PSYCHOSIS AND RELIGION

The patient was a 30-year-old, single man from India who was raised as a Muslim. He had been hospitalized three times in the past year; this admission was occasioned when he assaulted a passerby. At the time, the patient was under the influence of a psychotic delusion that he was a secret agent whose cover had been betrayed by his therapist.

Upon his admission, the patient refused medication on the ground that he was a Christian Scientist. The surprised resident learned that the patient had, while psychotic on his last admission, encountered a Christian Science practitioner who was visiting the ward and decided to join the Christian Science Church. Consultation with the practitioner raised the question of the extent to which the patient's choice of Christian Science should be seen as a free choice, especially since the practitioner did not view the patient as a true Christian Scientist. On the other hand, the patient, although delusional, was able to cite chapter and verse of Christian Science literature in support of his drug refusal. The dilemma facing the resident was whether this patient's religious choice was suspect because of his concurrent delusional state, and thus whether his drug refusal based on this choice was competent.

Questions

1. (1) The First Amendment gives us a right to freedom of religion. Would this right be violated if this patient were forced to take medication?

2. […]

When a therapist and a patient meet to address the needs created by mental disorder, their developing relationship is bounded by rules that determine the appropriateness of interventions considered and performed. These rules are based not only on knowledge about the biological and psychological bases of disorder, but also on values which, like the therapies that can be employed, not only provide a range of alternatives, but also set limits on actions.

This book is about a particular subset of values dealing with ethics. Ethics is a discipline concerned with understanding the right-making and wrong-making characteristics of actions. The practitioners who analyze the ethical dimensions of human thought and interaction must examine deeply held beliefs derived from personal experience concerning right and wrong, cultural mores founded on the conventions of tradition, values received from and embodied in decisions of courts and legislatures, historical conventions developed by the health care professions over time and embodied in documents such as ethical codes, and scholarly works on ethics.

In this book, we approach ethics through case studies. Our goal is to present case material that can provide clinicians with a basis for learning and reflection, preferably in interaction with their colleagues. The cases used are real and are derived from clinical situations and consultative experiences of the authors, and their colleagues. The use of the case method, as applied to problems of mental illness, was developed by the authors at the Massachusetts Mental Health Center, where ethics rounds were begun in 1979 and continue in the present.

PROTECTING CHILDREN

A 9-year-old girl was admitted to the Children's Psychiatric Unit with a history of multiple somatic complaints, refusal to go to school, and in the past year, although not currently, a history of such minor self-abuse as inflicting scratches on herself. The patient evidently had been having trouble for some time, but only recently had the parents agreed to bring her in for psychiatric evaluation. When she does attend school, she does well. She has a 6-year-old sibling who, according to the clinicians in the Children's Unit, has attempted suicide recently, certainly an unusual occurrence in a child that young. In addition, it is reported that prior to admission the patient was sleeping up to 17 hours a day.

Five days after admission the patient's mother called, saying that she intended to take the patient home with her that afternoon. The clinicians at the Children's Unit do not view this family sympathetically. The father was described as withdrawn and anxious, and the mother as anxious with pressured speech. The ostensible reason for their wanting to take the child out of care was that the child's grandmother had just been hospitalized for a bleeding ulcer, and the family wanted to have her back home so that they would not worry about her as well. The clinicians thought that perhaps the real reason they wanted her at home was to care for her younger brother while the mother was off tending to grandmother.

Now that the reader is familiar with the historical and theoretical aspects of ethics in mental health practice, a more practical issue must be addressed: How does one teach mental health ethics? To answer that question, this chapter examines the possible goals of instruction in this area, the variety of approaches taken to the teaching of mental health ethics, and the use of case-oriented material, which the authors have found to be especially useful in the clinical mental health setting. Given the sparseness of the literature on teaching mental health ethics and the commonalities with pedagogic efforts in biomedical ethics as a whole, the works in these areas are cited interchangeably. The subsequent section of the book provides sample case materials that can be employed for case-oriented learning and teaching.

GOALS OF TEACHING MENTAL HEALTH ETHICS

There is widespread agreement among those who teach professional ethics that one goal must serve as the predicate to all others in this discipline. That goal is to heighten the sensitivity of trainees and clinicians to the ethical dilemmas they are likely to confront in routine clinical practice (1–7). In the words of Clouser, “One of the most surprising phenomena about students and professionals is their inability to recognize moral problems as such” (8). Yet, unless the participants in an ethics program begin by acknowledging the relevance of the material to be discussed to their own professional lives, motivation and interest will evaporate, and any more elaborate objectives will remain unfulfilled.

GIVING IN TO THE PATIENT

A 52-year old married woman, whose paranoia has been reasonably stable for 18 years, lives with her husband and a niece. Her only psychiatric hospitalization occurred 2 years ago when she was treated with antipsychotic medication. It is not clear what benefit, if any, she obtained from the medication, but she developed a feeling of “heaviness” in her right leg about that time, which she attributed to it. She has since been quite unwilling to take medication.

Two days before the present admission, the patient's home was raided by the police, who were under the mistaken impression that it was a hangout for an escaped drug dealer. The patient was quite shaken by this experience. She became agitated and much more delusional than usual, particularly about her family as well as people in the neighborhood. Although the admission form alleges that she threatened and kicked her husband and niece, it is unclear whether she was ever actually aggressive toward them. They may have fabricated this story to ensure that she would be admitted to the hospital. However, it is clear that she was quite agitated, taking off her clothes repeatedly, and having difficulty getting to sleep. She was evaluated the day following the police raid and was thought not to be committable at that point. But the following day, after a sleepless night, the family obtained an order for commitment.

ARE THERAPISTS THEIR BROTHERS' KEEPERS?

The patient is a 39-year-old male with a diagnosis of chronic schizophrenia. His condition is followed in a Schizophrenia Clinic, where he comes every two weeks for an injection of medication. He has a low IQ, severe character problems, and occasionally develops paranoia, which is well controlled with medication. He sometimes engages in voyeuristic behavior, which diminishes when the dose of medication is increased.

While under this psychiatric treatment, the patient suffered a gall bladder attack and had his gall bladder removed. Two months after the operation, he called on the psychiatrist complaining of increasing pain and difficulties in moving his left hand. He was referred to an internist who found stiffness in his left arm and loss of sensation and muscular atrophy of the fourth and fifth fingers. He was treated with drugs for possible nerve damage for several months, but without improvement.

At this point, the psychiatrist began to question him about when he had first noticed the problem. The patient replied that it had begun about 2 or 3 days after discharge from the hospital. He said that the problem did not interfere with his life, because he was still able to perform basic housekeeping chores and go shopping for his mother, but that he would like to know what is going on. Since the psychiatrist was affiliated with the hospital where the operation took place, a review of the hospital chart by him, including the operative report, was possible without the patient's knowledge.

“DO NOT RESUSCITATE” FOR THE LIVING

The patient is a 50-year-old man with a diagnosis of mental retardation and a concomitant depression, as well as epilepsy. He has been an inpatient for the last three years at a community mental health center (CMHC), to which he was transferred from a large state hospital. He was the illegitimate child of alcoholic parents and has been a ward of the state since he was 3. Since that move two nursing home placements have been attempted, neither of which lasted longer than a month. According to the latest treatment plan, the patient requires services and training in the following problem areas: retardation and depression, personal hygiene, need for a citizen advocate to ensure availability of services, routine medical and psychological evaluations, grooming, eating, weight loss, chronic obstructive lung disease, seizure and movement disorder, obsessive concerns with death, a tendency toward masturbatory self-stimulation in public settings, the need to increase production rate at work, functional academic training, skills for self-preservation in society, learning of social skills, dentures, home placement.

The patient's transfer to the mental health center was part of a plan by the state's department of mental health to close down several units at the state hospital and to deinstitutionalize a number of patients. The review team in charge of this process of transfer determined that this patient and another had the greatest potential of all for development.

In the middle of the 1960s, a revolution took place that pushed away the veil shrouding the ethical dilemmas of health care. It exposed not abuse, but misunderstanding, and a widespread unawareness of the ethical context of the relationships among medical personnel, patients, and society. Without some knowledge of this revolution in general medicine, the related developments in mental health cannot be fully understood.

HEALTH CARE AS A RIGHT

The ethics movement was the outcome of multiple events, linked by their focus on rights. Particularly important was the effort at the beginning of this century to equalize the quality of care among the diverse strata of American society.

A traditional attitude in the United States toward social provision of health care had been that meeting the basic needs of life was the responsibility of the individual. Society would intervene when an illness posed a long-term threat to a person's health, the care for the disease was time-consuming and placed substantial burdens on the family, or the disease posed a danger to the community. By these definitions, persons afflicted with tuberculosis, mental illness, and retardation were candidates for social support, and many hospitals were built during the 19th and 20th centuries to treat these disorders. Society also responded to the general medical needs of the poor by constructing institutions for their care: Indigency was a condition that legitimized social intervention.

The movement to give people broad access to health care, regardless of their specific illness or financial state, met with continued resistance from the time it began in the early 20th century right up to 1960.

READING A CLOSED BOOK

Mr. y. is a 30-year-old man with prune-belly syndrome (a serious metabolic disorder) and secondary chronic renal failure. The patient was born out of wedlock, abandoned by his mother. Prunebelly syndrome was evident at birth. The patient was placed in a foster home, but the multiple medical problems of his condition necessitated admission to a state hospital, where he remained for approximately 15 years before transfer to a state school for the retarded.

The patient's renal problems have been chronic, severe, recurrent, and nearly untreatable. He had had nine separate major urologic surgical procedures, including total removal of a left kidney at the age of 7. His course has been complicated by numerous infections, imbalances of his electrolytes and metabolism, hypertension, and general progressive deterioration. In the several years before admission, he developed a left brain hemorrhage after a fall, which required surgery; he then required the same procedure after another fall a year later. Regrettably, a seizure disorder developed (which is often the case in such injuries) and the patient is now on anticonvulsant medication. The patient was recently begun on chronic hemodialysis because of the functional failure of his kidney. However, the course of his treatment has been extremely stormy with the patient being both despondent and uncooperative. Repeated shunts to connect the patient to the dialysis machine have had to be placed in the patient's blood vessels because he frequently manipulates the shunt tubing and has had recurrent infections around the shunt site.