Bioethics

From HealthyLiving

Bioethics

Today, 2006-3-31, the hospital held an ethics workshop. The first case discussed was the following:

A resident comes back to the unit intoxicated and is physically and verbally abusive towards other residents and staff.

What do you do?

Possible answers:

• A therapeutic understanding
• Have him declared incompetent
• Withdraw his outing privileges and/or outfit him with a monitoring bracelet
• Permanent discharge
• Call a code white

In my opinion, this case needs to be discussed in three timeframes: short term, medium term, and long term.

In the short term, the immediate issue is safety for the resident, other residents, and staff. If the intoxicated resident is assaulting people, and there is a "code white" team available, that team should be called immediately to intervene with the patient. In the meantime, other staff might make efforts to prevent harm to other residents. If there is no code white team, it may be necessary to call the police to subdue an assaultive intoxicated person. If necessary, the resident could be transferred to an acute care hospital.

In the medium term, a decision must be made about the consequences for the resident of having committed a criminal act by his assault(s). If the victim is competent and wishes to press charges, he or she should be assisted in doing so. If the victim is not competent, the family and/or legal representative should be contacted, and can similarly make a decision about pressing charges.

If a staff member has been the victim of an assault, that individual can also call the police to press charges.

If there is no victim willing to press charges, and there are reliable witnesses to the criminal behaviour, then the team looking after the patient should reflect on the issue of whether or not to call the police. There are arguments for and against involving the police.

If the intoxicated resident is physically ill, it might be argued that calling the police is itself abusive to a sick person. If the person has a psychiatric disorder, mania for example, one could say that the person can't be held responsible for his behaviour because of the mental illness, so why involve the police? Finally, if the resident has dementia, it makes little sense to impose consequences for the assaultive behaviour if the person is unable to learn and thus modify future behaviour.

The above are all valid points. Additionally, there may be the feeling among clinical staff that involving the police represents an admission of defeat, that the team has failed at controlling the patient.

Before discussing the points in favour of calling the police, it may be worthwhile to review what would be likely to happen if the police were called, for example on the day after the intoxication, when the patient is back to usual. Typically, two uniformed officers would come to take a report, based on interviewing the "perp", any victims, as well as witnesses. If the police consider that there is enough evidence to consider laying charges, the report will go to a prosecuting attorney, who will make a decision about pressing charges. If the case proceeds this far, the patient will then appear in front of a judge.

The judge after hearing the evidence, can decide to throw the case out, or render a judgment that the person is guilty or not guilty. In the case of a patient who was unable to control his or her behaviour because of mental illness (for example, command hallucinations telling the person to defend himself against a perceived attacker) the judge has the option of finding the individual not responsible or with reduced responsibility due to mental illness.

If the judge's verdict is guilty, a sentence will be imposed. If not responsible because of mental illness, the judge can impose conditions, for example, that the individual must attend a detox program, or has to take their medication, or has to attend outpatient followup appointments. In cases where the individual refuses to accept that they have a mental illness, and are therefore unmotivated to accept treatment or to comply with treatment regimens, the judge's power to impose conditions can be extremely helpful in setting up conditions to prevent a recurrence.

So, why should we consider calling the police, when a patient has committed a criminal act, and we believe there are mitigating circumstances such as mental illness? In my opinion, if we do not call the police, we have made a decision that the person is not responsible because of their mental illness, for the criminal act which was witnessed. Are we in the best position to make such a decision? By law, the judge has the power to render such a judgment. They are equipped, by their education and experience, to make those sorts of decisions.

Similarly, the prosecuting attorney has the training and experience to decide whether charges should be laid in any particular situation. And the police, we believe, possess the expertise to decide whether to go to a prosecuting attorney with their evidence.

If we do not call the police, we have made a series of decisions which by law, are supposed to be made by the police, the prosecuting attorney, or the judge. Are we trained to make these decisions? Do we have the requisite experience to make these decisions? If not, then we are usurping their role by taking over their decision-making power for our patient.

Moreover, by substituting our decision, made without the requisite training and experience, for a decision by the police, prosecutor, and judge, we are failing to respect the right of our patient to have the people with the appropriate training and with the legal responsibility, make these kinds of important decisions which may have far-reaching implications for the patient. Even though unintentional, this disrespect goes against our mandate which is to act in the patient's best interests. And clearly, the patient's best interests lie in having the most appropriate personnel having this kind of decision-making power over them.