Franke Irina, Speiser Oskar, Dudeck Manuela, Streb Judith
Department of Forensic Psychiatry and Psychotherapy, Ulm University, Ulm, Germany.
Psychiatric Services Graubuenden, Department of Forensic Psychiatry, Cazis, Switzerland.
Front Psychiatry. 2020 Mar 13;11:186. doi: 10.3389/fpsyt.2020.00186. eCollection 2020.
Mental health care professionals deal with complex ethical dilemmas that involve the principles of autonomy, justice, beneficence, and non-maleficence. Such dilemmas are even more prominent in forensic mental health care, where the restriction of personal rights is legitimated not only by patient well-being but also by public safety interests. Little is known about either the use of formal ethics support services or specific ethical needs in forensic mental health care. Knowledge about the current structures and how they compare with those in general psychiatry would help to identify the most important ethical issues and to analyze whether there are unmet needs that might require specific ethics support. We performed a survey study in all general psychiatric and forensic psychiatric inpatient departments in Germany. The aims were to compare the availability and functioning of clinical ethics structures and to identify specific ethical needs in inpatient forensic and general mental health care. Clinical ethics support was available in 74% of general psychiatric hospitals but in only 43% of all forensic psychiatric hospitals and 25% of those offering treatment for offenders with substance use disorders. Most ethics support services were interdisciplinary. The most frequently requested retrospective and prospective ethics consultations were on issues of omission and termination of treatment, coercive measures, and advance directives. Among the hospitals without access to ethics support, 71% indicated a need for training in ethics. Our results show that ethics consultation is well established in general psychiatry, but less so in forensic psychiatry. Mental health care professionals in forensic psychiatry seem to have a need for ethics support and training in clinical ethics. We also found a difference in access to ethics structures between hospitals that treat mentally disordered offenders and those that treat offenders with substance use disorders. Further research should focus on how ethics support can be comprehensively implemented in forensic mental health care and how this might improve treatment quality and patient and staff well-being.
精神卫生保健专业人员面临着复杂的伦理困境，这些困境涉及自主、公正、行善和不伤害原则。此类困境在法医精神卫生保健中更为突出，在那里，个人权利的限制不仅因患者福祉而合法化，也因公共安全利益而合法化。对于法医精神卫生保健中正式伦理支持服务的使用或具体伦理需求，人们了解甚少。了解当前的结构以及它们与普通精神病学中的结构相比情况如何，将有助于确定最重要的伦理问题，并分析是否存在未得到满足的需求，而这些需求可能需要特定的伦理支持。我们在德国所有普通精神病学和法医精神病学住院部进行了一项调查研究。目的是比较临床伦理结构的可用性和功能，并确定住院法医精神卫生保健和普通精神卫生保健中的具体伦理需求。74%的普通精神病医院提供临床伦理支持，但所有法医精神病医院中只有43%，为物质使用障碍罪犯提供治疗的医院中只有25%提供此类支持。大多数伦理支持服务是跨学科的。最常被要求进行回顾性和前瞻性伦理咨询的问题是治疗的遗漏和终止、强制措施以及预先指示。在无法获得伦理支持的医院中，71%表示需要伦理培训。我们的结果表明，伦理咨询在普通精神病学中已得到很好的确立，但在法医精神病学中则不然。法医精神病学中的精神卫生保健专业人员似乎需要伦理支持和临床伦理培训。我们还发现，治疗精神错乱罪犯的医院和治疗物质使用障碍罪犯的医院在获得伦理结构方面存在差异。进一步的研究应侧重于如何在法医精神卫生保健中全面实施伦理支持，以及这可能如何提高治疗质量以及患者和工作人员的福祉。
