Ethical complexities in assessing patients’ insight

Abstract

The question of whether a patient has insight is among the first to be considered in psychiatric contexts. There are several competing conceptions of clinical insight, which broadly refers to a patient’s awareness of their mental illness. When a patient is described as lacking insight, there are significant implications for patient care and to what extent the patient is trusted as a knower. Insight is currently viewed as a multidimensional and continuous construct, but competing conceptions of insight still lack consensus on the specifics. Studies also give contradictory evidence regarding the frequency and consequences of poor insight. A number of crucial questions remain unanswered. After outlining some of the key theoretical disagreements about what insight means, I highlight ethical issues that have not received much attention in the literature. Given the conceptual ambiguities and the absence of standardised bedside tools, there are significant ethical concerns about insight assessments. I highlight two main ethical concerns, specifically that these assessments risk: (1) marginalising patients by setting unattainable ideals for self-knowledge and (2) minimising the patient’s own perspective on their mental health. I close with recommendations for documenting and responding to concerns about poor insight, so patients who are vulnerable to losing epistemic trust are better supported in their therapeutic relationships.

Removing Compliance: Interpersonal and Social Factors Affecting Insight Assessments

“…It is essential in devising support. As Guidry-Grimes argues, it should go beyond standard biomedical views of the patient's condition (5). We have suggested that it is a profoundly relational, dynamically negotiated understanding of one's own experience, where the particular relationship to the clinician is a variable affecting it through their interactions.…”

“…When self-knowledge might include a number of dimensions, one might think the dimension that is relevant in the context of psychiatryand in the related legal settings-is about self-knowledge about one's mental illness or impairment 4 . Many have expressed concerns that the scales then essentially measure a discrepancy between the assessed individual and the clinician (5,31) or in relation to a "gold standard" (24), a concern discussed in relation to insight since Jasper's and Lewis's definitions of "correct" attitudes and judgments [(17) Attributing the perceived changes to illness Practically oriented-the scale is based on a wider concept of insight as self-knowledge, knowledge of the illness and how it might affect his/her ability to function within the environment. It focuses on the subjective experience of the patient and his/her relationship to the environment, rather than diagnosis or labeling.…”

“…Second, submitting only individuals whom we perceive to have an impairment, to stringent tests about their beliefs, with the consequence of potentially coercing them into something, is problematic from human rights perspective. We all operate with certain beliefs in the background of our thinking, which not all others would share 5 . Most importantly, such approach is counterproductive in terms of assessing insight, as it affects one's ability to think and reflect 6 .…”

“…Studies often try to get around the trait desirability influence by using third person vignettes, and/or scenarios where admitting a psychiatric problem brings the protagonist some kind of (financial) benefit. Despite this way around, however, in the 5 For a good account of holding subjective beliefs that give meaning and enable our "cultural" existence, and exist in the paradox of simultaneously not to be questioned but also not to be imposed on the others, see (36 (38) show that stress in the form of interpersonal challenge decreases metacognitive sensitivity. 7 See, for example, Bowles and Sharman (39) and Perlman et al (40) on the effects of using leading interview questions in court with vulnerable adults.…”

“…Nonetheless, there is little research on how the concept of insight features in routine clinical practices on wards. The research there is, shows that in clinical settings insight is used with little detail and specificity [( 4 ), ( 5 ) p. 2]. Whilst insight tools are rarely relied on [( 3 ) p. 1], there is some evidence that psychiatrists’ accounts of insight are still informed by the dominant 1 psychiatric literature.…”