently withheld from such patients. For example, psychiatric patients were prescribed medicines without being informed about potentially serious risks of the medicines (Lidz, Meisel, Zerubavel, et al.; Beck). More recent studies suggest that patients continue to be underinformed about their medications (Schachter and Kleinman). For informed decision making, a patient needs to understand the benefits and risks of prescribed medications and why the doctor believes that the benefits outweigh the risks.

Patients, even those with mental illnesses and disabilities, expect and deserve to be told the truth. This does not mean that the truth should be disclosed insensitively. Health professionals should consider how to convey difficult information in a manner most appropriate to a particular patient, but the information should be provided. Psychiatric patients, like all medical patients, need to feel they can trust their healthcare providers.

Confidentiality

All doctor-patient relationships demand confidentiality. In the special setting of psychotherapy the need to protect a patient's privacy can be paramount. The special importance of confidentiality in psychotherapy was underscored by a 1996 Supreme Court ruling that protects a patient's statements to a psychotherapist from compelled disclosure (Jaffeev. Redmond).

But a patient's need for privacy must be balanced against the rights and needs of others. Suppose a man in treatment for alcohol abuse reveals that he has been aggressive toward his child while intoxicated. State laws mandate the reporting of incidents of child abuse, yet a physician or counselor who reported this man would breach the patient's confidentiality. Here, the clinician must consider whether the man's actions towards his child constitute an offense that must be reported in order to protect this child or others in the future. The decision is made all the more difficult because the man's treatment could help to keep his child safe from harm yet the man may leave treatment if he feels the clinician has betrayed him to state authorities.

Situations other than child abuse pose similar dilemmas. Rules about a physician's duty to warn and protect a person who is threatened by a patient now apply in most states and provinces. Such rules do not dictate a therapist's decision, however. Since the majority of threats made by patients do not represent serious danger to others, clinical judgment is required to decide whether a threat, that a patient utters during the course of a psychotherapy session or merits a breach in confidentiality (Weinstock).

Allocation of Scarce Resources

It would be unjust to withhold healthcare resources from a mental patient strictly due to her mental illness. Yet an exception is sometimes made in the case of extremely scarce resources, such as organ transplants. A patient who is chronically mentally ill and also has severe liver or kidney disease might benefit from a transplant. But persons who receive transplants require drug-induced immunosuppression for the rest of their lives to prevent graft rejection, and it can be difficult for mental patients to comply with such extensive follow-up care (Bunzel and Laederach). Reasoning that transplanted organs should go to patients who will reap the most benefit from them, transplant programs may withhold organs from individuals who are seriously mentally ill (Wolcott). In a survey of heart-transplant programs, most programs considered certain psychiatric conditions to be an absolute contraindication to transplant: A person who has schizophrenia with active psychotic symptoms, or a person with a history of multiple suicide attempts will be automatically denied a transplant (Olbrisch and Levenson).

Such automatic denials are not clearly ethical. In the event that a transplant candidate has a serious mental illness, it is important that the potential for treating the mental illness be considered before the patient is refused a transplant (Council on Ethical and Judicial Affairs). The patient's desire to commit suicide, for example, may be caused by a treatable depression. For transplant programs, the question of how to respond to evidence of a patient's psychological instability is difficult. Case-by-case evaluations of individual patients may yield greater fairness in these sorts of situations than systematically applying formal guidelines. Some patients with mental illness may benefit from early intervention and psychosocial support, while other patients may be unable to adhere to post-transplantation treatment regimens even with help.

Conclusion

In a number of key areas, a mentally ill person may lose certain rights with regard to medical and psychiatric treatment due to the effects of mental illness. As a result, healthcare providers who care for such patients can face difficult ethical dilemmas. The decision to hospitalize a mentally ill person involuntarily is often easily justified on moral grounds. However, decisions to breach a patient's confidentiality, or to withhold scarce resources such as organ transplants, are generally not as clear. Finally, it is probably rare that a physician or therapist who withholds the truth from the patient, or coerces the patient into complying with a recommended treatment, will be acting in an ethical manner.

miriam shuchman (1995)

revised by author

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Encyclopedia of Bioethics