Global challenges and ethics in protecting and promoting the interests of psychiatrically ill patients

This special edition provides a compendium of information about global and human rights challenges facing psychiatry and the steps required to meet those challenges. It focuses on the ethical issues that rise from cultural disadvantages experienced by psychiatric patients or prospective patients, including discrimination and inequalities in access to care, and on the vulnerabilities and needs of special groups. This collection should pull at us; it should make us quite unsettled – uncomfortable with the state of mental health sciences, services, and suffering throughout the world. It is a call to action for the profession, in concert with primary health care providers, health care leaders, administrators, legislators, the media, patient advocacy groups and other interested parties.

The virtues of compassion, self-sacrifice, self-effacement, and integrity constitute the bedrock of an ethical approach to the clinical and administrative practice of psychiatry (McCullough, 1997, 1998; McCullough & Chervenak, 1994). We are entrusted with protecting and promoting the interests of patients and practising medicine to the highest intellectual standards. The articles published in this special edition well illustrate these virtues, even if these have not been explicitly identified. Compassion promotes the relief of pain and suffering through identification with patients’ distress. Self-sacrifice is the routine willingness of physicians to take risks in their own lives to protect and promote the interests of patients. Self-effacement enables physicians to set aside their own concerns and to put aside differences such as ethnicity, social class, and economic status when these should not count as clinically relevant. Integrity commits physicians to practise with the highest intellectual and moral standards. Together these virtues obligate us as mental health professionals to bring our best efforts to identify and relieve suffering, to search for novel therapies, to advocate for our patients, and to improve the quality of their lives within the constraints of our moral authority and expertise.

The articles are presented in three groups. The first concerns global issues in mental health care, including health disparities and mental illness throughout the world, stigma, mental health care in low- and middle-income countries and in marginalized populations. The second concerns special groups such as children and adolescents with psychiatric disorders, old-age patients, patients with addictions, and patients with neuropsychiatric diseases, as well as cultural aspects of suicide. The first two sections thus deal with the concerns of individuals with mental illness and other situational sources of vulnerability or injustice in life. The third discusses requirements for ethics training to meet the challenges identified by our authors in responding to the many millions of people throughout the world who live with mental illness and its consequences.

Global issues

Ngui, Khasakhala, Ndetei, & Roberts (2010) underscore the vital importance of mental health to general health and framed the issues – such as inequalities in access and in outcomes, burden, stigma, discrimination – encountered in the provision of mental health care in developing nations. A key insight of the article is the observation that widespread mental illness is not only a cause of suffering in economically developing nations but that endemic lack of treatment for mental illness becomes a threat to the economic strengthening of these countries. In other words, developing countries experience a disproportionate burden of mental illness and this sets in motion a disadvantage that is likely to be perpetuated. Poverty is identified both as a determinant and consequence of poor mental health. It is argued that one solution to mental health service deficits in developing nations is to integrate mental health care with other primary services. The authors argue that inequalities in mental health must be addressed in efforts to fulfil the key bioethics principles of medicine and public health. This strong language is consistent with those of other prominent authors. Patel and Bloch (2009), for example, referred to an ethical imperative to scale up health care services for people with mental disorders in low- and middle-income countries. Thornicroft (2007), in asking why we have allowed this global and gross neglect to persist for so long, suggested that actions are needed now to reduce this silent scandal.

Hanlon, Tesfaye, Wondimagegn, and Shibre (2010) identify the day-to-day challenges confronted by clinicians in low- and middle-income countries. A comprehensive MEDLINE and PsycINFO literature search revealed three key themes, in the analysis of the authors. The first of these, identical to an issue that Ngui and Roberts (2010) discuss, concerns the gross underfunding and limited access of culturally appropriate mental health care in most low- and middle-income countries. They note that there is an important ‘treatment gap’. Clearly, the principles of respect for individuals and justice are undermined when resources are not made available to allow psychiatrists to adequately treat patients.

A second theme Hanlon et al. (2010) identify is that patients become open to abuse during processes of admission to psychiatric institutions when they lose the capacity to consent or decline admission and are unable to advocate for themselves. The ethical issues of substituted judgement (Buchanan & Brook, 1989) and beneficence (Engelhardt & Coverdale, 1993) are considerations in decision making. The authors note the importance of accurate diagnosis and, by extension, the importance of an accurate assessment of benefits and costs related to admission decisions. They also describe legal protections as important: regarding these, readers should appreciate the role of procedural justice in commitment decisions (McKenna, Simpson, & Coverdale, 2000; McKenna, Simpson, Coverdale, & Laidlaw, 2001). These processes differ across regions and nations, with some entities emphasizing the well-being of society above the well-being of the ill individual. Enactment of these processes should serve to reduce patients’ experience of coercion and to promote a working alliance as well as patients’ adherence to ongoing treatments. The use of physical force (the authors refer to placing disruptive patients in chains, which occurs throughout the world) is antithetical to the enactment of procedural justice (McKenna et al., 2000).

The third theme concerns issues of informed consent and coercion in context of the covert administration of medications (for example, hiding medication in food) and the use of electroconvulsive therapy. These two issues are potentially controversial, and the psychosocial harms associated with betraying trust by administering covert medications could be very serious. The authors cite a systematic overview and meta-analysis of randomized controlled trials and observational studies of treatment of depressive disorders that suggest that electroconvulsive therapy is an efficacious and at times life-saving treatment, even perhaps more so than drug therapy (UK ECT Group, 2003). Nevertheless electroconvulsive therapy can evoke strongly negative attitudes, especially in light of past abuses or the early use of ECT without adequate safeguards. Furthermore, many patients do not feel that they had freely consented to electroconvulsive therapy even when they had signed a consent form (Rose, Wykes, Bindman, & Fleischmann, 2005). Thus, in the case of electroconvulsive therapy, Hanlon et al. (2010) correctly emphasize the importance of providing reliable information to patients and their families and to being alert to the possibility that patients will feel coerced to accept electroconvulsive therapy.

The authors do not take a position on the use of coerced psychotropic medications, however, and a consensus on the ethical justification of covert psychotropic medications has not been achieved (McCullough, Coverdale, & Chervenak, 2007). A beneficence-based case may be made for covertly administered medications in occasional circumstances when the illness process is immediately life-threatening and/or patients are so seriously cognitively impaired that they lack appreciation of trust and when potentially beneficial medications are resisted that might prevent patients from serious deterioration (McCullough et al., 2007). In these circumstances of administering electroconvulsive therapy or concealed medications, there clearly should be a careful process of formal review, suitable alternative decision-making, and institutional accountability. This notion of a need for thoughtfulness and rigour in ethical arguments and practice is consistent with Drane's (1984) concept of a sliding scale for standards of consent related to the seriousness of the decision to be made (Roberts & Dyer, 2004). Careful educational efforts and intentional training curricula will be an important component of learning how to manage these controversial issues with sensitivity and with integrity.

Kastrup (2010) emphasizes the importance of human rights considerations in preventing abuse of patients with mental disorders and in ensuring an adequate access to care. She reminds us to be alert to differences, as a moral obligation, in attitudes and practices between majority groups and ethnic and cultural minorities. Ngui and Roberts (2010) discuss the potent role of stigma in leading to discrimination and human rights violations against patients with mental illness. Of course, mental health providers, being immersed in these cultural processes, are not themselves immune to holding erroneous beliefs about mental illness, to stigmatizing attitudes, or to treating patients unjustly. We should adequately identify our potential biases and ‘sharpen our cultural sensitivities’ as Kastrup argues. Kastrup and Ngui et al. therefore implicitly signal the importance of training for this demanding work, which, we suggest, should include training in cultural competency (Boehnlein, Leung, & Kinzie, 2008; Fung, Andermann, Zaretsky, & Lo, 2008; Harris, McQuery, Raab, & Elmore, 2008; Kirmayer, Rousseau, Corin, & Groleau et al., 2008a; Kirmayer, Rousseau, Guzder, & Jarvis 2008b). In this work we must attend to our ethical codes, declarations, and guidelines to promote the interests of patients and to prevent discrimination and human rights abuses.

Special groups

Several of the articles in this issue give emphasis to special groups with multiple, diverse and overlapping sources of vulnerability, whether early or advanced age, severity of illness, limited access to care, social attitudes, or economic disadvantages. Individuals with mental illness are especially affected by these barriers to well-being, self-advocacy, and independence. Koelch and Fegert (2010) emphasize the vulnerability of children and adolescents with psychiatric disorders and focus on the United Nations Conventions in protecting the rights and dignity of children and adolescents as subjects of research and as patients. The authors report that these conventions positively assert that children who are mentally disabled or mentally ill should enjoy the same rights and fundamental freedoms as other children and, therefore, that the highest allowable standards of health care should be readily accessible to them. The authors also talk about the balance of protecting children and adolescents as research subjects yet providing equal opportunities for their inclusion. We understand this as a justice-based concern in that denial of access to clinical trials on the basis of their vulnerability may impede the development of scientific and clinical knowledge specific to their health needs. This is an ethical challenge of immense importance in that scientific neglect of the concerns of people with mental illness and additional sources of vulnerability represent a further injustice beyond the unfairness of first living with mental illness, and second having few resources for improvement (Roberts & Roberts, 1999). Such research should nevertheless be rigorously designed, conducted, and monitored and should meet high standards for informed consent processes. The authors comment on treating psychiatrists’ obligation to engage in ongoing education and to practise evidence-based approaches to ensure the transferability of best evidence to patients.

Similarly, as Rabins and Black (2010) argue, elderly patients with psychiatric and/or cognitive disorders also constitute a potentially vulnerable group. The overarching theme of this article concerns the appropriate weight to be given to respecting elderly patients’ autonomy when this becomes impaired and to protecting patients from adverse consequences to their decision making. Given the proportion of the population who are aged throughout the world, this is an issue of real significance in this decade. An underlying question concerns when obligations of beneficence override respect for patients’ preferences (autonomy). These questions arise, for example, when deciding whether to honour a patient's request to retain confidentiality when doing so is judged not to be in the patient's best interest or when a patient prefers to remain at home when doing so confers additional risks to the patient's safety. The issues become more complex and more serious when the well-being of other family members is involved, as may occur in multigenerational households with young children and dependent and severely ill elders living together. These issues are complex and involve assessment of the severity of impediments to decision making and of the risk issues. The concept of geriatric assent (Coverdale, McCullough, Molinari, & Workman, 2006) directs the physician to involve the geriatric patient with irreversibly impaired decision making to the extent that the patient is able to be involved, under the constraint of protecting future health status and therefore remaining autonomy. It also directs the physician to support and counsel surrogates to adopt care plans that promote the patient's values and preferences when possible (Coverdale et al., 2006). Rabins and Black make two very important points about these judgements: that autonomy exists on a continuum and that clinicians should maximize autonomy unless circumstances dictate otherwise.

The elderly are also at an increased risk for adverse drug reactions. Therefore Orfei, Caltagirone, and Spalletta (2010) argue that there is a need to fund research that identifies the specifics of the benefits and costs of prescribing for this population. They identified three special groups (depressed patients with Parkinson's disease, post-stroke patients and patients with Alzheimer's disease) and systematically conducted a search of the literature. They found a relative dearth of controlled trials on the treatment of depression in each of these groups relative to the prevalence of these conditions and relative to younger patients. They suggest that one possible explanatory hypothesis concerns the lack of economic advantages for pharmaceutical companies to undertake this research. Such potential biases or conflicts of interest in the conduct of research should be identified, therefore, and addressed.

Uchtenhagen (2010) focuses on ethical issues in the care of individuals who continue to abuse substances. He cites human rights and medical ethics declarations that balance protecting individual rights with the interests of society and shows how the relevant ethical standards inform clinical practice and legal and policy positions in managing patients with addictions. These issues (among others) are discussed in relation to needle exchange programmes, drug consumption rooms, and opiate substitution programmes that serve as alternatives to the promotion of abstinence (Geppert & Roberts, 2008; Roberts & Dunn, 2003). The author makes the important point that ethical principles and standards, along with evidence from research on the wide range of benefits and costs (including economic costs) of these programmes, are critical for judging their ethical justification. That is, neither evidence nor ethics alone suffice to allow a comprehensive judgement of individual programmes.

Khan and Mian (2010) identify the importance of an understanding of autonomy and beneficence in the management of suicidal patients and note the profession's duty to try to prevent suicide while recognizing that not all suicides are preventable. In this light they argue that preventive efforts should take account of the cultural and social circumstances relating to suicidal behaviours, such as the possibility of abuse, gender discrimination, ignorance, poverty, and unemployment. The authors comment on training directly; clinicians should be sensitized to various cultural perspectives on suicide and trained in the ethical standards of the profession to prevent and manage suicidal behaviours. As others have argued (Coverdale, Roberts, & Louie, 2007; Fang et al., 2007), psychiatry training programmes should teach suicide care as an integral part of training and should prepare trainees for the possibility of a suicide of a patient and to learn how best to respond to the suicide of a patient (Balon, 2007; Ellis, Dickey, & Jones, 1998; Hamaoka et al., 2007; Mangurian, Harre, Reliford, Booty, & Cournos, 2009; Melton & Coverdale, 2009; Pilkinton & Etkin, 2003; Ruskin, Sakinofsky, Bagby, Dickens, & Sousa, 2004; Schwartz, Kaslow, & McDonald, 2007; Sockalingam, Flett, & Bergmans, 2010; Sudak, 2007).

Training

A determinant of the ethical conduct of psychiatric care for people living with mental illness is the knowledge and skills of psychiatric practitioners (Jain, Hoop, Dunn, & Roberts, 2010; Johnson, Brems, Warner, & Roberts, 2006; Roberts & Dyer, 2004; Roberts et al., 2005; Warner, Geppert, Massone, & Roberts, 2006). Indeed, the challenging global and ethical issues identified in this edition and the potential for exploitation or discrimination against vulnerable patient groups necessitate close attention to how we train psychiatrists. Some of these educational needs were identified in the above articles and in this editorial. Ghias and Ahmer (2010) and Tsao and Guedet (2010) provide considerably more detail on what such training should constitute. Ghias and Ahmer lament the dearth of information on ethics-related curricular needs and curriculum development in developing countries. They found that only a minority of training programmes in Pakistan, for example, require formal training.

Tsao and Guedet proposed a model curriculum, broad in scope, for senior psychiatry residents. They note that the curriculum is adaptable to allow incorporation of additional topics, should these be identified as important or relevant in local contexts. Moreover, the different needs of learners of both genders and with different sub-speciality interests and clinical experiences should be supported by the curriculum of training programmes. Modelling forthright communication was deemed to be an important element in addressing sensitive ethical issues. Learners should also appreciate that psychiatric ethics is founded on a rich history of discourse and argument; stated differently, ethics knowledge and skills and professionalism more broadly are not innate attributes. Asking focused questions, effectively searching the literature, and utilizing the methodologies of ethical analysis and argument (Jecker, 2007; McCullough, Coverdale, & Chervenak, 2004; Sugarman & Sulmasy, 2001) are important skills to teach. Moreover, we need to learn more about how to optimally sequence, integrate, and balance the curriculum (Oliva, 2001) and about the methods of instruction that most efficaciously meet the goals and objectives relevant to knowledge acquisition and attitudinal and skills development, as noted elsewhere (Coverdale, Roberts, & Louie, 2004; Jain, Warner, Dunn, & Roberts, in press; Lapid, Moutier, Dunn, Green Hammond, & Roberts, 2009; Lehrmann, Hoop, Green Hammond, & Roberts et al., 2009; Miles, Lane, Bickel, Walker, & Cassel, 1989).

Conclusions

These articles together reveal the necessity of learning about the prevalence of mental illness and the ethical concerns that accompany the care of people living with these devastating diseases that affect the very qualities that make us human and make individual people distinct – thoughts, beliefs, personality, hopes, and attachments and capacities to work and contribute in this world. They demonstrate the importance of becoming routinely sensitive to different cultural perspectives and to unmet needs. They inform us about specific barriers in access to mental health care and about our professional obligations, underscored by the virtues of compassion, self-effacement, self-sacrifice, and integrity, to protect and promote the interests of vulnerable, disadvantaged, or marginalized patients. The authors implore us to reduce the stigma and discrimination against psychiatrically ill patients, to reduce the emotional and economic burden of mental disorders for patients and their families, to advocate for improvements in the quality of systems of care, and to work to provide and improve policy, guidelines, and human rights interventions, as well as to provide comprehensive training on the requisite knowledge, attitudes, and clinical ethics skills.

As editors we were humbled to learn about some of the adversities faced by the psychiatrically ill in the international settings presented here, and we were inspired to do more to serve others. We hope that our readers will similarly value this compendium. We also hope that readers will feel similarly motivated to contribute to the hard and critically important work of identifying and addressing vulnerabilities and inequalities in psychiatric health care.