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

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
1
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)
2
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.

3
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.
4
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. 5
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).

6
精神醫療的倫理議題
Ethical and Legal Issues in Psychiatry
The boundaries of mental disorder
 Abuse of psychiatry
 Competence, autonomy and coercive treatment
 Mental disorder and responsibility
 Confidentiality
 Others (enhancement…)

7
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.
Ｉ
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”?
8
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。」

9
醫療中的強迫性
(Coercion in Health Care )
10
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)
11
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
12
精神科強制治療的正當性
(Justification of Compulsory Treatment in Psychiatry)
13
嚴重精神疾病的本質與治療對策
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
14
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)
15
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)
16
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?
17
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)
18
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


19
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
20
restrictive manner.
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

21
強制社區治療
Compulsory Treatment in Community Mental Health Care
Community movement
 Different 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?

22

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。
23
如何減少精神醫療的強迫性?
(How to Reduce Coercion in Psychiatry?)
24
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.
25
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
26
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)
27
金錢報酬用於精神醫療
(Financial Incentive for Patient in Treatment of
Psychosis)
28
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?
29
Financial Incentives for Medication Adherence
in Psychiatric Practice (Claassen 2007)
First applied to his patients in England
 10 GBP for 1 depo injection
 Significant effects3/4 patients never readmitted to hospital in 2
years

30
Financial Incentives for Medication
Adherence-
YES!
High effects and low cost
 Less coercive
 Rewards already exit

31
Financial Incentives for Medication
Adherence-
NO!
Incommensurable Value
 Exploitation
 Fairness

32
Incommensurable Value
What money can buy/ What money cannot
buy
 Commodification
 A failure of “respect for the person”
 Destroying therapeutic relationship as it is a
corruption

33
Exploitation
Taking advantage of patients
 Impairing patients’ capacity to make an
informed decision
 Fostering patients’ dependence, instead of
empowering them

34
Fairness
How about the patients who comply with
taking medication?
 Why patients should comply with medication?
 Patients with other diseases- Hypertension,
Diabetics….

35
Conclusion
Financial incentives, like instant foods,
may be easy, quick, and efficient, however,
it is not good for long-term benefits.
36
精神科醫療人員在醫學倫理的角色
(The Role of Psychiatrists in Medical Ethics)
37
The Role of Psychiatrists in Medical Ethics
The character of psychiatrists
 Ethical issues of psychiatry
 Capacity assessment
 Clinical 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)
38
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. 39
謝謝聆聽!! 問題與指教?!
40