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Paternalism, autonomy and reciprocity: ethical perspectives in encounters with patients in psychiatric in-patient care.
Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital. Psychiatric Research Centre.
Barn- och ungdomsvetenskapliga institutionen, Stockholms universitet, Stockholm, Sweden.
Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Psychiatric Research Centre, Örebro University Hospital, Region Örebro County, Örebro, Sweden.
2013 (English)In: BMC Medical Ethics, ISSN 1472-6939, E-ISSN 1472-6939, Vol. 14, no 1, p. 49-Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Psychiatric staff members have the power to decide the options that frame encounters with patients. Intentional as well as unintentional framing can have a crucial impact on patients' opportunities to be heard and participate in the process. We identified three dominant ethical perspectives in the normative medical ethics literature concerning how doctors and other staff members should frame interactions in relation to patients; paternalism, autonomy and reciprocity. The aim of this study was to describe and analyse statements describing real work situations and ethical reflections made by staff members in relation to three central perspectives in medical ethics; paternalism, autonomy and reciprocity.

METHODS: All staff members involved with patients in seven adult psychiatric and six child and adolescent psychiatric clinics were given the opportunity to freely describe ethical considerations in their work by keeping an ethical diary over the course of one week and 173 persons handed in their diaries. Qualitative theory-guided content analysis was used to provide a description of staff encounters with patients and in what way these encounters were consistent with, or contrary to, the three perspectives.

RESULTS: The majority of the statements could be attributed to the perspective of paternalism and several to autonomy. Only a few statements could be attributed to reciprocity, most of which concerned staff members acting contrary to the perspective. The result is presented as three perspectives containing eight values.Paternalism; 1) promoting and restoring the health of the patient, 2) providing good care and 3) assuming responsibility.Autonomy; 1) respecting the patient's right to self-determination and information, 2) respecting the patient's integrity and 3) protecting human rights.Reciprocity; 1) involving patients in the planning and implementation of their care and 2) building trust between staff and patients.

CONCLUSIONS: Paternalism clearly appeared to be the dominant perspective among the participants, but there was also awareness of patients' right to autonomy. Despite a normative trend towards reciprocity in psychiatry throughout the Western world, identifying it proved difficult in this study. This should be borne in mind by clinics when considering the need for ethical education, training and supervision.

Place, publisher, year, edition, pages
BioMed Central, 2013. Vol. 14, no 1, p. 49-
Keywords [en]
Staff; Psychiatric care; Paternalism; Autonomy; Reciprocity; Qualitative theory-guided content analysis; Diary method; Ethical considerations; Ethical issues
National Category
Bioethics Medical Ethics Social Sciences
Research subject
Psychiatry
Identifiers
URN: urn:nbn:se:oru:diva-43921DOI: 10.1186/1472-6939-14-49ISI: 000328501900001PubMedID: 24314345Scopus ID: 2-s2.0-84889026420OAI: oai:DiVA.org:oru-43921DiVA, id: diva2:798958
Available from: 2013-12-30 Created: 2015-03-27 Last updated: 2018-05-26Bibliographically approved
In thesis
1. Ethical considerations in psychiatric inpatient care: The ethical landscape in everyday practice as described by staff
Open this publication in new window or tab >>Ethical considerations in psychiatric inpatient care: The ethical landscape in everyday practice as described by staff
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

This thesis focuses mainly on the general ethical considerations of staff and not pre-defined specific ethical problems or dilemmas. The aims of this thesis were: first, to map ethical considerations as described by staff members in their everyday work in child and adolescent psychiatry as well as in adult psychiatry; second, from a normative ethical perspective, examine encounters between staff and patients; and third, to describe staff justification for decisions on coercive care in child and adolescent psychiatry. The material in the three first studies comprised ethical diaries written by staff in 13 inpatient clinics. The fourth study included all the medical records of patients who were admitted to coercive care during one year in child and adolescent psychiatry in Sweden.

In a final analysis, combining all the four studies, three staff ideals were identified: being a good carer, respecting the patient’s autonomy and integrity and having good relations with patients and relatives. Staff often felt that the only reasonable way in many situations was to act in a paternalistic way and take responsibility, but they considered it to be problematic.

Four main themes were identified as ethical considerations. These were the borders of coercion, the emphasis on order and clarity rather than a more reciprocal relationship with patients, a strong expectation of loyalty within the team, and feelings of powerlessness, mostly in relation to patients.

I have identified four challenges for inpatient psychiatry. First, formal and informal coercion in inpatient care raise ethical concerns that also can be emotionally difficult for staff. Second, the professional role and care needs to be redeveloped from providing routinised care to providing more individualised care. Third, staff often worry about how patients manage their life after discharge, indicating that patients need better support. Fourth, staff also need support; they often experience feelings of being alone with their thoughts about ethical difficulties at work. Future research could contribute in the mapping of ethical considerations, in helping to develop, implement and evaluate methods for managing these issues in psychiatric settings, and to develop the normative ethical language so that it is more relevant to the clinic reality.

Place, publisher, year, edition, pages
Örebro: Örebro university, 2015. p. 97
Series
Örebro Studies in Medicine, ISSN 1652-4063 ; 120
Keywords
Staff, psychiatric care, diary method, qualitative content analysis, ethical issues, decision making, coercive care, adolescent
National Category
Psychiatry
Research subject
Psychiatry
Identifiers
urn:nbn:se:oru:diva-43270 (URN)978-91-7529-069-0 (ISBN)
Public defence
2015-05-08, Universitetssjukhuset, hörsal C3, Södra Grev Rosengatan, Örebro, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2015-03-04 Created: 2015-03-04 Last updated: 2017-10-17Bibliographically approved

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Pelto-Piri, VeikkoEngström, Ingemar

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