Balancing competing interests and obligations in mental health‐care practice and policy

Abstract

It is often challenging for mental health-care providers and health organizations to perform their various roles and to meet their varied obligations. In complex mental health-care circumstances the concurrent application of relevant ethical principles and values often leads to the emergence of completing obligations that need to be carefully weighed and balanced in the making of care-related decisions. Although some clinical circumstances, such as those potentially triggering the duty to warn, are adequately guided by existing rules based on legal precedents, there is a gap in decision-making support in other mental health-care domains. This article proposes that a set of targeted, decision-making approaches be developed to assist in the handling of specific, challenging circumstances. By way of illustration, two novel approaches are introduced; that is, choosing to work within a moral relational space of optimal therapeutic engagement (at the micro level of clinical practice), and the use of a health policy development approach that instantiates deliberative engagement (at the meso and macro levels of health organization). K E Y W O R D Scompeting obligations, decision-making support, deliberative engagement, mental health care, moral relational space 4 Kirby, J. (2017). Medical assistance in dying for suffering arising from mental health disorders: Could augmented safeguards enhance its ethical acceptability?

Mapping the ethical aspects in end-of-life care for persons with a severe and persistent mental illness: A scoping review of the literature

“…In a few cases authors mention the role of the ethics committee or an ethical expert, in order to further explore a case and offer tools for dealing with moral stress ( 2 , 19 , 61 ). Only one of the consulted sources mentioned a specific methodology – a value-based deliberative tool, in the context of the development of an ethically grounded policy on medically assisted dying for persons with a psychiatric condition ( 62 ).…”

An Ethics-informed, Policy-based Approach to the Management of Challenges Posed by Living-at-Risk, Frequent Users of Emergency Departments

“…This is a particular vulnerability for persons with severe and persistent mental illness, given the historical failure of many HIC health jurisdictions to augment existing and develop new community-based services for this subset of the population after the deinstitutionalization movement of the late 20 th century. This vulnerability is also negatively shaped by chronically low allocations of healthcare resources to fund community-based and in-hospital mental health care services, despite the demonstrably high, legitimate needs for such services in HICs (22).…”

“…The principle of beneficence requires that HCPs and health organizations provide continuity of care to their patients (22). It is widely accepted that HCPs, who have existing therapeutic relationships with patients, have an obligation to continue to provide healthcare and treatment services within their professional purview or to refer their patients to (an)other, appropriate HCP(s) as per the mechanisms established by their relevant professional regulatory body.…”

Interpreting Irremediability When a Mental Health Disorder is the Sole-qualifying Medical Condition for MAiD

“…However, these are rarely identified and articulated as such in the literature and lay press. I have previously published a described set of MAiD ethics substantive principles and values (which are of relevance to the development of government health legislation and macro-and meso-level MAiD policies through the use of deliberative engagement methodologies), i.e., individual autonomy, health equity, nonmaleficence and social justice, beneficence and duty-of-care, conscience and professional autonomy, non-abandonment and continuity-of-care, professional competency, and accountability and oversight (7). In this commentary, I focus on the relevance of some of these substantive principles and values and other, pertinent ethics considerations to the development of an optimal interpretation of irremediability in the MD-SUMC context.…”