Editorial The scandalous neglect of mental health care ethics - Contemporary Nurse: Healthcare Across the Lifespan

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Editorial

The scandalous neglect of mental health care ethics

Megan-Jane Johnstone
Professor of Nursing; Director of Research, Division of Nursing and Midwifery, RMIT University, Bundoora West Campus, Melbourne VIC

PP: 142 - 144

Article Text

At an interdisciplinary health ethics conference earlier this year, I took the opportunity to ask the 200 strong audience to raise their hands to indicate whether they had ever been involved in the care of patients/ clients who had:

Asked for euthanasia
Had an abortion
Been part of an organ transplantation program; or
Participated in an IVF program.

Respective responses indicated that between 15 to 30 per cent of those present had cared for people in these categories. I then asked how many in the audience had been involved in the care of patients/clients suffering from:

Mental illness; or
Isolating and immobilising psychogenic distress (clarified to include states of overwhelming despair, hopelessness! depression, emotional turmoil, suicide ideation and so forth).

Significantly, all conference participants raised their hands in response to this later query. What was the point of seeking this anecdotal information? To lay the foundations for demonstrating that while almost all health care professionals have or will at some stage, become involved in the care of people with mental health problems and/or psychogenic distress. The mainstream bioethics movement has failed to either anticipate or adequately address the many and complex ethical issues that can and do arise in the context of caring for people with mental health and related problems. This failure in turn, has left many health professionals grossly unprepared to deal with the very special breed of moral problems that arise in the area of mental health care.

Significantly, even only a cursory search of the mainstream bioethics literature will reveal a plethora of texts and articles on the subjects of euthanasia, abortion, organ transplantation and reproductive technology, despite these being what I shall call 'minority issues' for most health care professionals (these issues affect and are relevant to only a [dis]proportionately small number of health care workers). By contrast, there is a paucity of bioethics literature on mental health care ethics despite the relevance of this area for most health care practitioners. To illustrate this, consider the following example: While the bioethics literature abounds on the topic of 'assisted suicide' (voluntary euthanasia) in the case of end stage life-threatening physical illness, there is a demonstrable lack of bioethics literature on the subject of unassisted suicide' (or 'suicide proper' as I call it) as tends to be commonly associated with mental illness and/or psychogenic distress. An investigation of other ethical issues raised in and by mental health care lends further support to the informal observation that the whole field of mental health care ethics has been scandalously neglected in the mainstream bioethics literature, or/ if it has been considered, the attention given has been inadequate or inappropriate. An important question to ask here, is how has this state of affairs arisen?

There are, I believe, a number of processes contributing to the neglect of mental health care ,ethics not just in the mainstream bioethics movement, but within our society and indeed within the health care professions including nursing. One such process concerns the historical association of mental illness with things 'irrational'. This association has, I believe, seen mental illness-or rather the people who suffer from it, and the issues raised by it, placed into the 'too hard basket' by moral philosophers. Among the reasons for this is that the Cartesian (mind/body split) logic of mainstream Western philosophical thought, simply cannot cope with the challenges posed by the field of mental health. Particularly in regard to such central and traditional philosophical notions of what it means to be a 'person', to have a 'personal identity' (a notion which becomes especially problematic for people with dissociative identity disorders and who may have several personal identities), to have 'self interest' (a notion that is particularly problematic for people who have such a diminished sense of self, that there is no 'self' tangible enough to have 'interests' for), and 'how to live the good life'. For example, Western moral philosophy has historically endorsed 'rationality' (erroneously presumed to be an 'objective property) and more specifically the qualities of rationality (for example: the capacity to think, reason logically, understand, make prudent judgments, reflect critically and so on) as key and central criteria of 'personhood'. In short, to be a person one must be 'rational'; by this view, any being who is not 'rational' is not a person and, incidentally, also lacks the capacity to be moral and have moral status. Historically, the mentally ill have been deemed 'irrational' and consequently have been denied moral status as human beings (note, people certified as being 'rationally incompetent' can still be treated against their will). As such, they have fallen outside the scope of philosophic inquiry into, what it means to be a moral being (that is, a being with moral status) and how to live the morally good life (it has long been assumed that without rationality, entities lack the capacity to even have a good life). In short, this attitude; this mode of thinking, has seen the mentally ill and psychogenically distressed devalued, dehumanised, degraded, (re)traumatised and disenfranchised as human beings.

Another process contributing to the neglect of mental health ethics involves the legacy of stigmatisation that surrounds mental illness and psychogenic distress. At the same conference, I asked participants to raise their hands if they had ever suffered a bout of influenza or had a common cold. All raised their hands. I then suggested that if I was to ask how many had suffered a bout of depression or experienced an episode of moderately severe psychogenic distress or suicide ideation, few if any would probably raise their hands; not because they had not experienced these things, but because they did not want it publicly known that they had experienced these things (after I made this suggestion, you could have heard a pin drop!). Why this response? One possible reason is that unlike declaring the physical distress associated with suffering from a common cold, publicly declaring one's own personal history of psychogenic distress is still 'too risky' on account of the enormous stigma that is still tied to this kind of distress. To disclose one's history of psychogenic distress is to risk being labelled and stigmatised. It also carries the risk of being mistrusted and marginalised on grounds of being (potentially, if not actually) 'irrational' or 'rationally incompetent' and hence a risk to the public order.

A third process contributing to the neglect of mental health care ethics rests on the emotional nature of the topic. Examining ethical issues in mental health care can sometimes be very unpleasant, particularly if it inadvertently triggers deeply embedded (although not always consciously known or acknowledged) emotions in the investigator. There is something strangely universal about psychogenic suffering that even the most 'mentally well' of us cannot fail to be affected by in some small way. Consider the following.

In a small but important article entitled 'Recovering our sense of value after being labelled' a survivor of mental illness (as she calls herself) speaks powerfully of the deep suffering and the overwhelming isolation experienced by people labelled as being mentally ill. Referring to her own experiences as a young adolescent and being labelled schizophrenic (she now has a PhD and is a mental health activist) she makes the following poignant observation:

Try to understand that most professionals, in fact most people, are afraid to sit quietly and to be with a person who is suffering. It's the same sort of thing that happens at a funeral-when people line up to console the person who is bereaved, they get all anxious and awkward and don't know what to say. (Deegan 1993, p.8)

And then speaking to her inner child, she continues:

People find it frightening to just spend time with people who are in great pain. You see, a person who is in great anguish is crying out. Even if they are totally silent like you are, way down deep I can hear you crying out. And that cry, the cry of an anguished person, has the power to awaken the cry, the wound, the brokenness that exists inside every person. Every person, no matter how high up the social ladder they have climbed or no matter how valued their role in our society, every person has a cry, a wound, a brokenness down deep inside of them. Thus, to be with a person who is anguished is to risk experiencing the cry that is way down deep inside each of us. That is why the professionals have been so busy doing things to you, rather than being with you [that is, to cover up, to distract themselves or to dissociate from the experience]. (Deegan 1993, p.8)

Investigating and writing about mental health care ethics is to enter into a vicarious relationship with mentally ill and psychogenically distressed people who are anguished, and thereby 'to risk experiencing the cry that is way down deep inside each of us'. It is to face the suffering of others that many of us would prefer not to face, not to acknowledge and sometimes, not even to believe let alone engage with in a compassionate and empathetic manner. In many respects, I think we also prefer to avoid mentally ill and psychogenically distressed people (and the moral issues associated with their care) because at one level we perceive them as failures and gross moral failures at that; they failed to 'pull themselves together' and to discover the moral secret of 'how to live the good life'. Through this 'failure', they have embarrassed our morality and all it represents - including our own (in)ability and commitment to be moral towards those made vulnerable by their mental health difficulties and psychogenic distress. Morally dispossessed, the mentally ill and psychogenically distressed also remind us of our own vulnerability and our own capacity 'to fail', 'to come apart', 'to become unhinged' in the face of life's many unexpected and unpredictable adversities, and ultimately to lose our own membership as moral beings in the moral community.

Mainstream bioethics has tended to focus on the more 'real' and 'tangible' (and dramatically appealing) issues of: euthanasia, abortion, organ transplantation, reproductive technology and so on. Upon examining the mainstream bioethics literature we could, I think, be forgiven for not only thinking that mainstream bioethics is essentially a movement of physical health ethics (its preoccupation has been with the bioethical issues associated with physical health conditions/illness) but that this physical health ethics is the 'norm'; it is, if you like, 'benchmark ethics' and anything that fails to measure up to this benchmark ethics is 'other', inferior and ipso facto not credible or worthy of attention. Mental healthcare ethics tends to fall short of physical health care (benchmark) ethics and, as such, tends to lack the kudos commonly associate with bench mark (mainstream) bioethics. Not only does it lack the kudos, but in some respects seems to even have become 'contaminated' with the unpalatable aspects of the field that most people would probably prefer to avoid or ignore; or, as the American psychiatrist and author Judith Herman might put it, 'culturally dissociate' themselves from. In a word, mental health care ethics is unsettling, not just because it challenges our logic and our taken-far-granted perceptions of the world, but because it strikes something deeply emotional within us, the very thing that is not supposed to happen when trying to advance a so called 'rational debate' about matters bioethical.

If the field of mental health care ethics has been the most neglected (and it has), it is nevertheless also the most promising. New and important work is currently being undertaken in an attempt to 'make visible' and to validate the lived experiences and profound suffering of the mentally ill and psychogenically distressed and to develop a new field of mental health care ethic that is both responsive to and reflective of these lived experiences. Whether this work will succeed, however, will depend very much on how successful the health care professions and the community at large are in demystifying mental illness and psychogenic distress,-and stripping these things of the stigmata that historically has seen them relegated to the 'too hard basket' not just in mainstream bioethics, but in the minds of us all.

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