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Ethics in Clinical Practice: What’s the right thing to do?

Written by Philip Houghton on . Posted in Clinical Psychology Bite-Size

Ethics in Clinical Practice: What’s the right thing to do?

Issue 28 – July 2011

Author: Phil  Houghton (philip.houghton@nottshc.nhs.uk)

Key points

  • Within clinical practice we are often faced with the question “what’s the right thing to do?”
  • Whilst we can not guarantee making the “right” decision, ethical frameworks exist which can help us make decisions in the right way 

Implications for practice

  • Paying attention to our emotional reactions within clinical practice can help us stop and identify ethical dilemmas and lead to consideration of different ways forward
  • Trying to articulate our underlying assumptions about mental health and allowing them to be questioned can promote ethical practice
  • Ethical dilemmas faced by clinicians can be discussed at the clinical ethics committee. 
Ethics and ethical practice can be notoriously difficult to define. My belief is that within clinical settings ethics often boils down to being faced with a decision and considering the question “what’s the right thing to do?” 1. For example: do we section this person? Do we pass on information about this service user without explicit consent? Do we discharge this person from services even though they still present with risk factors? Such questions often prompt us to feel uneasy. But why do certain decisions prompt an uneasy gut feeling? My belief is that our emotional reaction represents a type of moral or ethical barometer. We may not be able to articulate it, but the decision we are faced with makes us uncomfortable as it challenges our individual or collective values, our sense of right and wrong. It is not simply an intellectual debate but a sense which is part of our bodies, it feels right, or it feels wrong. I believe such feelings are influenced by our own individual experiences of life as well as the social and cultural context we grew up in and continue to exist in. For example when we make a decision we may on some level be influenced by how we feel our family and friends, colleagues, NHS inquiries / investigations and the media may react to the choice we make. My belief is that such a feeling is invaluable in providing information about a decision. To me it should act as a red flag, forcing us to stop and think. Where I then think ethics as a discipline can be helpful is providing various theories and frameworks which allow us to articulate that gut feeling, and can aid us in making a decision. For example, take the dilemma of whether service users’ rooms on the wards should be locked for a certain amount of time each day. We may take what is referred to as a Utilitarian approach. Within this approach the right decision is the one which brings the greatest happiness or benefit to the greatest number of people. So we may argue that whilst it may not benefit all inpatients on the ward, that forcing everyone to be in a social environment will reduce the distress and aid the recovery of the majority of people. Alternatively we may argue that we can not ignore the means we employ to justify the ends and that there are fundamental rights which should be followed (e.g. Kantism). From this point of view one could argue that it is fundamentally wrong to prevent someone accessing their room. Or we could think about what is a virtuous choice (virtue ethics), which would lead us into a debate about what underlying virtues underpin such a decision and which virtues as a collective we may favour. From a clinical perspective frameworks also exist which are designed for the type of ethical dilemmas that are faced within clinical practice. For example, the Ethox Centre ( www.ethics-network.org.uk 2) have developed a structured framework for analysing ethical dilemmas which includes:
  • What are the relevant facts? What’s the appropriate decision making process?
  • What are the possible options and morally significant features of each?
  • What does the law or published guidance say about each option?
  • What are the moral arguments in favour and against each option?
  • Identify the strongest counter argument to your favoured option and try and rebut this
  • Make a decision and review and learn from it in light of what happens
Such frameworks can help us weigh up the various options and make explicit why we are taking a given direction. In other words they help us make the decision in the right way. In addition to trying to respond in the right way to the feelings of discomfort described above, I believe ethical practice extends to a much broader consideration of the values and theories which underpin what we do within our clinical work. Within the area of mental health, the question of what causes psychological distress and the best way to respond to it is highly contested. For example, consider the following question: does schizophrenia refer to a discrete medical illness driven by distinct biological and genetic abnormalities or is it simply a label describing a group of experiences which has little to say about what led to those experiences or how to respond to them? Our practice is infused with such questions which are often left unconsidered or unarticulated, but have a profound impact on what we do. Indeed history is littered with actions we would now deem as abhorrent and certainly unethical but at the time were based on underlying assumptions about the nature of distress (e.g. insulin coma, prefrontal leucotomy and extermination 3,4,). Ethical practice is therefore not simply about justifying our choices when faced with an uneasy ethical dilemma, it is also about trying to clarify the values and assumptions we have regarding mental health and how these may affect our practice5. This is often difficult as we may rarely articulate them, and may only notice them when they are directly challenged. However, bringing our assumptions out into the open for questioning through conversation and debate from an open and inquisitive stance can lead us closer towards ethical practice. In sum, when faced with an ethical dilemma it is impossible to be fully confident we are doing the right thing. But by acknowledging our emotional reactions, clarifying our underlying assumptions and taking account of ethical frameworks we can improve the process by which decisions are made. In short we can make the decision in the right way. Of course this is very difficult to do by oneself. Rather, open debate and discussion with others is often essential in trying to make decisions in the right way. This can often be available through supervision, team discussion or more informal support from colleagues. Sometimes however, for clinicians within our Trust it can be helpful to bring ethical dilemmas to the Adult Mental Health Clinical Ethics Committee. This enables a fuller discussion to take place with a broad variety of viewpoints, and without the restraints of usual hierarchies. It can provide support for clinicians and teams to take decisions which they may feel very uncomfortable with, or raise considerations which have previously not been articulated. If you or a colleague would like to discuss an ethical dilemma with the group please feel free to contact me on philip.houghton@nottshc.nhs.uk.

REFERENCES

  1. Sandel, M, J. (2009) Justice: What’s the right thing to do?. Penguin
  2. UK Clinical Ethics Network: www.ethics-network.org.uk (accessed 25.05.11)
  3. Bentall, R. (2004) Madness Explained: Psychosis and Human Nature. Penguin
  4. Houghton, P. (2008) Understanding Psychosis. Clinical Psychology Bite-Size, edition 1
  5. Houghton, P (2008) Values Based Practice. Clinical Psychology Bite-Size, edition 9

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