Negotiating Risk Ethically

Coast Mental HealthEthics 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, community-based 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, self-neglect

• 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 preferencesIII. quality of lifeIV. contextual features

of the case.

Elements of ethical analysisProblem – 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 / non-discriminatory 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 Critical

Pressure 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, non-maleficence, 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, non-judgment, 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.

• 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

ore-mail ethicscorner@coastmentalhealth.com

or call: 604-512-3735

Thank you for your attention!