Mental health: principles
Students should be able to demonstrate in practice an understanding of:
- ethical, legal and professional implications of the care of patients with mental illness
- the implications of mental capacity legislation for clinical practice
- mental health legislation relating to compulsory detention and treatment
- the ethical and legal issues of restraint.
Mental health: teaching and learning resources
Mental Health Act: Code of Practice, Department of Health (revised 2008)
e-Learning for Deprivation of Liberty Safeguards, Department of Health
Dunn, C, 1998: Ethical Issues in Mental Illness, Aldershot, Ashgate Publishing.
This book is an attempt to address the ethical issues raised by mental illness and its treatment by focusing on the question of autonomy. The mentally ill may be regarded as non-autonomous by virtue of irrationality, which may result in treatment models which deny them a voice. As a counter to this, some have moved to the other extreme and argued that the mentally ill must be regarded as fully autonomous in all circumstances, and consequently that all their wishes regarding treatment must be respected. This book examines the ethical consequences of such simplistic approaches towards autonomy and mental illness, and considers the ethical issues raised by specific forms of treatment. It is suggested in conclusion that improvement in the care and treatment of the mentally ill requires not only a fundamental change in social attitudes but also a less impoverished conception of autonomy than some of those currently employed.
Barker, P (ed.) 2011: Mental Health Ethics: The Human Context. Abingdon, Routledge.
Including sections on Ethics and Mental Health, the Professional Context, Care and Treatment, The Human Context, The Legal Context and the Ideological Context.
Hope T et al, 2008: Medical ethics and law: The Core Curriculum (chapter 11: Mental Health). The book is in two sections. The first considers general aspects of ethics (in the context of medicine); the second section covers the topics identified in the consensus agreement. The content of medical law is not intended to be comprehensive and relates very much to the ethical issues. (Amazon).
For helpful diagrams for visual learners on the interface between the Mental Capacity and Mental Health Acts, see:
Richards, S and Mughal, A F, 2009: Working with the Mental Capacity Act (2nd ed.) Matrix Training Associates.
Films and documentaries
Patient interview: Mental health diagnosis
In this clip, from healthtalkonline.org, the patient says he used to think diagnosis was helpful as it was something tangible, but he now feels diminished by it, and thinks there are other ways of seeing reality. The clip is relevant to the ethics of treating mental illness differently from other illnesses, in terms of consent and refusal, and also the issue of stigma associated with diagnosis.
Copyright © 2011 University of Oxford. Used under licence from DIPEx. All rights reserved.
Videos on mental health discrimination, Time To Change
Minds on Film blog: film reviews, Royal College of Psychiatrists
One Flew Over the Cuckoo’s Nest (1975). Upon arrival at a mental institution, a brash rebel rallies the patients together to take on the oppressive Nurse Ratched, a woman more a dictator than a nurse. (IMDB.com)
Girl, Interrupted (1999). Based on writer Susanna Kaysen's account of her 18-month stay at a mental hospital in the 1960s. (IMDB.com)
Spider (2002). A mentally-disturbed man takes residence in a halfway house. His mind gradually slips back into the realm created by his illness, where he replays a key part of his childhood. (IMDB.com)
Donnie Darko (2001). A troubled teenager is plagued by visions of a large rabbit that manipulates him to commit a series of crimes, after narrowly escaping a bizarre accident. (IMDB.com)
Attitudes to Mental Health, NHS Choices. Four people who have had mental health issues talk about the negative reactions they faced and how they overcame them.
Bipolar and Proud of It, Mind Cymru (2011)
Patient experiences of mental health conditions, Healthtalkonline
Young people's experiences of depression and low mood, Healthtalkonline
Social Care Institute for Excellence resources
Videos on parental mental health and child welfare, Social Care TV
Interactive case studies: waiting room 1, GMC. Jason has mental health problems including depression and anxiety.
Medical Protection Society resources
For information on the Deprivation of Liberty Safeguards, relevant for the interface between The Mental Capacity and Mental Health Acts, see:
Department of Health publications
Mental health and ill health in doctors, DH (2008)
Ethical, legal and professional implications of the care of patients with mental illness
Kapur N.,et al Advance directives and suicidal behaviour, BMJ 2010; 341:c4557
Implications of mental capacity legislation for clinical practice
Inside the Ethics Committee: Mentally Ill and Refusing Surgery, BBC Radio 4 (2010). Should a man who believes his life-saving surgery is a conspiracy to kill him be forced to consent?
Richardson, G, ‘Mental Capacity at the Margin: the Interface between two Acts’ (2010) 18 Medical Law Review 56-77
Owen, G et al, Mental capacity and psychiatric inpatients: some implications for the new mental health law in England and Wales (2009) 195 British Journal of Psychiatry 256-263
Compulsory detention and treatment
Glover-Thomas, N, A new 'new' Mental Health Act? Reflections on the proposed amendments to the Mental Health Act 1983, Clinical Ethics 2007; 2: 28–31
Dale, E, Is supervised community treatment ethically justifiable? J Med Ethics 2010; 36:271-274
Ethical and legal issues of restraint
Slowther, A, Restraint of patients in health care, Clinical Ethics, 1 June 2007; 2: 71-73
Electronic tagging of mental health patients, 25 August 2010. South London and Maudsley Hospital is trialling tracking of mental health patients. The tracker system involves fitting patients with a steel ankle strap linked to a GPS tracking system that can then monitor the location of the person.
Behrman, S, Dunn M, 'Physical restraint of medical inpatients: Unravelling the red tape' 2010 Clinical Ethics, 5(1):16-21
Behr, G, Ruddock, J, Benn, P, and Crawford, M, Zero tolerance of violence by users of mental health services: the need for an ethical framework, 2005, British Journal of Psychiatry, 187
Hughes, J C, Louw, S L, Electronic tagging of people with dementia who wander. BMJ, 2002;325:847-8
Electronic Tagging of Vulnerable Patients, UK Clinical Ethics Network Newsletter, Issue 13, Autumn 2004, page 11
Lepping, P et al, Deprivation of liberty safeguards: how prepared are we? J Med Ethics 2010;36:170-173
Giordano S, For the Protection of Others, Healthcare Analysis, 8, 3, 2000, pp.309-19
Taken from Steinert, T, Lepping, P, Legal provisions and practice in the management of violent patients. A case vignette study in 16 European countries, European Psychiatry, Volume 24, Issue 2, March 2009, 135-141
Case vignette 1
A patient with a clear diagnosis of a psychotic disorder (e.g. schizophrenia, mania) has been admitted to an in-patient psychiatric unit three days ago. (Comment: unit can be locked or open, different types of unit possible, but imagine a type of unit where acute psychotic patients are usually admitted in your country.) At the time of the following event, the patient is an informal/voluntary patient (regardless of his legal status when he was admitted). The patient now exhibits increasing agitation, shows paranoid psychotic symptoms (delusions of reference, auditory hallucinations) and denies being ill. He has been offered oral medication by several staff members, but always refused. While arguing about medication with staff he gets increasingly angry and hits a nurse once on the shoulder with his fist.
Case vignette 2
A patient with a clear diagnosis of a psychotic disorder (e.g. schizophrenia, mania) has been admitted involuntarily/ formally three days ago to an in-patient psychiatric unit. (Comment: unit can be locked or open, different types of unit possible, but imagine a type of unit where acute involuntary psychotic patients are usually admitted in your country.) The current legal status of the patient is involuntary/formal. The patient shows psychotic symptoms (delusions, hallucinations) and denies being ill. He has been offered medication several times by several staff members, but always refused. There is no evidence of danger to self or others.
Case vignette 3
A patient with a clear diagnosis of a psychotic disorder (e.g. schizophrenia, mania) lives in the community in an apartment with his parents. He has been in a psychiatric hospital several times before, but never in a forensic institution. He has been refusing to take medication, see a doctor or any kind of community mental health service staff for some months. The patient’s mother now calls a mental health worker (see below) by phone and tells him/her that the patient is becoming increasingly aggressive and has hit his father. She asks for help.
(2 more case vignettes in: Piyal Sen, Harvey Gordon, Gwen Adshead, et al., Ethical dilemmas in forensic psychiatry: two illustrative cases J Med Ethics 2007 33: 337-341)