RESUMO
BACKGROUND: The effectiveness of clinical ethics counselling in medicine in terms of satisfaction of the participants, support of ethical decision-making, perceived impact on clinical care, moral competence and quality of communication is now empirically well validated. In psychiatry, more and more institutions have structures for clinical ethics consultation as well; however, there is still a lack of evaluative accompanying research on the benefits and differential indications of the various forms and models of clinical ethics counselling in psychiatry. AIM OF THE WORK: The article presents the principles and the step by step application of the principle-oriented clinical ethics consultation according to the Basel model 2.0. MATERIAL AND METHODS: The article is based on material and procedures developed at the Clinical Ethics Unit of the University Hospital Basel and the University Psychiatric Clinics Basel for the principle-oriented clinical ethics consultation according to the Basel model 2.0. RESULTS AND DISCUSSION: Principle-oriented clinical ethics consultation according to the Basel model 2.0 is suitable for dealing with moral issues and conflicts in psychiatric practice and for their ethical reflection; however, further evaluative accompanying research is needed on the benefits and differential indications of this and other models of clinical ethics support in psychiatry.
RESUMO
Background and aim: Coercive measures in patient care have come under criticism leading to implement guidelines dedicated to the reduction of coercion. This development of bringing to light clinical ethics support is hoped to serve as a means of building up awareness and potentially reducing the use of coercion. This study explores the specific features of ethics consultation (EC) while dealing with coercion. Material and method: Basel EC documentation presents insight to all persons involved with a case. The EC database of two Basel university hospitals was developed on the grounds of systematic screening and categorization by two reviewers. One hundred fully documented EC cases databased from 2013 to 2016 were screened for the discussion of coercive measures (somatic hospital and psychiatry: 50% cases). Results: Twenty-four out of 100 EC cases addressed coercion in relation to a clinically relevant question, such as compulsory treatment (70.8%), involuntary committal (50%), or restricting liberty (16.6%). Only 58.3% of EC requests mentioned coercion as an ethical issue prior to the meeting. In no case was patient decisional capacity given, capacity was impaired (43.5%), not given (33.3%), or unclear (21.7%; one not available). Discussion: As clinical staff appears sensitive to perceiving ethical uncertainty or conflict, but less prepared to articulate ethical concern, EC meetings serve to "diagnose" and "solve" the ethical focus of the problem(s) presented in EC. Patient decisional incapacity proved to be an important part of reasoning, when discussing the principle of harm prevention. While professional judgment of capacity remains unsystematic, rationality or even ethicality of decision making will be hampered. The documented EC cases show a variety of decisions about whether or not coercion was actually applied. Ethical reasoning on the competing options seemed to be instrumental for an unprejudiced decision complying with the normative framework and for building a robust consensus. Conclusions: The recommendation is whether EC should be used as a standard practice whenever coercion is an issue-ideally before coercion is applied, or otherwise. Moreover, more efforts should be made toward early and professional assessment of patient capacity and advance care counseling including the offer of advance directives.
RESUMO
In Switzerland, the practice of lay right-to-die societies (RTDS) organizing assisted suicide (AS) is tolerated by the state. Patient counseling and accompaniment into the dying process is overtaken by RTDS lay members, while the role of physicians may be restricted to prescribing the mortal dose after a more or less rigorous exploration of the patient’s decisional capacity. However, Swiss health care facilities and professionals are committed to providing suicide prevention. Despite the liberal attitude in society, the legitimacy of organized AS is ethically questioned. How can health professionals be supported in their moral uncertainty when confronted with patient wishes for suicide? As an approach towards reaching this objective, two ethics policies were developed at the Basel University Hospital to offer orientation in addressing twofold and divergent duties: handling requests for AS and caring for patients with suicidal thoughts or after a suicide attempt. According to the Swiss tradition of “consultation” (“Vernehmlassung”), controversial views were acknowledged in the interdisciplinary policy development processes. Both institutional policies mirror the clash of values and suggest consistent ways to meet the challenges: respect and tolerance regarding a patient’s wish for AS on the one hand, and the determination to offer help and prevent harm by practicing suicide prevention on the other. Given the legal framework lacking specific norms for the practice of RTDS, orientation is sought in ethical guidelines. The comparison between the previous and newly revised guideline of the Swiss Academy of Medical Sciences reveals, in regard to AS, a shift from the medical criterion, end of life is near, to a patient rights focus, i.e., decisional capacity, consistent with the law. Future experience will show whether and how this change will be integrated into clinical practice. In this process, institutional ethics policies may—in addition to the law, national guidelines, or medical standards—be helpful in addressing conflicting duties at the bedside. The article offers an interdisciplinary theoretical reflection with practical illustration.
