July 5 juillet 13:45 – 17:45
(extended session)
Room NCDH–101
Chair:
Melvin
L. Rothman
, Cour d’appel du Québec
Discussants:
Frédéric Grunberg
, Université de Montréal
Gordon Kugler
, Attorney, Montréal
While the economics of health care have become a concern
worldwide, the institution of managed care has taken on a life of its own in the
United States.
Managed care originated as a cost containment strategy and has
evolved into a convoluted system that maximizes profits by limiting
physician autonomy
and decision-making. As market forces, pre-selected provider panels
and various levels of gatekeepers insert themselves, (actively or
passively, consciously or unconsciously) into the
doctor-patient relationship–the challenge of maintaining a consistently ethical medical practice
increases. For
complicated reasons of self-preservation, identity and perhaps a sense of
duty to patients, the field of psychiatry in the United States has
attempted to adapt to these constraints. As a
result, the entity of “medication back-up” has come into being. Non-medically trained therapists
may refer to psychiatrists
without ever consulting with the physician before or during
treatment. Theoretical and philosophical orientations, training and experience are less relevant than the
ability of the physician to see several more patients exclusively for
“medication management” than would have been possible in the previous role
as physician-psychotherapist.
The presentation will discuss the ethical conflicts inherent in a system
that often
relegates physicians to the position of observer and hand-maiden to the
therapist. The physician, paradoxically, remains liable for treatment outcomes and consequences. We will
consider the case of a young woman with chronic, life-threatening Anorexia Nervosa and her efforts to
access treatment
in a small Midwestern university town. It is within this context,
and from the vantage point of the medication back-up, that the
presentation will examine the pitfalls of attempting
to maintain an ethical practice.
Lawyers and clinicians and their competing interests often
meet in the arena of proceedings over involuntary admission. The wishes of the
client often differ from the best interests or beliefs of the clinician. The
presenters of this session will review the purpose and effect of involuntary
admission, the public policy and legal justification for confinement with review
of US and Illinois case law. The presenters will then review the clinical
rationale for confinement and the Illinois standards
for involuntary commitment as a general standard for commitment. Both the
Illinois Code and case law will be reviewed. The distinctions between the legal
description of mental illness and commitment and the clinical descriptions will
be emphasized. Clinical and legal aspects of “imminence”, “nexis”,
“dangerousness”, “psychiatric iatrogenics” as well as other issues, will
be discussed. The dynamics of these clinical and legal principles–when applied
to actual cases in which both presenters were involved–will be highlighted. A
workshop format will be used and participation encouraged.
Forensic psychiatrists and psychologists are often asked to
conduct presentence assessments. However, our experience suggests a lack of
clarity in the nature and goals of these assessments, both by the experts who
conduct them and by the legal authorities who request them. It is our opinion
that the psychiatric/psychological issues discussed should be directly linked
with relevant legal issues. Both the experts and the referral agents need to
share a clear understanding of all of the medical/psychiatric issues that could
be addressed in these assessments. In addition, the presentence assessment
should explicitly guide the legal system with regard to rehabilitation
and risk reduction strategies for the mentally ill offender. The authors outline
a framework for the presentence assessment that clarifies and structures the
issues that should be addressed regarding individuals who suffer psychiatric
illnesses.
The privilege and responsibility of serving as a member of
the Consent and Capacity Board raises certain ethical issues. As the medical
member at the Hearing, the Psychiatrist can contribute knowledge of mental
illness, including the epidemiology of the condition in question, providing a
context to the natural history of the patient’s experience. As a member
appointed to an administrative tribunal, the Psychiatrist is required to observe
policies and procedures in the same manner as the Lawyer and Community members.
At times, the dual roles are divergent. Concern for the individual and concern
for society must be considered in the formulation of the issue that is brought
to the attention of the Board. This divergence reflects other dimensions of
psychiatric care in the community, now highlighted by the option of Community
Treatment Orders. The possibility of offering treatment that requires an
agreement and can be enforced if not continued, adds another dimension to the
consideration of capacity. The capacity to continue to consent and the continued
appropriateness of the agreed treatment have to be factored into the
presentation brought to the Board. This situation may be compared to the
challenges posed by conditions regarded as medical, such as AIDS and
tuberculosis, where public health regulations apply. The incidence and
prevalence of non-communicable disease is recognised to provide a burden to the
healthcare system, in addition to the individual, the family and society. The
inclusion of Community Treatment Orders brings the reality of the burden of
community mental health to the table, and further challenges the roles of the
Psychiatrist on the Review Board.
Almost all forensic clinicians agree that it is unwise, if
not unethical, for a treating clinician to serve as an expert witness for a
patient who is involved in litigation. Proponents of this stance usually justify
their position by reference to the supposed increased “objectivity” of the
third-party forensic clinician, who is supposedly more free to examine all the
available evidence without the “subjective” pull that is often experienced
by the treating clinician. In this presentation, I too argue for the wisdom of
separating the clinician and forensic roles, but I argue that it is not because
the forensic clinician offers the legal process “objectivity.” Instead, the
forensic clinician offers a different type of subjectivity, one that then
interacts with the subjectivity of the examinee to create a localized and
temporary, but quite real, relationship. Drawing on current research and writing
on the neurobiology and psychodynamics of intersubjective experience, I argue
that all forensic encounters, like all clinical encounters, have to carry within
them the seeds of a mutual enactment: a mutual, if only temporary, living out of
both the examinee’s and, far too often, the examiner’s interpersonal
relationship patterns. I argue that by conceptualizing forensic encounters as a
special subclass of mutual, intersubjective enactments, forensic clinicians may
both more accurately assess the complexities of an examinee’s psychology and
then more effectively foresee and perhaps forestall potential ethical dilemmas
in a particular forensic encounter.
Forensic Psychiatry represents many interactions of Social, Psychiatric, Criminal Behavior, Legal, Political, and the Sociology of Political; within its definitions, assignments, ideologies and practices.
The contact points, and the manifestations, implications, as well as both problems and solutions; of some of these aspects are discussed in the paper.
Particularly difficult and complicated ethical concerns are
to be found in the boundaries of professional helping relationships. It is in
the boundaries that we find the “slippery slope,” the slope where
professionals slide from small personal acts not strictly in the therapeutic
realm (like sharing a cup of coffee with a client) to more serious relationship
violations (like a sexual encounter). Professionals are cautioned to protect
their clients from harm by careful avoidance of the slippery slope and by the
strict maintenance of relational boundaries. Yet it can be argued that rigid
boundaries diminish therapeutic effectiveness. Clients may experience fixed
boundaries and role assignments as a barrier between them and those who seek to
help them. There can seem a diminishment in the humanity of the encounter. This
paper explores the concept of “boundries”, as based on the findings of an
interdisciplinary study in relational ethics. The implications of the
“boundary” metaphor will be discussed and alternate metaphors addressed.
There is a suspicion among many in the community that professional groups, particularly those that are self-regulating, discipline members who breach the standards of conduct differently than the community would discipline its members who commit analogous ‘wrongs’. This paper examines the Australian data to determine whether professions do take a different approach to disciplining their members, and whether there are ‘internal’ differences in approach between various professions.
Freudenberger (1980) is considered to have coined the
metaphor burn out (named in French, épuisement
professionel) as a job-related stressful process that affects many of the
helping professionals. In 1982, Maslach introduced a scale to measure the level
of burn out of workers. The Maslach burn out inventory> (MBI) is conceptually
framed by emotional exhaustion, personal accomplishment and depersonalisation.
Nursing professionals are highly exposed to burn out. It is even considered as
being the nurse’s greatest professional hazard. The purpose of this paper is
to present the metaphors used by nurses to express their experiences of burn out
and to initiate discussion about the language they use. This study is a
secondary analysis of transcripts from a previously conducted study on the
incidences revealing how nurses practice
nursing. The understanding of metaphors, as an interpretative process, is
congruent with a Heideggerian hermeneutic method. As such, it pertains to the
exposure of hidden meanings. (Kiesel, 1985), such as suffering.
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