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精神科強制治療的倫理議題Ethical Issues of Compulsory Treatment in Psychiatry

張宏俊 2011/12/01

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大綱 引言 (Introduction) 〝醫療中的強迫性〞議題 (Coercion in

Medicine) 精神科強制治療的正當性 (Justification of

Compulsory Treatment in Psychiatry)如何減少精神醫療的強迫性 (How to Reduce

Coercion in Psychiatry)金錢報酬用於精神醫療 (Financial Incentive for

Patient in Treatment of Psychosis) 的倫理議題精神科醫療人員在醫學倫理的角色 (The Role of

Psychiatrists in Medical Ethics)

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倫理的理論與運用The Theory and Practice of Ethics

Theory: The illustration of “ought and should” in

interpersonal relationship Practice: Working with dilemmas in human

relationship/making space for and reflecting on different values between people

In health care: Ethical problems are commonly viewed as

the tension between two or more morally defensible alternative actions, including inaction.

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如何處理倫理困境 ?(1)How should we make difficult ethical decision?(1)

We need to find some mechanism for resolving ethical dilemmas that goes beyond an appeal to our ‘gut instincts’.

In order to convince others, it is necessary to point to some coherent reasoning process, or moral principle, which explains or justifies one’s position.

It is usually not possible for bioethics to look for an right answer. One possibility might be that reasoned argument and deliberation is simply the most rational way to resolve difficult or controversial questions.

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如何處理倫理困境 ?(2)How should we make difficult ethical decision?(2)

基本倫理理論 Basic Moral Theories:

效益論 /結果論 Utilitariansim /Consequalialism judges an action/inaction by its consequences or

outcomes. 道義論 Deontology (Duty) based on the argument that moral duties or

obligations determine whether an action/inaction is moral or immoral. Deontologists concern the rightness of an action itself and the respect for a person’s rights.

德行論 Virtue ethics is concerned with working out what a “virtuous”

person would do in a particular situation. Virtue ethics values intention.

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如何處理倫理困境 ?(3)How should we make difficult ethical decision?(3)

當代的生命倫理學 Contemporary bioethics

原則論 Principlism The ‘principlist’ approach lay out for key

principles: autonomy, beneficence, non-maleficence, and justice.

決疑論 Casuistry (Case) In casuistry, in stead of starting with broad,

abstract theories and principles (a top-down approach), we instead begin with our response to concrete cases and reason by analogy (a bottom-up approach).

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精神醫療的倫理議題Ethical and Legal Issues in Psychiatry

The boundaries of mental disorderAbuse of psychiatryCompetence, autonomy and

coercive treatmentMental disorder and responsibilityConfidentialityOthers (enhancement…)

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Tarasoff case 的解讀The Interpretation of Tarasoff Case 溝通特權止於公共危害之起 “Protective privilege ends where public peril begins.” Confidentiality is a privilege, not a (absolute) right and

when in doubt should be overridden by considerations of safety.

Only imminent risk( 即將發生 )of serious harm( 嚴重傷害 ) would justify disclosure.

Only if the treat is serious and disclosure the only means of averting harm( 揭露是防止傷害發生的唯一徒徑 ).

“Disclosure can therefore only be justified where an identifiable person( 可指認的他人 ) is at serious risk.” (The General Medical Council,GMC, UK)

The key issue here is transparency and being honest with the patient about plans to disclosure, why and to whom.

Against: Is there any “friend’s duty”?

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保密的判斷處境 / 預警與舉發 ( 通報 ) 妨害秘密罪 : 刑法第二十八章第 316 條妨害祕密罪，載明專業人員須保守業務機密 ：「醫師、藥師、藥商、助產士、心理師、宗教師、律師、辯護人、公證

人、會計師或其業務上佐理人，或曾任此等職務之人，無故洩漏因業務知悉或持有之他人秘密者，處一年以下有期徒刑、拘役或五萬元以下罰金。」

溝通特權 : 刑事訴訟法第 182 條，載明專業人員出庭時非當事人允許得拒絕證言：「證人為醫師、藥師、助產士、宗教師、律師、辯護人、公證人、會計

師或其業務上佐理人或曾任此等職務之人，就其因業務所知悉有關他人秘密之事項受訊問者，除經本人允許者外，得拒絕證言。」

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醫療中的強迫性 (Coercion in Health Care )

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強迫治療的定義 Definition and Nature of Coercion

Coercion/ Treatment Pressures

Definition: One person (or organization) exerts pressures on another with the intention of making the letter act in accordance with the wishes of the former.

Coercion is inherent in clinical relationships and that relevant factors may be continuous- for example, the potential harms to patient, the intensity of influence exerted by the clinician, or the level of decisional competence of patient. (Olsen 2003)

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強迫治療的不同層面 The Spectrum of Treatment Pressures

Persuasion( 以良好的理由說服 ) Interpersonal leverage( 利用醫病關係的影響力 ) Inducements/offers ( 鼓勵、獎賞、利誘 ) Threat( 威脅 ) Compulsory treatment( 以法律為位階的強制治療 )

“The greater coercion needs the greater justification.”

George Szmukler &Paul Appelbaum, Treatment Pressure, Leverage, Coercion, and Compulsion in Mental Health Care Journal of Mental Health 2008,17(3): 233-244

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精神科強制治療的正當性 (Justification of Compulsory Treatment in Psychiatry)

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嚴重精神疾病的本質 治療對策一種腦部疾病 藥物治療的重要性

症狀嚴重且具多樣化 醫療專業性的提昇

好發於青少年，病程慢性，容易復發

預防復發，延續性治療

造成功能退化，不容易在社區中獨立生活 ，造成家庭負荷

精神科復健、在社區中宜有適當的支持

沒有病識感，不會主動求醫 外展性服務、強制性治療

嚴重精神疾病的本質與治療對策

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精神科強制治療的正當性 (Justification of Compulsory Treatment in Psychiatry)

Justification based on preventing harm to others (protection of others)

Justification based on acting in the health interest of the patients (protection of patients)

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Justification based on preventing harm to others(1)

“The only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to other.” ( John Stewart Mill, On Liberty,1859)

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Justification based on preventing harm to others(2)

但是，有三個問題要回答… .

1. Are the mentally ill dangerous?2. Can dangerousness can be

predicted?3. If the dangerousness can be

predicted, does it justify compulsory intervention?

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Justification based on preventing harm to others(3)

“Preventive detention/preventive coercive measures” discriminate against people with mental disorders since people not suffering from a mental disorder but who are equally risky cannot be dealt with in such a manner unless they have first committed an offence.

‘ “A person should not be preventive detained.” What worries me is that this applies to those without mental disorder but not to those with mental disorder. And that is unfair.’ (Hope 2004)

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Justification based on acting in the health interest of the patients(1)

Conflict between respect for autonomy and promoting the well-being

“As to disease, make a habit of two things- to help, or at least to do no harm” (Hippocrates, 460-370 BC)

“The health of my patient will be my first consideration.” (Declaration of Geneva, 1948)

Doctrine of informed consent/ respect the informed and voluntary choice of a competent patient

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Justification based on acting in the health interest of the patients(2)

Medical paternalism( 親權主義 )

To justify psychiatric paternalism by 4 preconditions (Waithe, 1983)

1.The prospective paternalised person must be morally non-responsible for his action.

2.The prospective paternalised person must be causing, or about to cause, wrongful harm to those of his interest.

3.This paternalistic action will ultimately enhance the individual’s competence or prevent further deterioration.

4.This paternalistic action takes place in the least restrictive manner.

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精神病人的能力議題The Capacity Issue in Psychiatry

Four functional abilities to assess the competence to consent (Grisso and Appelbaum 1998):

1. the ability to understand information, 2. the ability to appreciate the significance of

information for one’s own situation (especially concerning one’s illness and the probable consequences of one’s treatment options),

3. the ability to reason with relevant information in order to engage in a logical process of weighing treatment options.

4. the ability to express a choice. Mental Capacity Act 2005 in U.K.: Understanding, Retaining, Weighing, Communication

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強制社區治療Compulsory Treatment in Community Mental Health Care

Community movementDifferent weight of justification Protection of the

patients>>Protection of others互惠原則 principle of reciprocity

(Eastman 1994): the right to adequate resourced care is in exchange for the infringement of civil liberty

The mechanism of benefit: intensive care or compulsion?

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精神衛生法第四十一條 嚴重病人傷害他人或自己或有傷害之虞，經專科醫師診斷

有全日住院治療之必要，其保護人應協助嚴重病人，前往精神醫療機構辦理住院。

精神衛生法第四十五條 嚴重病人不遵醫囑致其病情不穩或生活功能有退化之虞，

經專科醫師診斷有接受社區治療之必要，其保護人應協助嚴重病人接受社區治療。

精神衛生法第三條第四款 嚴重病人 : 指病人呈現與現實脫節之怪異思想及奇特行為，

致不能處理自己事務，經專科醫師診斷認定者。

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如何減少精神醫療的強迫性 ? (How to Reduce Coercion in Psychiatry?)

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如何減少精神醫療的強迫性 ? How to Reduce Coercive Interventions in Mental Health?

Objective and subjective coercion

Perceived coercion

Giles Newton-Howes (2010). Coercion in psychiatric care: where are we now, what do we know, where do we go? The psychiatrist. 34:217-220.

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如何減少精神醫療的強迫性 ? How to Reduce Coercive Interventions in Mental Health?

Make services as acceptable and attractive to users as possible

Enhance patients’ involvement in planning their own care: Using “advance directives” to reduce coercion

Use approaches to reduce levels of perceived coercion

Use pressure or coercion only when it is necessary: Justifying coercive interventions

George Szmukler &Paul Appelbaum, “ Treatment Pressure, Coercion, and Compulsion” In George Szmukler (ed.) The Textbook of Community Psychiatry (2011) New York: Oxford University Press. Chapter 27

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如何減少精神醫療的強迫性 ? How to Reduce Coercive Interventions in Mental Health?

“…in the light of human rights abuse perpetrated under the guise of psychiatric treatment, there is a need for a self-critical and chastened paternalism.” (Roberson & Walter, 2008)

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金錢報酬用於精神醫療(Financial Incentive for Patient in Treatment of Psychosis)

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Background

How to keep psychotic patients in continuous treatments is a crucial issue.

Definition of “Financial Incentives for Medication Adherence” :

Patients are paid to keep on taking medication

Should we apply it to psychiatric patients?

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Financial Incentives for Medication Adherence in Psychiatric Practice (Claassen 2007)

First applied to his patients in England

10 GBP for 1 depo injectionSignificant effects- 3/4 patients never readmitted to

hospital in 2 years

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Financial Incentives for Medication Adherence- YES!

High effects and low costLess coerciveRewards already exit

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Financial Incentives for Medication Adherence-

NO! Incommensurable Value ExploitationFairness

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Incommensurable Value

What money can buy/ What money cannot buy

CommodificationA failure of “respect for the

person”Destroying therapeutic

relationship as it is a corruption

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Exploitation

Taking advantage of patientsImpairing patients’ capacity to

make an informed decisionFostering patients’ dependence,

instead of empowering them

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Fairness

How about the patients who comply with taking medication?

Why patients should comply with medication?

Patients with other diseases- Hypertension, Diabetics….

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Conclusion

Financial incentives, like instant foods, may be easy, quick, and efficient, however, it is not good for long-term benefits.

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精神科醫療人員在醫學倫理的角色 (The Role of Psychiatrists in Medical Ethics)

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The Role of Psychiatrists in Medical Ethics

The character of psychiatristsEthical issues of psychiatryCapacity assessmentClinical ethics consultation

Richard M. Zaner, Trouble Voices: Stories of Ethics and Illness (1993) New York: Pilgrim Press. ( 醫院裡的哲學家 心靈工坊 )

Richard M. Zaner, Conversations on the edge: Narratives of Ethics and Illness (2004): Georgetown University Press.( 醫院裡的危機時刻 :醫療與倫理的對話 心靈工坊 )

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Reference (Financial incentive)

Claassen, D. (2007a). Financial incentives for antipsychotic depo medication: ethical issues. Journal of Medical Ethics. 33:189-193.

Claassen, D. (2007b), Fakhoury W, Ford R, et al. Money for medication- financial incentives to improve medication adherence in Assertive Outreach patients. Psychiatric Bulletin. 31:4-7.

Christensen, R.C. (1997). Ethical issues in community mental health: cases and conflicts. Community Mental Health Journal. 7; 33:5-11.

Beauchamp, T.L. and Childress, J. (1979) Principle of biomedical ethics, 1 st edn. New York: Oxford University Press.

Burns, T. (2007) Is it acceptable for people to be paid to adhere to medication? British Medical Journal. 335:232-233.

Szmukler, G. (2009) Financial incentives for patients in treatment of psychosis. Journal of Medical Ethics.35:224-228.

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謝謝聆聽 !! 問題與指教 ?!