Health problems and health care frequently raise ethical issues of various types. The discipline that addresses such ethical issues is currently called bioethics, a field of practice, research, and education that influences public policymaking and legislature, as well as clinical research and care. It is grounded in philosophy, law, and social sciences, as well as in health care sciences, such as medicine and nursing. Contemporary bioethics involves social institutions such as bioethics committees, bioethics consultants, professional codes of bioethics, associations of bioethics, and texts of bioethics (Beauchamp & Childress, 2001).

Ethics in general, including bioethics, addresses moral problems, sometimes called ethical dilemmas. Moral problems primarily comprise conflicts of accepted principles or values that arise in particular situations. In health care, such situations are frequently related to the end of life, such as in euthanasia (mercy killing for people with terminal illnesses), when the value of preserving life conflicts with the value of reducing suffering, or to the beginning of life, such as in abortion, when the conflict is commonly stated as prolife (protecting the fetus)  versus pro-choice (protecting the pregnant woman). 

Moral problems are commonly resolved by applying ethical theories, as well as moral intuitions, preferably by engagement in a process of deliberation and dialogue with the parties involved (Rudnick, 2002b). Well-known ethical theories used in bioethics include utilitarianism, which addresses the consequences of actions; deontology, which addresses duties; and virtue ethics,  which addresses character traits and intentions. 

Perhaps the most commonly used bioethical approach is principlism, which combines some of these well-known theories while balancing the principle of respect for persons (addressing autonomy or self-determination of the patient), the principle of beneficence and nonmaleficence (addressing maximal benefit and minimal harm to the patient), and the principle of justice (addressing fairness to the patient and to others).

Mental health problems and care raise various ethical issues or moral problems, as reflected in areas such as involuntary commitment and substitute decision making. Some of these issues have been addressed in other sections in this site.

This section focuses on two important ethical issues that are not directly addressed by other section in this site, and that are important enough to deserve separate consideration. These are the issues of the ethics of client-centered care for people with schizophrenia and of research on people with schizophrenia. The section on client-centered care is primarily authored by Rudnick, and the section on research is primarily authored by Weijer.

KEY POINTS

• Bioethics addresses conflicts of values that arise in health care situations.
• Mental health care such as psychiatric rehabilitation for individuals with schizophrenia is not ethically and conceptually sound if it is (purely) client-centered at all costs.
• A dialogical approach to the mental health care of individuals with schizophrenia may provide an ethically and conceptually sound alternative to a purely client-centered approach when the latter fails ethically or conceptually.
• Research ethics considers the moral principles and rules that govern the conduct of scientific studies on human beings.
• Clinical research is governed by Federal regulations that are implemented through an upfront review of research by IRBs.
• Whereas obligations of the State to protect the research subject are fulfilled by IRB review, clinicians have an obligation to use clinical judgment to protect patients in research from harm.
• Placebo-only controlled clinical research on subjects with schizophrenia may be ethically justified only under special circumstances, such as when evaluating the effects of medications on treatment-refractory patients or the effects of ancillary medications on associated symptoms (e.g., cognitive impairment).

Abraham Rundick
Charles Weijer

REFERENCES

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• Rudnick, A. (2002b). The ground of dialogical bioethics. Health Care Analysis, 10, 391 - 402.
• Rudnick, A. (2007). Processes and pitfalls of dialogical bioethics. Health Care Analysis, 15, 123 - 135.
• Stewart, M., Brown, J. B., Weston, W. W., McWhinney, I. R., McWilliam, C. L., & Freeman, T. R. (2003). Patient-centered medicine: Transforming the clinical method (2nd ed.). Oxon, UK: Radcliffe.
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• Weijer, C. (1999). Placebo-controlled trials in schizophrenia: Are they ethical? Are they necessary? Schizophrenia Research, 35, 211 - 218.
• Weijer, C., & Miller, P. B. (2004). When are research risks reasonable in relation to anticipated benefits? Nature Medicine, 10, 570 - 573.