What Is ‘Mental Health Ethics’ and Why Do We Need It?
In this week’s blog Dr Nuala Kane addresses the need for Mental Health Ethics and why it is so important. Nuala is supported by Mental Health Research UK on the MD(Res) programme at Kings College London. Her research is into Contested Capacity Assessments.
Mental health ethics is a branch of medical ethics, a discipline which asks the question ‘how should we act?’ in the context of providing healthcare for patients. Modern medical ethics talks about four guiding ethical principles – autonomy (a patient’s freedom to make her own decisions), beneficence (the need to act for the good of the patient), non-maleficence (the ‘do no harm’ principle), and justice (or fairness in allocation of health resources). Ethical dilemmas can arise in situations where these principles seem to clash, for example, if a patient refuses a life-saving treatment, or several patients need a treatment with limited availability.
In mental health ethics, a central question is in which circumstances (if any), in the context of mental illness or other problems, we should override a patient’s right to refuse treatment. In England and Wales there are two legal frameworks relevant to this: The Mental Health Act covers involuntary admission and treatment in situations in which a mental disorder places a patient’s health or safety (or that of others) at risk. The Mental Capacity Act deals with situations in which a temporary or permanent impairment of mind or brain causes a person to be unable to decide and allows for a ‘best interests’ process to take place. Both pieces of law refer to use of the ‘least restrictive option’, reminding us that overruling a person’s wishes should only ever come as a last resort. Even with this legislation in place, its application can be tricky in some situations. My MD(Res) project focuses on hard capacity assessments in the courts and clinical practice, looking at what happens when there is difficulty or disagreement as to whether a person has capacity to decide about their medical treatment, social care, or another important issue.
While old ethical questions evolve, new ones also arise. Researchers in mental health ethics consider difficult issues such as whether and how patients with severe episodic mental illness should be able to make binding treatment decisions in advance; whether patients with dementia or mental illness should be permitted to request assisted dying; and the ‘epistemic injustice’ of ignoring the voices of those receiving mental healthcare. Some researchers investigate using philosophical or theoretical approaches, some draw on their own lived experience of mental illness, while others use empirical or research study approaches to test ethical hypotheses. For me, mental health ethics is so important because it constantly reminds us to ask whether people with mental health difficulties are getting the best care and treatment (in the broadest sense) with the knowledge and resources we have. In doing so, and by informing mental health policy and legal reform, it can bring about real change.
 Beauchamp, T. L., & Childress, J. F. (2001). Principles of biomedical ethics (5th ed.). Oxford University Press.
 Mental Health Act, England and Wales, (1983).
 Mental Capacity Act, England and Wales, (2005).
 Kane NB, Keene AR, Owen GS, Kim SYH (2021) Applying decision-making capacity criteria in practice: A content analysis of court judgments. PLoS ONE 16(2): e0246521. https://doi.org/10.1371/journal.pone.0246521
 Gergel, T., Das, P., Owen, G., Stephenson, L., Rifkin, L., Hindley, G., ... & Keene, A. R. (2021). Reasons for endorsing or rejecting self-binding directives in bipolar disorder: a qualitative study of survey responses from UK service users. The Lancet Psychiatry, 8(7), 599-609.
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 Crichton, P., Carel, H., & Kidd, I. J. (2017). Epistemic injustice in psychiatry. BJPsych bulletin, 41(2), 65-70.