Ethical dilemmas in psychiatry: When teams disagree

Abstract

SummaryMany ethical dilemmas in medicine are associated with highly unusual clinical situations and are an almost daily challenge for mental health teams. We describe the ethical issues that arose in relation to a significant difference of opinion between team members about using nasogastric clozapine in the treatment of a severely ill patient. We discuss how conflicting emotions and perspectives within teams acquire ethical significance and how negotiation and reflection are essential for good-quality ethical reasoning to take place.Learning Objectives• Understand the different effects and importance of reasoning and emotions in moral decision-making• Use a clinical scenario involving a difficult and controversial procedure to explore the impact of social persuasion in moral decision-making• Consider the effects of heuristics against rational thinking

The assertive approach to clozapine: nasogastric administration

“…Although all health professionals prefer to initiate treatments with patients who fully understand and actively consent and cooperate, in these rare cases, the status quo is clearly unacceptable and the ethical argument for this very assertive approach to clozapine, once conceived of, is not hard to make to establish and maintain patients on clozapine 10 …”

“…As Silva et al 10 discuss, teams that embark on this approach are faced with very difficult decision-making, such as how long to persist with one attempt at passing a nasogastric tube? When is a patient's distress at the procedure too great?…”

“…Explored by Silva et al 10 , there are ethical dilemmas with administering nasogastric clozapine. These involve balancing the risks and benefits of an unacceptable status quo against the uncertainties of the possible risks and benefits of intervention, alongside containing and resolving the emotions of the team when using a novel, restrictive and coercive treatment on a vulnerable and incapacitous patient.…”

“…With injectable clozapine unavailable in the UK until very recently, when presented with a crisis, 10 nasogastric clozapine was successfully used for the first time at Ashworth high-security hospital in 2010 and has been used subsequently to help establish and maintain treatment with clozapine. We now present the first systematic description of the ‘assertive approach’ to clozapine via nasogastric clozapine, which commences not on the first administration of nasogastric clozapine, but on its approval for use; this in itself is often enough.…”

Clozapine rechallenge and initiation despite neutropenia- a practical, step-by-step guide

“…It is very helpful to acknowledge this in the plan itself. We have also had experience of the use of enforced naso-gastric clozapine [2] and with clozapine given after severe physical health comorbidities [3]; whilst clear and informed clinical decision making is essential, careful thought must also be given to the team and institutional factors that can facilitate or interfere with these sorts of intrusive and unusual interventions [4].…”