Paternalism, autonomy and reciprocity: ethical perspectives in encounters with patients in psychiatric in-patient care

Abstract

BackgroundPsychiatric staff members have the power to decide the options that frame encounters with patients. Intentional as well as unintentional framing can have a crucial impact on patients’ opportunities to be heard and participate in the process. We identified three dominant ethical perspectives in the normative medical ethics literature concerning how doctors and other staff members should frame interactions in relation to patients; paternalism, autonomy and reciprocity. The aim of this study was to describe and analyse statements describing real work situations and ethical reflections made by staff members in relation to three central perspectives in medical ethics; paternalism, autonomy and reciprocity.MethodsAll staff members involved with patients in seven adult psychiatric and six child and adolescent psychiatric clinics were given the opportunity to freely describe ethical considerations in their work by keeping an ethical diary over the course of one week and 173 persons handed in their diaries. Qualitative theory-guided content analysis was used to provide a description of staff encounters with patients and in what way these encounters were consistent with, or contrary to, the three perspectives.ResultsThe majority of the statements could be attributed to the perspective of paternalism and several to autonomy. Only a few statements could be attributed to reciprocity, most of which concerned staff members acting contrary to the perspective. The result is presented as three perspectives containing eight values.•Paternalism; 1) promoting and restoring the health of the patient, 2) providing good care and 3) assuming responsibility.•Autonomy; 1) respecting the patient’s right to self-determination and information, 2) respecting the patient’s integrity and 3) protecting human rights.•Reciprocity; 1) involving patients in the planning and implementation of their care and 2) building trust between staff and patients.ConclusionsPaternalism clearly appeared to be the dominant perspective among the participants, but there was also awareness of patients’ right to autonomy. Despite a normative trend towards reciprocity in psychiatry throughout the Western world, identifying it proved difficult in this study. This should be borne in mind by clinics when considering the need for ethical education, training and supervision.

Facilitators and Barriers to Person‐centred Care in Child and Young People Mental Health Services: A Systematic Review

“…Finally, all studies but one (Molesworth & Crome, ) presented findings in a comprehensive manner providing quotes illustrating the main themes obtained by the analysis. Nonetheless, several studies did not provide sufficient detail on issues such as justification of the research design ( n = 3; Iachini, Hock, Thomas, & Clone, ; Molesworth & Crome, ; Street, ), recruitment strategy ( n = 6; Lee et al, ; LeFrançois, ; Ma & Lai, ; Molesworth & Crome, ; Offord, Turner, & Cooper, ; Street, ), data collection ( n = 3; LeFrançois, ; Molesworth & Crome, ; Street, ), the relationship between researcher and participants ( n = 14; Buckley et al, ; Harper, Dickson, & Bramwell, ; Hart, Saunders, & Thomas, ; Iachini et al, ; Kovshoff et al, ; Lee et al, ; LeFrançois, ; Molesworth & Crome, ; Offord et al, ; Oruche, Downs, Holloway, Draucker, & Aalsma, ; Pelto‐Piri, Engstrom, K., & Engstrom, ; Street, ; Tam‐Seto & Versnel, ; Wisdom, Clarke, & Green, ), ethical issues ( n = 4; Abrines‐Jaume et al, ; LeFrançois, ; Molesworth & Crome, ; Wisdom et al, ) and rigour of data analysis ( n = 4; Hart et al, ; LeFrançois, ; Molesworth & Crome, ; Street, ). Finally, contribution to research, knowledge or policy was not discussed in two studies (Molesworth & Crome, ; Street, ), new areas of research were not identified in six studies (Buckley et al, ; Hart et al, ; Lee et al, ; Molesworth & Crome, ; Pycroft, Wallis, Bigg, & Webster, ; Street, ) and generalizability of findings was not taken into account in nine studies (Buckley et al, ; Bury, Raval, & Lyon, ; Coyne et al, ; Kovshoff et al, ; LeFrançois, ; Molesworth & Crome, ; Offord et al, ; Pelto‐Piri et al, ; Street, …”

“…At the service level, professionals, service users and carers reported a lack of resources and extensive policy regulations as key barriers to PCC, which reduce the flexibility with which professionals can provide treatment aiming to address the individual needs of the service users (Buckley et al, ; Grealish, Tai, Hunter, & Morrison, ; Idenfors, Kullgren, & Salander Renberg, ; Ma & Lai, ; Oruche, Downs, Holloway, Draucker, & Aalsma, ; Pelto‐Piri, Engstrom, K., & Engstrom, ; Pycroft, Wallis, Bigg, & Webster, ; Simmons, Hetrick, & Jorm, , ; Street, ).…”

Patients' perspectives on care pathways and informed shared decision making in the transition between psychiatric hospitalization and the community

“…Rather than notional or theoretical participation in their own care, they wanted this manifestly present in reality. Pelto‐Piri found that paternalism still clearly appears to be the dominant perspective among staff caring for patients in psychiatric inpatient care settings.…”

Informed Consent: A Complex Process in Iran's Nursing Practice

“…Paternalism has been one of the traditional characteristics of the therapeutic relationship in medicine. In paternalism, staff should only use their knowledge and skills for the benefit of patient, and never do harm and always act in the patient's best interest [24]. Are we allowed to decide on behalf of the patients?…”