Negotiating Risk Ethically
Coast Mental Health
Ethics Committee Presentation
May 2011
Latest trends in Risk Management
• Individual expectations : clients as consumers vs.
patients; client rights, client-driven treatment
• Professional: obligation to respect, communitybased treatments, client-centered approaches,
safety at workplace
• Political / systemic: democratic freedoms,
multiculturalism, de-institutionalization, shorter
hospital stays, bed shortage
• Societal: liberal values, autonomy and choice,
community integration, tendency to litigious claims
Who defines the risk?
How the risk is defined?
Living at Risk
• Living at risk results
from client’s
autonomous but
imprudent decisions
that have potential
for negative
outcomes.
Living at Risk Dilemma
Most ethical dilemmas related to living at risk
are related to the conflict over obligation to
honor client autonomy vs. obligation to
provide care / benefit the client (beneficence
vs. non-maleficence) and by assuming
paternalistic position to avoid / minimize
harm to the client / others. (based on Haddad, 1992)
Risk Defined
• At self – self harm, suicide, reckless activities
/ lifestyle, refusal of or non compliance with
treatment / medications, substance use, selfneglect
• At others – threats, physical violence,
property damage,
• By others – physical / sexual / emotional
abuse, abuse of power, neglect, financial
indiscretions, discrimination, bullying
Formulating Ethical Question
re Risk / Living at Risk
• Given uncertainty of outcomes or conflict
about values, what decisions or actions
related to living at risk are ethically
justifiable?
OR
• Given uncertainty of outcomes or conflict
about values, is it ethically justifiable to allow
clients live at risk?
Four Quadrant Approach to Ethics
Questions in Healthcare
I. clinical / health
indications
II. client preferences
III. quality of life
IV. contextual features
of the case.
Elements of ethical analysis
Problem – ethical question
Information gathering (four quadrant approach)
Options and their ethical grounding
Preferred choice / decision
Ethical rationale for the preferred choice(s) / decision
Recommendations
Plan of action
Evaluation / Lessons learned?
Three Levels of Moral Reasoning
re Risk Management
LEVEL I: CASUISTRY
• Looking at present case of risk / potential risk
in the context of past cases and find out how
they were negotiated / resolved previously
Three Levels of Moral Reasoning
re Risk Management cont.
LEVEL II: RULES AND RIGHTS
• apply principles of bioethics: autonomy of a person to live at
risk; professional obligation to benefit / provide care and
support and avoid harm / protect others; justice / nondiscriminatory approach to risk management
• set specific codes: professional standards of competencies
and practice
• establish specific rules: obtaining informed consent
• reinforce rights & responsibilities of clients and professionals
• balance and consider rule challenges: respect for autonomy
rule vs. what if the autonomy would do more harm and break
the beneficence / do not harm rules?
Three Levels of Moral Reasoning
re Risk Management cont.
LEVEL III: NORMATIVE ETHICS (establishing
theoretical norms to justify rules and claims)
• Value consideration: what things related to
living at risk / taking risks / negotiating risk do
clients (also professionals, society) intrinsically
value?
• Virtue consideration: what are the traits of a
good mental health provider who negotiates
risk ethically?
Central Issues related to
Risk Management
• Prediction of risk
and consequences
• Duty to intervene
• Duty to protect
• Accountability and
rights of a person
Decision re risk – client factors:
refusal to comply vs. informed consent
• Competency /
decisional capability
• Voluntariness / lack
of undue influence
• Knowledge / access
to information
Risk Measurement - Factors
• Likelihood: rare, unlikely, possible, likely, almost
certain
• Severity: insignificant, minor, moderate, major,
extreme
• The degree: slight, tolerable, moderate,
substantial, critical / intolerable (reversible vs.
irreversible)
• Urgency for preventive action: slight, tolerable,
moderate, substantial, critical
Duty to intervene
Slight
Tolerable
Moderate
Explain
Negotiate
Persuade
Substantial
Pressure
Critical
Physically coerce
Risk Management Rules
• RULE #1:
Risk management interventions are never based on
convenience or gratification.
• RULE #2:
Negotiating risk ethically involves the minimal use
of power to attain maximum benefit and minimum
infringement on client’s liberty.
• RULE #3:
• The more grave consequences - the greater
obligation to intervene.
In case of Conflict
If the client is capable – the client should be considered a
decision-maker (respect for autonomy).
If the client is not capable, then family / advocate / substitute
decision maker / health care professionals may make
decisions. Decisions are made using:
• Substituted judgment – what the client would have chosen if capable
• Best interest – what a reasonable person in that situation would have
chosen
If the intervention is ineffectual (futile), too costly, and/or
harmful to client or others, or it compromises professional
integrity – the intervention may not be offered / client
preference not honored (justifiable withdrawal)
MH practitioners’ obligations
related to risk management
• Professional:
therapeutic alliance, duty
to serve
• Ethical / moral:
beneficence, nonmaleficence, respect for
autonomy, justice, veracity,
fidelity
• Legal:
protection from harm,
safety regulations
Factors in Risk Management
related to setting
Acute setting
• Professional / policy
centered
• Structured environment
• Client more sick /
vulnerable
• Short term relationships
Community setting
• Client-centered
• Less structured / home-like
environment
• Clients more stable
• Long term relationships
Approaches to negotiating risk
Protective factors
Client: strengths, abilities, insight,
decision making / problem
solving, coping skills;
Supports: information, supervision /
attention, time, accommodation,
respect, permission to make
mistakes, tolerance, nonjudgment, inclusion, flexibility,
creativity, client-focused care;
Administrative: safety agreement,
service agreement, standards of
practice(i.e. informed consent),
safety protocols, staff training,
multidisciplinary approach.
Approaches to negotiating risk
Dignity of risk (balance of
risk):
• tolerable vs. intolerable
• moderate vs. extreme
• reversible vs.
irreversible
Negotiating Risk Ethically
Paternalistic approach further
stigmatizes mentally ill people and
inadvertently denies them equal human
and moral standing; therefore, may be
considered unjust and hurtful.
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References
Browne, A. (2006). Community Care Toolkit for Ethical and Clinical decision making for
Complex
and High Risk Clients. Author
Browne, A. & Sweeney, V. (1995). A short guide to clinical ethics. Vancouver
Provincial health Ethics network www.phen.ab.ca
Vancouver Coastal Health (2004). Vancouver community health services / community mental
health
services ethical decision making framework and process. Vancouver: VCH
Weiss Roberts, L & Dyer, A. R. ((2003). Concise guide to ethics in mental health care. Washington, DC:
American Psychiatric Publishing.
Coast Mental Health
Ethics Committee
To contact Coast Ethics Committee:
e-mail: beataz@coastmentalhealth.com
or
e-mail ethicscorner@coastmentalhealth.com
or
call: 604-512-3735
Thank you for your attention!