Claassen Dirk
East London and The City Mental Health Trust, Assertive Outreach Team Newham, 150 Stratford High Street, London E15 2NE, UK.
J Med Ethics. 2007 Apr;33(4):189-93. doi: 10.1136/jme.2006.016188.
Giving money as a direct incentive for patients in exchange for depot medication has proved beneficial in some clinical cases in assertive outreach (AO). However, ethical concerns around this practice have been raised, and will be analysed in more detail here.
Ethical concern voiced in a survey of all AO teams in England were analysed regarding their content. These were grouped into categories.
53 of 70 team managers mentioned concerns, many of them serious and expressing a negative attitude towards giving money for depot adherence. Four broad categories of ethical concern following Christensen's concept were distinguished: valid consent and refusal (n = 5), psychiatric paternalism (n = 31), resource allocation (n = 4), organisational relationships (n = 2), with a residual category others and unspecified (n = 11).
The main concerns identified are discussed on the background of existing ethical theories in healthcare and the specific problems of community mental health and AO. Points for practice are derived from this discussion. A way forward is outlined that includes informed consent and an operational policy in the use of incentives, further randomised controlled trials and qualitative studies, and continuing discussions with all stakeholders, especially service users.
在积极外展服务（AO）的某些临床案例中，给钱作为直接激励患者接受长效药物治疗已被证明是有益的。然而，围绕这种做法的伦理问题已经出现，本文将对此进行更详细的分析。
对英格兰所有AO团队的调查中提出的伦理问题进行了内容分析，并将其分类。
70名团队经理中有53人提到了相关问题，其中许多问题很严重，并且对为长效药物治疗依从性给钱持负面态度。根据克里斯滕森的概念，区分出了四大类伦理问题：有效同意和拒绝（n = 5）、精神病学家长作风（n = 31）、资源分配（n = 4）、组织关系（n = 2），还有一个剩余类别“其他及未明确”（n = 11）。
在医疗保健领域现有伦理理论以及社区心理健康和AO的具体问题背景下，对确定的主要问题进行了讨论。从这次讨论中得出了实践要点。概述了一条前进的道路，包括知情同意和激励措施使用的操作政策、进一步的随机对照试验和定性研究，以及与所有利益相关者，特别是服务使用者的持续讨论。
