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Markkula Center for Applied Ethics

Ethical Issues in Mental and Behavioral Health

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This resource is designed for psychology educators and students and can also be useful for those seeking care for themselves or family members. Materials in this package include background information on the scope of behavioral care and its ethical challenges, case studies for use in classroom settings, and mental health care resources.

 

Introduction

A combat veteran has undirected angry outbursts that threaten his marriage and employment. A working mother struggles to get out of bed in the morning because of a sense of sadness she can’t understand and feels embarrassed to discuss. A teenager begins to hear frightening mysterious voices that others don’t. A young adult begins to alternate between periods of ecstatic energy and profound depression. A little girl languishes unengaged in the back of her classroom while her older brother is repeatedly suspended from school; school staff know little of their family life and don’t connect the two cases. A well-educated professional resigns from a promising job after becoming obsessively anxious about making the modest morning commute required. A middle-aged father loses his health and family to alcoholism. A young mother has her child removed from her custody as a result of her opioid addiction. A healthy elderly person feels no reason for living after many friends die in a short period. In one neighborhood, family and friends grieve the death by suicide of a youth previously extolled in the community as a model teen. In another, family and friends grieve an adult loved-one who died by suicide after they believed he was on the road to recovery from a repeated cycle of depression and substance abuse. 

Stories like these play out tragically all across the USA, often with connections to wider global trends. Nearly 1 in 5 people, 19% of U.S. adults, experience mental illness in a given year. Of those 46.6 million people, 11.2 million -- 4.5% of the adult population--experience a serious mental illness that interferes with major life activities. Social and economic disruptions of the Covid-19 pandemic are expected to dramatically increase mental illness and addictions (as of May 2020) Health professionals and others who care for people experiencing mental health distress face distinctive ethical challenges.

Although there is increasing recognition that the conceptual dichotomy between physical and mental health is a false one, it remains true that mental health afflictions create special conditions of vulnerability. Conditions that affect the workings of the mind particularly acutely affect people’s perceptions, personalities, emotions, memory, and behavior. Health care professionals treating behavioral health patients must cultivate perceptive sensitivity to associated vulnerabilities. 

What are “mental health” and “behavioral health?” 

This resource treats mental and behavioral health as one general area of healthcare, summarizing the two as “behavioral health.” 

Often used interchangeably, the terms “mental health” and “behavioral health” subtly imply different emphases. Behavioral health focuses on personal habits either helpful or unhelpful to mental health. Behavioral health, for example, includes treatment for compulsive disorders and substance abuse. Substance abuse is one of the largest and fastest growing problems in the American landscape of mental health. While it falls within the spectrum of behavioral health, substance abuse also poses some unique ethical challenges beyond the scope of this general resource. 

Behavioral health also addresses habitual behaviors that can either contribute to or protect from chronic health challenges such as obesity, diabetes, and cardiovascular disease. Mental health encompasses emotional, psychological, and social well-being, and all the factors that impact such well-being. These factors include genetic, physiological, family, and trauma histories.

Mental health treatment includes addressing illnesses such as schizophrenia and bipolar disorder, and conditions such as depression and anxiety. Because these conditions impact behavior, there is no clear line between mental and behavioral health. Moreover, “mental health” has historical connections to a dichotomous view of physical and mental health that has been repudiated scientifically. Physiological factors affect behavioral health and behavioral health affects physiology. 

Behavioral health and mental health issues are usually inter-linked in people’s lives. Both can be impacted significantly by social, economic, and environmental factors. While using the term “behavioral health” as an umbrella term, this resource resists individualistic interpretations of “behavior” that fail to attend the full array of factors that can challenge good behavioral health. 

Consequences: For the Patient and Beyond 

Mental and behavioral health disorders, especially left untreated or improperly treated, can have severe consequences not only for the individuals suffering from them but also for family members, friends, schools, workplaces, the health care system, the community, and the economy. Suicide is the 10th leading cause of death in the United States and the second leading cause of death of young people. Mental illness among prisoners is so prevalent that critics of American incarceration practices have begun calling prisons “the new asylums.” As of 2014, it was estimated that 20% of jail inmates and 14% of prison inmates had a serious mental illness. Studies estimating the cost of unaddressed mental illness in the American workplace have concluded ranges from 80 to 190 billion dollars. 

Whose job is it? 

Conversations about who should respond to mental health needs are changing. In early American history, many who suffered from severely stigmatized mental illness were treated as demonically possessed or as criminals. From the mid-19th to mid-20th centuries, large government psychiatric hospitals were a primary locus of care that advanced a medical model of care while seeking to segregate those with mental health challenges from the general community. A de-institutionalization movement began after the Civil Rights movement, as many formerly marginalized groups sought integration into common society. Deinstitutionalization coincided with a period of increasing specialization in American medicine, and an associated decline in the relative number of primary care practitioners. (Primary care practitioners are those trained widely to be both the initial point of contact for patients, and to develop long-term therapeutic relationships with them, facilitating care for their unique arrays of medical needs. Primary care providers include general practitioners, internists, family medicine physicians, pediatricians, and some categories of nurse practitioners.) Referral of patients with mental and behavioral health challenges to psychiatrists, psychologists, social workers, and counselors became the norm. 

However, in recent decades American health policy has advocated improving and expanding primary care as a foundation of the health system. Accordingly, many mental health advocates now call for better integration of primary care with mental and behavioral health care. Such integration can occur bilaterally. Most commonly, it includes increased mental health assessment and treatment in primary care clinics, especially for the most common forms of depression, anxiety disorders, and substance abuse. While less common, it can also include more chronic disease treatment in mental health settings serving the seriously mentally ill--since there is evidence that significant chronic diseases such as diabetes and cardio-pulmonary disease disproportionately go undiagnosed in those who have been labeled as mentally ill, resulting in higher mortality. While integrative strategies are being deployed, critics voice concerns about whether associated provider training, systems structures, and insurance practice are currently adequate to support such integration. 

An initial major government study conducted in 2000 found that approximately 25 percent of all primary care patients have diagnosable psychiatric disorders--most commonly, anxiety and depression--while primary care providers now deliver over half of the treatment for these conditions nationwide. However, still, only about 10% of patients with depression receive standard-of-care treatment from their primary care physician.1

Community advocates call for an integration of behavioral health support in the wider community. In particular, they focus on how non-health-professionals can support mental health in families, schools, workplaces, prisons, and faith communities.

1 Mechanic, D. (2014). More people than ever before are receiving behavioral health care in the United States, but gaps and challenges remain. Health Affairs, 33(8), 1416-1424. 

Focus and limitations of this resource 

This resource focuses on ethical issues that arise treating people suffering with behavioral health problems. It does not address ethical issues in research on mental and behavioral health issues.2

Of course, treatment occurs within a wider healthcare structure. This resource touches on systems-issues only lightly. It highlights background conditions that exacerbate the complexity of ethical decision-making in clinical mental health--such as current gaps in coordination of care and in professional training for mental health services. However, it does not explore the full array of “systems challenges” raised by mental and behavioral health, which include: 

It only tangentially addresses wider community education and institutional response such as in schools, prisons, and workplaces. However, in alignment with Santa Clara University’s Jesuit mission, it does attend to ethical issues of mental health response in faith communities. 

2 James M. DuBois, Ethical Issues in Mental Health Research: Principles, Guidance, and Cases. Oxford University Press, 2008.



This resource began with the vision, research, and writing of a remarkable undergraduate student, Jenna Bagley. Faculty and staff who contributed to its development include Margaret McLean, Miriam Schulman, Anna Kozas, and Ann Mongoven. Professors Thomas Plante (Santa Clara University) and Judith Andre (Emeritus, Michigan State University) generously provided critical peer review. 

In all areas of healthcare, tensions among ethical goods often require a reflective process to negotiate the tensions and balance competing obligations. However, several factors result in distinctive permutations of such challenges in mental and behavioral health: 

Two conceptual tools can assist clinicians, patients, and others supporting people with behavioral health challenges to deliberate ethically challenging cases: 

  • a systematic approach to thinking through ethical dilemmas.

The Markkula Center Framework helps to identify tensions between ethical goals. A systematic approach to negotiating dilemmas enables the embrace of all ethical goals to the extent possible.

Through a collegial process among diverse ethical thinkers, Santa Clara University’s Markkula Center for Applied Ethics developed a general framework for ethical decision-making:

Learn More...

Approach to the cases 

The cases that follow first present the case and then pose an open-ended question about what should be done. 

To facilitate pedagogical use, that case presentation is separated from the following discussion. 

For the sake of brevity, the discussion does not systematically report on each question-prompt from the Markkula Center for Applied Ethics Framework for Ethical Decision Making. Rather, the discussion imagines case conversationalists as having already done that. The discussion then: 

  • identifies key tensions, with special attention to unique vulnerabilities of mental and behavioral health; 
  • identifies options; 
  • considers ways of minimizing harms of infringement if the case is interpreted as a strict dilemma; 
  • considers preventive clinical ethics or systems responses that could help avoid dilemmas. 

The discussion does not argue that there is one clear best course of action, but rather presumes that different responses are arguable given the moral complexities of the case. At the same time, the discussion presumes some possible courses of action may be ethically unacceptable; that there may be spectrums among better or worse options; and that a chosen course of actions may be executed more or less adroitly. 

In other words, the approach exemplifies a reflective systematic process of ethical case-reasoning to address hard cases that have no easy answer. 

Cases: 

  1. Use of deceptive treatment – A psychiatrist considers whether to use a placebo (a fake treatment) on a patient whom the clinician thinks might benefit.
  2. Decline of treatment; involuntary commitment – An adolescent medicine physician considers how to help a potentially suicidal non-minor young adult who declines treatment. Potential options include the possibility of
    petitioning the court to coerce inpatient treatment.
  3. Confidentiality and duty to warn – A psychologist considers whether there is a duty to warn a couple whom the jealous patient has expressed a desire to stalk and frighten.
  4. Request to withhold diagnosis in medical record for fear of stigma – A physician considers whether to honor a promising medical student’s request to withhold a diagnosis of depression from her record. The medical student fears a record of depression could hurt her career.
  5. Appropriate level of expertise? (Primary care/specialty care) – A primary care physician considers if s/he can competently provide treatment to a patient who may have a serious psychiatric disorder and does not wish to go to another doctor.
  6. Appropriate level of expertise? (Spiritual care/medical care) –A religious cleric considers how to support a member of the community struggling with depression and alcoholism, who declines recommended referral to expert medical treatment.
  7. A second chance at drug treatment? – A drug treatment counselor considers whether to allow a patient a second chance in the drug- treatment program, against stated program rules.
  8. Obey law on criminal reporting for a pregnant mother addicted to heroin?– An obstetrician treating a heroin-addicted mother considers whether to comply with state law requiring medical professionals to report drug-addicted pregnant women to law enforcement for child endangerment.
  9. Concern for a clinician-colleague “frontlining” in a pandemic surge - (coming soon)

The Covid-19 pandemic associated with the novel coronavirus has increased mental health stresses globally.  Danger and fear of illness, economic displacement, social isolation from infection-control policies, and uncertainty associated with the pandemic all can trigger or heighten mental health burdens.  The mental health crisis of Covid-19 has underscored the need for broad attention to mental health in emergency-preparedness planning. 

In May 2020, experts from the Wellbeing Trust warned that the pandemic could cause 75,000 “deaths of despair” from drug and alcohol abuse, and suicide, in the United State. Half of Americans surveyed reported the pandemic has hurt their mental health. Yet mental health was not earmarked for support in the first two coronavirus-relief bills passed by the U.S. Congress.

The coronavirus outbreak has exacerbated long-standing challenges posed by a diffuse American mental healthcare delivery-system, within a complex health-insurance landscape that failed to provide universal coverage before the pandemic. Pandemic job-loss has caused massive loss of employer-sponsored health insurance in the midst of a public health emergency. (In March and April of 2020, approximately 34 million Americans are known to have lost employment during “lockdowns,” with the American Medical Association estimating 27 million at immediate risk of losing health insurance.) Hispanic and African-American communities have experienced disproportionately high rates of job loss compared to others.

Frontline medical responders in areas where Covid-19 surges strain emergency and intensive care resources report high levels of post-traumatic stress with future delayed reactions likely. Two suicides among frontline responders in hard-hit New York City called national attention to the toll. (Researchers at New York’s Mount Sinai Hospital estimate that 25-40% of frontline responders will suffer some form of PTSD.)

 At the same time, innovative responses to the increased mental health needs generated by the pandemic have the potential to improve support for mental health care beyond the pandemic. These responses include creative uses of technology; policy changes especially regarding treatment across geographic boundaries; new coalitions of lay support for those in distress; increased public attention to personal and social habits that increase mental health resiliency; new initiatives to provide trauma support for frontline medical responders; increased community training in psychological first-aid;  and renewed attention to mental health in emergency preparedness planning. 

Following we briefly articulate:

  • Pandemic stresses on mental health.
  • Effects on mental and behavioral health.
  • Ethical questions related to mental and behavioral health highlighted by the pandemic.
  • Innovative responses.
  • Resources.

More Information

See the added section at end of list with new resources in response to Covid-19. Added May 2020.

Suicide Prevention

Substance Abuse

Depression

  • Everyday Health: List of Resources, Phone Numbers, Websites, for Depression

General Mental and Behavioral Health

Resources for Schools and Educators

Resources for Faith Traditions

Mental Health Resources in Response to the Covid-19 Epidemic

For people experiencing mental health distress

(See also general resources for suicide prevention, mental illness or mental health distress, and addiction services above.)

For mental health providers and policy-makers