Ethical dilemmas in community mental health care is the focus of this article. The dilemmas are derived from a discussion of the results of a qualitative research project that took place in five countries of the European Union. The different stakeholders are confronted with the following dilemmas: community careversushospital care (clients); a life with careversusa life without care (informal carers); stimulation of the client toward greater responsibilityversusprotection against such responsibility (professionals); budgetary controlversusfinancial incentives (policy makers), and respect for the clientversusparticular private needs (neighbourhood residents). These dilemmas are interpreted against the background of a value based ethical model. This model offers an integral approach to the dilemmas and can be used to determine policy. The dilemmas are discussed here as the result of conflicting values—namely autonomy and privacy, support and safety, justice and participation, and trust and solidarity.

Oyster Care is the result of the search by caregivers in Flanders, Belgium, to develop quality care for patients with a Severe and Persistent Mental Illness (SPMI). This article offers a conceptual analysis of the Oyster Care model, based on experiences, analysis, and reflection of the authors, and on several examples. The starting point of the development of this new care model is the complex and difficult context of the care for SPMI patients. Their needs and suffering are very challenging on account of a wide variety of causes. At the same time they are in danger of being neglected by the care system. Paradoxically, the development and implementation of psychosocial rehabilitation in Belgian mental health care puts the care for these patients under pressure. In practice, they are often exposed to over-or undertreatment. Another aspect that has influenced the search for more qualitative care in cases of severe psychological suffering in general and palliative approaches in particular is the background of the legal regulation of euthanasia in Belgium. Oyster Care is an innovative form of the palliative approach and philosophy, tailored to the specific target group of SPMI patients. The caregivers create an "exoskeleton" or "shell" in which SPMI patients can "come to life": they are mainly dependent on the "external structure" they receive in order to function, rather than on the "internal structure" of their abilities. It is a dynamic approach that responds to the needs, possibilities and pace of each patient: within this safety, people can fold back or take new steps. Oyster Care is also a holistic care approach, based on four pillars: physical care adequately responding to the somatic impairments of these patients; psychological care changing the scope of therapy by focusing on mental comfort and wellbeing; social care providing a structure of daily activities and contacts; existential care enhancing the experience of life as valuable and meaningful. The wellbeing of patients is paramount and requires a range of interventions, such as a highly personal approach, a flexible dealing with rules, a great dose of creativity in everyday life, extensive expertise in somatic care, and specific attention to existential needs and the search for meaning. The development of this care model in a number of care units in Flanders increases the wellbeing of the patients and creates a significant positive dynamic among caregivers. However, more research and resources are needed to further develop and integrate this model.

Researchers and practitioners collaborated in a project across five European countries aimed at defining the characteristics of good community care for people with severe mental illnesses and to explore the values ofstakeholders in this debate (clients, families, professionals, policy makers, other citizens). In a concept mapping procedure all stakeholders gave highest priority to a trusting and stimulating relationship between clients and professionals. Secondly, good care was seen as effective treatment tailored to the individual needs. Accessibility of services came in the third place. Differences between the views of stakeholders are discussed.

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In psychiatry, caregivers try to get free and informed consent of patients, but often feel required to restrict freedom and to use coercion. The present article develops ethical advice given by an Ethics Committee for Mental Health Care. The advice recommends an ethical ideal of shared deliberation, consisting of information, motivation, consensus and evaluation. For the exceptional use of coercion, the advice develops three criteria, namely incapacity to deliberate, threat of serious harm and proportionality between harm and coercion. The article also discusses the viewpoints of the ethical advice and of the European Convention on Human Rights and Biomedicine: is the advice in agreement with the Convention and can the advice refine the guidelines of the Convention for the particular context of psychiatry? Although the Convention emphasises the autonomy of the individual patient, whereas the advice focuses on the relationships between the partners involved, the advice enjoys a complementary and supportive function in the application of the Convention.

The present ethical advice tackles the question as to how caregivers in a Catholic mental health service can take care of psychiatric patients requesting euthanasia because of their unbearable mental suffering. The question arises because the Belgian act on euthanasia allows euthanasia under certain conditions, while the Roman Catholic Church forbids euthanasia in all circumstances. The ethical advice is based on the assessment of fundamental values: the inviolability of life, the patient's autonomy, and the care relationship between caregivers and patient. To integrate these values, caregivers should in a timely fashion make clear that life is inviolable, attentively respect the patient's autonomy, and provide the best possible care relationship, including counseling for existential questions. If the request for euthanasia persists, the only sensible option is to refer the patient to another physician, guaranteeing the continuity of the care relationship. In the tension between the inviolability of life and the patient's autonomy, the care relationship is the binding value.

Background Assisted dying for adults with psychiatric conditions (APC) is highly controversial but legally possible in a few countries, including Belgium. Previous research has suggested that the complex euthanasia assessment procedure may cause additional suffering in APC but may also induce positive experiences. This study reports on the impact of the euthanasia assessment procedure as experienced by APC on three counts: 1) their mental state, including death ideation; 2) their treatment trajectory; 3) their social relationships. Methods We performed an in-depth qualitative interview study with 16 APC in Flanders, Belgium, who had voiced a euthanasia request between 2016–2020. Thematic coding was used. Findings We interviewed 16 APC. Euthanasia assessment procedures brought out a plethora of experiences in APC, both favourable and unfavourable. Whereas thoughts of suicide remain present to a certain extent, being in the assessment procedure allows some APC to reconsider alternatives towards life, and also to attempt new treatment options. However, many APC experience ambivalence about the supposedly inherent desirability and dignity in euthanasia. Worries also surfaced about the rationale behind and effects of involvement of APCs’ social circle, and about the impact it could have on them. Conclusion Further research, including other stakeholder perspectives, is recommended with a view to maximising favourable and minimising unfavourable impacts for all involved. In clinical practice attention to these impacts is paramount, and clear communication and management of expectations between physician and patient, seems appropriate to address the many ambivalent experiences that accompany APC during the euthanasia assessment procedure. Policy attention could in this regard go to clarifying certain sources of ambivalence and issues that are insufficiently addressed, such as modalities of relatives’ involvement.

Although philosophy and theology on the one hand and psychiatry on the other have become separate disciplines, they continue to function as 'parallel discourses'. This is apparent in the work of Morel, whose theory of degeneration was based on a belief in creation and the existence of a moral law. He was influenced by Buffon's naturalism, whose tenets were opposed to Darwin's recently published theory of evolution. Morel's nosological concept of pathology grew from his beliefs about the relation between the body and the soul, and the role of free will and passion. He borrowed from Gall's account of phrenology to refute accusations of materialism and determinism, but he also drew on the doctrines of Thomism to explain the relation between the body and the soul. He was acquainted with the work of Buchez and Morin, whose writings were an early and almost unknown source of Thomistic revival in the mid-nineteenth century.