Dirty work: well-intentioned mental health workers cannot ameliorate harms in offshore detention.

Professional providers of mental health services are motivated to help people, including, or especially, vulnerable people. We analyse the ethical implications of mental health providers accepting employment at detention centres that operate out of the normal regulatory structure of the modern state. Specifically, we examine tensions and moral harms experienced by providers at the Australian immigration detention centre on the island of Nauru. Australia has adopted indefinite offshore detention for asylum-seekers arriving by boat as part of a deterrence strategy that relies on making detainment conditions harsh. This has known deleterious mental health effects. As a token to fiduciary care obligations, Australia employs mental health professionals to work on Nauru. These providers are often motivated to make a positive difference for detainees' lives. We examine the overall impact of the providers' work with detainees and the implications of their presence. The strongest evidence supports that the small mitigation of harms offered by these providers does not outweigh the harms of supporting a system designed to perpetuate human suffering. For mental health professionals considering working in offshore detention, we offer specific topics to scrutinise and weigh prior to employment. Because optimising detainee's mental health is beyond the capacity of individual providers, we call for the organisations standardising and supporting mental health professionals to oppose employment of their associates in offshore detention. Lessons from this case study are generalisable to other jurisdictions to help inform organisations that licence and support mental health providers and individual providers considering work in similar settings.

Evaluating an Adolescent's Decision-Making Capacity Whilst in the Harsh World of Detention.

Reports of children participating in hunger strikes while detained in offshore detention centres raise interrelated ethical issues and recognizable challenges for the medical decision-makers at these sites. A composite case study, informed by reports in the public domain, is employed to explore the unique challenges of consent and decision-making in these circumstances and the perennial issues inherent in adolescents' developing capacity and autonomy. We present an amalgamated case of a fourteen-year-old adolescent who refused to consent to medical reversal of her hunger strike protest. The medical team became the final arbiter when her parents, who were also in detention, could not agree with each other even after mediation. The case explores the complexity of evaluating the adolescent's capacity to provide informed consent while influenced by the opinions of co-detainees in this extreme setting. We argue that the parents and the child had compromised decisional capacity due to the effects of detention. The challenges to the medical team are recognized and discussed. The team members faced a difficult dilemma and considered the competing values of the multiple cultural and ethical factors. Each team member integrated his or her own roles, duties, and discipline-specific professional guidelines with the primary goal of mitigating potential harms.