Clinical ethics in forensic psychiatry: Fostering reflection and dialog on the ward through moral case deliberation

Introduction

Forensic psychiatry is an area of healthcare that shows specific moral tensions, since it concerns both psychiatric treatment and the application of criminal law.^1,2 As a domain within psychiatry, forensic psychiatry has to deal with ethical issues such as deciding whether or not to treat a patient involuntarily or whether or not to use coercive measures (such as seclusion or forced medication). The context of criminal law influences such decisions and brings about new moral issues. The legal status of the patient inherently implies a context of involuntariness, which may complicate the therapeutic alliance. It may also induce a tendency to disregard patient autonomy in direct or more subtle ways. Forensic psychiatry also knows a tension between rehabilitation and risk reduction. On the one hand, care should support normalization and reintegration in society. On the other hand, the legal context and the expectations of society at large imply a need to guarantee security and to prevent new criminal actions. ²

The abundance of ethical issues in forensic psychiatry does not seem to go hand in hand with the development of clinical ethics support (CES). ³ Although professionals are trained in law and psychiatry, and are certainly aware of ethical issues in the care for patients, they tend to make decisions in an implicit way and not to discuss their moral concerns or doubts. ⁴ Thus, more structural attention for ethics seems to be required. This is in line with the core goal of CES, that is to foster the awareness of and reflection on ethical issues in all professionals involved.^5–7 This implies the need for approaches which address the moral concerns of professionals and stimulate them to discuss these openly. Moreover, it implies the need for a clear structure to discuss ethical issues. Given these preconditions, moral case deliberation (MCD) might be a useful approach for offering CES in forensic psychiatry, as it combines a focus on the moral experience of participants with a structured method which aims to foster reflection and dialog. ⁸

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Table 1.

Perspectives, values and norms in the case of Peter.

Perspective	Value	Norm
Peter	Autonomy Safety Acknowledgement	“I have to keep control” “I have to stay in the seclusion room” “I should be heard”
Nurses	Safety Connectedness Good care Concern for colleagues	“I have to feel safe on the wardin the department” “We should keep in touch with Peter” “We cannot seclude Peter forever” “We should take nurses’ needs into consideration”
Psychiatrist	Autonomy Safety	“We should give Peter back his life” “Whatever we do, it should be safe for Peter and the staff”

In this paper, we will show the value of MCD in forensic psychiatry. We will first go into the characteristics of MCD as a specific approach in CES. Next, we will present a concrete case, concerning a moral dilemma experienced by a forensic psychiatric team. We will illuminate the way in which the case was discussed in the team, following the steps of the method. In the discussion, we will reflect on the process of reflection and dialog in the example and on the role of the ethicist. Furthermore, we will draw some conclusions regarding the organization of MCD in forensic psychiatry.

MCD as an approach in CES

MCD is a specific kind of CES in which healthcare professionals systematically discuss a moral issue, from practice, facilitated by an ethicist or a trained professional. Compared to other types of CES (such as an ethics committee or an ethics consultant), MCD particularly focuses on joint dialog and mutual moral learning, and does not aim to give advice concerning ethical issues. ⁹ Conclusions are drawn by the participants themselves, rather than by an ethicist. Fostering dialog among participants is at the core of an MCD meeting.^5,10 The dialogical notions behind MCD as a specific kind of CES have been elaborated in dialogical ethics and pragmatic hermeneutics.^11–13

The dialogical approach which is characteristic of MCD implies that the views of the participants are not opposed to one another but regarded as meaningful and potentially valid. The participants are encouraged by the facilitator to investigate each other’s point of view by raising questions. This results in a joint inquiry in which participants learn to understand different perspectives and expand their own perspective, rather than a discussion in which given viewpoints are defended against each other. ¹⁴ In a dialog, all voices are equal. Equality has an emancipatory function. ¹² It also provides the opportunity to see the moral issue from as many perspectives as possible. This is again fostered by stimulating participants to ask questions rather than to express judgments.

In MCD, the facilitator has a neutral position toward the moral issue at stake in the session. ⁵ The facilitator is responsible for the quality of the dialogical process of investigating the issue. This ethical neutrality is rooted in the Socratic presupposition that knowledge is already available in the group and needs to be made explicit in order to stimulate the thinking process. Experiences are regarded as a valid source of knowledge which can be made explicit in the moral inquiry and help participants to understand the issue in detail.

Since 2000, in a growing number of healthcare institutions in the Netherlands MCD meetings are organized in order to stimulate ethical reflection. ¹⁵ MCD is also increasingly applied elsewhere in Europe. MCD is implemented in hospital care, elderly care, care for people with an intellectual disability, and mental healthcare. MCD has also been evaluated scientifically. Research shows the relevance of MCD for participants at three levels: (1) finding a shared answer to the moral issue (content level), (2) going through a joint moral learning process (process level during the MCD meeting), and (3) learning about and improving team communication (process level in the context of team cooperation). There are various methods which can be used to structure the MCD meeting. ⁸ A method which is frequently used is the dilemma method. In this method, the moral tensions in the case are expressed in the form of a dilemma. The method consists of eight steps. In the first step, one of the participants presents a case with a moral problem. The case has to be actually experienced by the case presenter, either in the present or in the past. Next, the group helps the case presenter to formulate the problem as a dilemma, which is a choice between two actions. In the third step, the participants ask questions for clarification, in order to get to know the concrete situation. This enables them to place themselves in the shoes of the case presenter. In the fourth step, the perspectives (or stakeholders) are defined, and for each perspective analyses the values and norms which are relevant in the dilemma. In the fifth step, alternative actions are formulated. In the sixth step, every participant makes his or her own choice in the dilemma and formulates the most important value or norm which lies behind this choice. Each participant also mentions the negative consequences of the choice, including the value or norm which he or she cannot realize, and possible actions to diminish the negative consequences. In the seventh step, the differences between the choices are investigated in a dialogical way. The aim is to better understand the view of each of the participants and to come to a shared view, and if possible a consensus on how to deal with the situation. In the eighth step, the MCD meeting is evaluated.

The eight methodological steps of the dilemma method ²⁴

Presentation of the case

An example: A team deliberating on a dilemma concerning seclusion

In this section, we present an example of a MCD on a forensic psychiatry ward in the Netherlands, using the dilemma method. We will elaborate the steps in the method and go into the way in which the case was examined during the MCD meeting. The reason for the MCD meeting was a crisis on the ward. The manager of the team called us and asked for a facilitator MCD. The question was urgent because of the desperate situation. Both the patient and the team were exhausted. Some nurses were sick and traumatized. The participants who attended this MCD meeting were the psychiatrist, six nurses, and the manager. Moreover, there were some observers, they were all nurses and one of them was a nurse who was on sick leave at the moment, but wanted to be present. The session lasted for 2 h.

The example is chosen because it gives a good impression of MCD in a difficult and complex situation. Moreover, the MCD was fruitful in terms of new insights in other perspectives and in the case. Because of privacy reasons, we changed some characteristics of the case. The team and hospital gave consent to use the example in presentations and articles.

a. The case

One of the nurses briefly sketches the case. Peter is 32 years old and works in the information technology. A few years ago he was admitted in a forensic ward of a mental health hospital after having committed arson in his house. Currently, he is in crisis again. He was admitted voluntarily at an acute admission ward, but later transferred to the forensic ward, as this ward seemed more appropriate given his care needs. In this current admission, he has not been admitted under criminal law. The diagnosis is uncertain but the psychiatrist considers it likely that he has autism (with psychosis) or schizophrenia. Peter refuses medication. His parents are also involved and they support him in his refusal of medication. During admission, Peter is repeatedly aggressive and attacks several nurses. Consequently, he is secluded. At the time of the MCD session, Peter had been secluded for 12 weeks. Peter does not want to come out of the seclusion room. He does not want to take a shower, he does not want to use the toilet, and he does not allow his food to be taken away. Consequently, the seclusion room is seriously polluted. The staff wishes to move him to another seclusion room, in order to clean the seclusion room he is in now. When they try to transfer him, another incident takes place. Peter becomes angry and aggressive, and two nurses get injured. The staff does not know how to continue care for Peter.

b. The moral dilemma

This case presents a situation in which the caregivers no longer know the right thing to do. Peter does not want to leave the seclusion room but, according to the nurses, the pollution of the seclusion room is no longer acceptable. On the one hand, after many incidents, the caregivers are afraid to force Peter to leave the seclusion room and make him stay on the ward. On the other hand, they do not want the present situation to continue, as it is also dangerous and inhumane. During the MCD, the dilemma is formulated as follows:

A: we follow Peter’s wish and let him stay in the seclusion room

After formulating the dilemma, the participants elaborate on the negative consequences of both choices. The choice between two alternatives in a dilemma always comes with a cost. ¹⁶ This shows what is at stake in the dilemma. According to the participants a negative consequence of letting Peter stay in the seclusion room is a deterioration of his mental condition, hygiene, and the possibilities for contact. Moreover, Peter’s long stay in the seclusion room is contrary to the institutional policy, which is to diminish seclusion.

A negative consequence of making Peter to leave the seclusion room is that this might endanger caregivers and increase their anxiety. Moreover, Peter will be anxious on the ward. There is also a risk that Peter will neglect his hygiene and pollute any room he will occupy. Finally, all participants are uncertain about how to get Peter out of the seclusion room.

c. Questions for clarification

After the presentation of the case and the formulation of the dilemma, all participants are invited to ask questions to the case presenter for further clarification. The aim of this step is to enable them to place themselves in the situation of the case presenter. Since all participants know the current situation, no questions are asked about that. The questions raised concern former admissions of Peter: Was the situation different? How did the staff deal with Peter at the time? How did he behave when he was doing better? The case presenter tells that throughout the former admissions, Peter was friendly and cooperative, and accepted medication.

d. Analysis of the perspectives in the case

After the step of clarification, the participants are asked to investigate the values of the stakeholders in the case, related to the dilemma. For each value, they are also asked to formulate a norm, which makes explicit what action is required to realize the value. First, the participants explore the perspective of Peter. Autonomy is mentioned as a central value, and the corresponding norm is formulated as: “I have to keep control.” Safety is also regarded as an important value for Peter, leading to the norm: “I have to stay in the seclusion room.” A third value is acknowledgment, associated with the norm “I should be heard.”

In the analysis of the perspective of the nurses, safety appears as an important value. The corresponding norm is “I have to feel safe in the department.” The nurses also mention connectedness as a value, referring to the norm “we should keep in touch with Peter.” Finally, they mention good care (“we cannot seclude Peter forever”) and concern for colleagues (“we should take nurses’ needs into consideration”).

The psychiatrist mentions autonomy as an important value. For her, the norm related to autonomy is that she is responsible to “give Peter back his life.” The psychiatrist also mentions safety as a value: “Whatever we do, it should be safe for Peter and the staff.”

Because of time reasons the values and norms of the manager were not investigated.

e. Exploring alternatives

After the analysis of perspectives, values, and norms, the participants are invited to think of alternative actions. What other options can be considered besides keeping Peter in the seclusion room or making him leave? This step aims to stimulate creativity and go beyond fixed ideas or opinions regarding the (solution of the) case. The following ideas are suggested:

We can transfer Peter to another institution;

In the next step, the participants individually chose whether they would let Peter stay in the seclusion room (A) or would try to get him out of the seclusion room as soon as possible (B). Moreover, they make explicit the values which motivate their choice, as well as the values which they cannot realize, and consider the consequences of not realizing these values.

It turns out that all participants chose to try and get Peter out of the seclusion room. Some mention contact as the core value and stress that Peter should be able to live among other people. Others regard autonomy as an important value, which for them entails the ability to live one’s life in a meaningful way. For all participants, the value which is at risk in this solution is safety for Peter and the staff. In order to repair the possible damage involved in not going for safety first, various suggestions are made, such as medication, involving the parents, and looking for staff members who have not worked with Peter recently and can approach him in a fresh way.

g. Dialogue

When comparing the individual judgments, the participants conclude that they share the view that enduring seclusion is inhumane. Moreover, they recognize that leaving Peter in the seclusion room would imply that they have given up on him. They also conclude that safety is an important issue to be addressed. Some participants remark that safety cannot be fully guaranteed, not even when Peter would remain in the seclusion room. The participants agree that in order to guarantee a minimum of safety, medication will be necessary.

The participants also conclude that making Peter leave the seclusion room and administering medication will compromise autonomy, which is a core value for Peter. This leads to a further exploration of the concept of autonomy. Some of the participants interpret autonomy as the right to refuse treatment and care. Others, including the psychiatrist, point out that Peter’s refusal on the one hand may be seen as an expression of autonomy, but on the other hand also limits autonomy, as it does not enable Peter to lead a meaningful life. They underline that Peter’s wish to keep control at the moment makes him distrust everyone around him. If a situation could be created in which Peter would feel safe to move around and relate (even minimally) to other people, his need for control might be realized in a less anxious and more open way. Taking action in order to get Peter out of the seclusion room might require overruling present autonomy, and going against his current need for control, with the intention to foster future autonomy, and enabling him to find new ways of having control.

The participants decide that everything should be done to get Peter out of the seclusion room. In this trajectory, it will be crucial to involve Peters’ parents, and convince them that the current situation is inhumane, and that medication is needed. They are aware that it will be unavoidable to administer medication against Peter’s wish. This will seriously disrupt the relationship between staff and patient. In order to counter this negative consequence, it is decided to transfer him to another ward or institution, in order to give him the chance to make a new start with other caregivers.

h. Evaluation

In the last step, the MCD meeting is evaluated. The participants reflect on what they have learned (content) and on the quality of the dialog (process). As to the content, the participants remark that the meeting resulted in a better understanding of the moral issues involved in the dilemma and the concerns they share about leaving Peter in the seclusion room. They also have come to see various aspects of autonomy and the relevance of future autonomy in the case of Peter. Finally, they are glad that a well-considered decision has been reached. As to the process, the participants appreciate the structure of the meeting and the guidance provided by the facilitator. They are positive about the time for listening to each other’s views and worries. A nurse explains:

It is difficult to mobilize enough inner capacity in daily practice, where you constantly have to move along, and sometimes feel as if you are a punch ball. It is really good to have the opportunity to express oneself, and to experience being listened to!

Discussion

At the start of the MCD meeting, the participants felt paralyzed and unable to decide how to provide good care to Peter. Deliberating on the case in a structured way provided room for new insights and created a basis for a joint decision on how to proceed further, recognizing the tensions and difficulties involved. Thus, the process of MCD helped the team to find a way out of the deadlock they were in, not by uncovering the one and only right solution, but by opening up possibilities and fostering the confidence needed to try them out in practice.

According to the participants, an important result of the deliberation was making explicit relevant values in the case. The exploration of their own values and norms showed that the team members shared the view that seclusion is inhumane and without prospect but that they were also concerned about safety. The investigation of Peter’s values and norms leads to a reflection on the concept of autonomy. The participants became aware that this concept can have several meanings. On the one hand, respect for autonomy can be interpreted as abstaining from treatment and care in case of refusal; on the other hand, it can be regarded as helping the patient to (re)gain the ability to lead his or her life, including making choices in an open way. These two concepts of autonomy are also known in bioethics literature, in which they are related to the distinction between negative and positive freedom. ¹⁷ Negative freedom refers to the possibility of making one’s own choices, without interference from others. Positive freedom refers to the possibility to make choices which are meaningful for the person, and which show consistency and authenticity. In the dialog, the participants became aware that these two conceptualizations of autonomy are different and are both useful to understand Peter’s perspective. Peter’s need to keep control currently expresses itself in a refusal of care, showing that negative freedom is for him the only way to have some grip on his situation. The hope and aim of the team is that, if Peter would feel safe to go out of the seclusion room, his need for control might be realized in a different way, allowing for more interaction with others and providing a more meaningful way of living his life. Thus, the need for control, which currently presents itself as a demand for negative freedom, might, so it is hoped, eventually serve as a basis for realizing positive freedom.

The dialog about autonomy shows that MCD can foster reflection on moral concepts and help participants to differentiate between various interpretations of these concepts. ¹⁴ In this sense, MCD helps participants to make ethically relevant distinctions and to take them into account when deciding about how to handle the case. In the MCD meeting, moral concepts are not introduced by the facilitator, and neither is their meaning explained by reference to ethical theory. ¹⁸ Rather, the participants are invited to make explicit their own values and to investigate the meaning these values have for them in the specific situation. ¹⁹ The facilitator can foster the process of reflection by stimulating the participants to ask questions about the meaning of the concepts used by others and thus assisting in furthering mutual understanding. ⁵ The facilitator might know relevant distinctions in theory, yet his or her role is not to use this knowledge to explain what the participants say, but to add to the dialog, by asking questions in a Socratic way.^20,21 The facilitator might ask the psychiatrist who explains autonomy by referring to “giving Peter back his life” in what sense this norm is a specification of autonomy, and what kind of autonomy is implied, thus helping the psychiatrist and the other participants to become aware of various interpretations of this concept. The role of the facilitator in MCD is similar to that of the ethicist described in other forms of CES, in that the focus is on helping the team to better understand the moral aspects of the situation and come to a decision in which these are taken into consideration which particularly applies to an escalating concept. ⁶ In contrast with other forms of CES, the main work is done by the professionals, and the ethicist focuses on keeping the dialog open and fostering the process of moral reflection among the participants.

In the example, all participants made the same choice when asked for their view on the case. This is not always the case in MCD. A presupposition of MCD is that stakeholders have different perspectives, which should be made explicit and investigated in dialog. Although the choices were the same, the perspectives differed, as can be seen in the dialog about the concept of autonomy. Some participants interpreted autonomy in terms of negative freedom. Others conceptualized autonomy in terms of positive freedom. The dialog led to the conclusion that both conceptualizations are relevant in defining good care for Peter.

MCD has the advantage over other kinds of CES, in that it fosters reflection of and dialog between professionals, so that they themselves learn to see the situation differently and find new ways of dealing with it. MCD stimulates openness and honesty regarding uncertainties. Yet, openness is not easily achieved. Participants may fear not being regarded as professionals, when expressing doubts about their work. They may think it is not done to consider aspects of their work, such as seclusion, as “inhumane.” After all, this may be perceived as “part of the job” in forensic psychiatry. Professionals in forensic psychiatry may also doubt the role of the facilitator. They may expect that an ethicist provides advice about how to deal with the problem at stake. When the ethicist refrains from giving advice, professionals may feel unsupported. Yet, when the aim of MCD and the role of the facilitator are clarified at the start, misconceptions may be prevented.

In the example described above, the evaluation of the meeting and the role of the ethicist by the team were positive. Positive outcomes are also reported in evaluation studies on MCD in various healthcare settings.^15,22,23 Yet, the implementation of CES in general, and MCD in particular, requires more work, involving all stakeholders in the process of organizing meetings in a regular way. ⁷ An example of a fruitful deliberation on a specific case may stimulate further attempts to introduce CES in forensic psychiatry, but in itself is not enough to make it an intrinsic element of the practice of mental healthcare.

Conclusion

Forensic psychiatry as an area of mental healthcare is pervaded by moral dilemmas. Professionals should provide good care for the patient, but also ensure safety of themselves, the other patients on the ward, and society at large. The dilemmas in forensic psychiatry require structural attention, which can be provided by CES. In this article, we elaborated on the possible contribution of MCD as an approach in CES. MCD aims to foster reflection and dialog among practitioners. MCD differs from other kinds of CES, as it takes seriously the ethical experiences of professionals, and is more robust, as it provides a structure to help professionals to reflect on them and jointly investigate them in a methodical way. Thus, we recommend a wider use of MCD in healthcare in general, and forensic psychiatry in particular.