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Paternalism, autonomy and reciprocity: ethical perspectives in encounters with patients in psychiatric in-patient care

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      Abstract

      Background

      Psychiatric staff members have the power to decide the options that frame encounters with patients. Intentional as well as unintentional framing can have a crucial impact on patients’ opportunities to be heard and participate in the process. We identified three dominant ethical perspectives in the normative medical ethics literature concerning how doctors and other staff members should frame interactions in relation to patients; paternalism, autonomy and reciprocity. The aim of this study was to describe and analyse statements describing real work situations and ethical reflections made by staff members in relation to three central perspectives in medical ethics; paternalism, autonomy and reciprocity.

      Methods

      All staff members involved with patients in seven adult psychiatric and six child and adolescent psychiatric clinics were given the opportunity to freely describe ethical considerations in their work by keeping an ethical diary over the course of one week and 173 persons handed in their diaries. Qualitative theory-guided content analysis was used to provide a description of staff encounters with patients and in what way these encounters were consistent with, or contrary to, the three perspectives.

      Results

      The majority of the statements could be attributed to the perspective of paternalism and several to autonomy. Only a few statements could be attributed to reciprocity, most of which concerned staff members acting contrary to the perspective. The result is presented as three perspectives containing eight values.

      Paternalism; 1) promoting and restoring the health of the patient, 2) providing good care and 3) assuming responsibility.

      Autonomy; 1) respecting the patient’s right to self-determination and information, 2) respecting the patient’s integrity and 3) protecting human rights.

      Reciprocity; 1) involving patients in the planning and implementation of their care and 2) building trust between staff and patients.

      Conclusions

      Paternalism clearly appeared to be the dominant perspective among the participants, but there was also awareness of patients’ right to autonomy. Despite a normative trend towards reciprocity in psychiatry throughout the Western world , identifying it proved difficult in this study . This should be borne in mind by clinics when considering the need for ethical education, training and supervision.

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      Most cited references 11

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      Three approaches to qualitative content analysis.

      Content analysis is a widely used qualitative research technique. Rather than being a single method, current applications of content analysis show three distinct approaches: conventional, directed, or summative. All three approaches are used to interpret meaning from the content of text data and, hence, adhere to the naturalistic paradigm. The major differences among the approaches are coding schemes, origins of codes, and threats to trustworthiness. In conventional content analysis, coding categories are derived directly from the text data. With a directed approach, analysis starts with a theory or relevant research findings as guidance for initial codes. A summative content analysis involves counting and comparisons, usually of keywords or content, followed by the interpretation of the underlying context. The authors delineate analytic procedures specific to each approach and techniques addressing trustworthiness with hypothetical examples drawn from the area of end-of-life care.
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        Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model.

        In this paper we revisit and add elements to our earlier conceptual framework on shared treatment decision-making within the context of different decision-making approaches in the medical encounter (Charles, C., Gafni, A., Whelan, T., 1997. Shared decision-making in the medical encounter: what does it mean? (or, it takes at least two to tango). Social Science & Medicine 44, 681 692.). This revised framework (1) explicitly identifies different analytic steps in the treatment decision-making process; (2) provides a dynamic view of treatment decision-making by recognizing that the approach adopted at the outset of a medical encounter may change as the interaction evolves; (3) identifies decision-making approaches which lie between the three predominant models (paternalistic, shared and informed) and (4) has practical applications for clinical practice, research and medical education. Rather than advocating a particular approach, we emphasize the importance of flexibility in the way that physicians structure the decision-making process so that individual differences in patient preferences can be respected.
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          Ethics needs principles--four can encompass the rest--and respect for autonomy should be "first among equals".

           R Gillon (2003)
          It is hypothesised and argued that "the four principles of medical ethics" can explain and justify, alone or in combination, all the substantive and universalisable claims of medical ethics and probably of ethics more generally. A request is renewed for falsification of this hypothesis showing reason to reject any one of the principles or to require any additional principle(s) that can't be explained by one or some combination of the four principles. This approach is argued to be compatible with a wide variety of moral theories that are often themselves mutually incompatible. It affords a way forward in the context of intercultural ethics, that treads the delicate path between moral relativism and moral imperialism. Reasons are given for regarding the principle of respect for autonomy as "first among equals", not least because it is a necessary component of aspects of the other three. A plea is made for bioethicists to celebrate the approach as a basis for global moral ecumenism rather than mistakenly perceiving and denigrating it as an attempt at global moral imperialism.
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            Author and article information

            Affiliations
            [1 ]Psychiatric Research Centre, Örebro County Council, Box 1613, SE 701 16, Örebro, Sweden
            [2 ]School of Health and Medical Sciences, Örebro University, SE 701 82, Örebro, Sweden
            [3 ]Department of Child and Youth Studies, Stockholm University, Frescati Hagväg 24, SE 106 91, Stockholm, Sweden
            Contributors
            Journal
            BMC Med Ethics
            BMC Med Ethics
            BMC Medical Ethics
            BioMed Central
            1472-6939
            2013
            6 December 2013
            : 14
            : 49
            24314345
            4029406
            1472-6939-14-49
            10.1186/1472-6939-14-49
            Copyright © 2013 Pelto-Piri et al.; licensee BioMed Central Ltd.

            This is an open access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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            Research Article

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