The particular relevance of clinical ethics support in psychiatry: Concepts, research, and experiences

Abstract

While Psychiatry is a field with documented susceptibility for ethical topics, the prevalence of clinical ethics support (CES), e.g. ethics consultation or moral case deliberation, observed in clinical institutions of mental healthcare in many countries, is rather marginal. This is the background and motivation for publishing this Thematic Issue on Clinical Ethics in Psychiatry. The characteristics of psychiatry as a professional healthcare domain give rise to various ethical challenges which are to a certain degree specific for psychiatry. One of these characteristics concerns the fact that, under specific conditions, mental healthcare professionals are entitled to use coercive measures which consist of, among others, limiting the freedom of patients or using forced psychopharmacologic treatments. Carefully defining and improving the quality of care within everyday practice necessarily involves facing ethical challenges; this is confirmed by recent empirical research and is also presented in this Thematic Issue. Dealing with ethical challenges requires a specific methodology. However, there are no universal standards for determining what is morally right, which means that moral disagreement does occur and may persist. Professional knowledge and results of evidence-based medical studies are certainly of help, but they do not exactly solve the ethical problems. In order to offer targeted guidance to understand and deal with ethical challenges, forms of clinical ethics support in psychiatry have been developed already beginning three decades ago. Recently, studies on CES in psychiatry seem to be increasing. However, insights into how CES in psychiatry is developing and how it actually works are still rare. Incidentally, some evaluation research reported that healthcare professionals and their managers appreciated ethics support. But in general, there is a lack of case studies, conceptual or programmatic papers and empirical (evaluation) research on CES in psychiatry. Furthermore, there is hardly any attention for the prevalence of various forms of CES and how they function within psychiatry. Finally, there seems to be some confusion about what distinguishes ethical from professional challenges, and how both the content and method of CES differ from psychological supervision. This thematic issue on CES in psychiatry aims at filling this gap in order to stimulate the use of CES in psychiatry and to discuss its particular relevance for psychiatry. In doing so, we want to stress that CES should not overtake the ethos and decisional responsibility of the healthcare professionals (this is why it is called ‘support’). Furthermore, we think that CES should not isolate the moral dimension of psychiatric practice as a separate entity, as if only within CES healthcare professionals were reflecting upon ethical challenges. Rather, paying attention to ethical challenges every now and then in an explicit and systematic way (as within CES) might also stimulate the way how regular meetings and reflections in daily practice are organised. In a vision, we can imagine a stepped-care for ethical challenges: regular, daily ethical reflections taking place in a rather natural and sometimes even implicit way, while more complex ethical challenges might be addressed in explicit CES meetings. One advantage of CES is that all healthcare professionals can participate on an equal basis since ethical insight and conclusions do not depend on hierarchical positions or professional expert roles. In this thematic issue, a broad overview of the particular relevance of CES for psychiatry is being presented by a variety of authors choosing different focuses. Reiter-Theil reflects upon initiating CES in various forms in psychiatry and maintaining its continuity. Ten tasks and relating challenges are formulated and illustrated by clinical examples each followed by a