Client-centered care, also termed patient-centered care and person-centered care, is now considered a mainstay of acceptable health care, both in mental health care and in physical health care (Stewart et al., 2003). It is commonly characterized as health care that serves the goals and the needs of the patient. It guides health care in the sense that clinical assessments and interventions are directed by the goals and needs of patients, rather than by those of others, including caregivers such as family members and clinicians. Thus, client-centered care clearly manifests the principle of autonomy or self-determination. Indeed, the recent rising of the recovery movement in mental health largely revolves around client-centeredness and self-determination. Yet schizophrenia challenges the notion of (purely) client-centered care and the underlying principle of self-determination, and requires the consideration of additional ethical principles in the provision of care.

People with schizophrenia demonstrate various psychiatric symptoms and cognitive impairments, some of which undermine self-determination. For instance, impaired insight into illness, which is common in schizophrenia, disrupts decision-making capacity, leading to the determination of incompetence to consent to or refuse treatment (Grisso & Appelbaum, 1998). Another example is that of delusions, which are very common in schizophrenia and by definition disrupt reality testing, leading to involuntary commitment if risk of harm to self or others is also involved. Both examples illustrate how impairments and symptoms of schizophrenia undermine self-determination. So how does this impact on client-centered care for people with schizophrenia?

The mental health care area that attempts to be most client-centered is psychiatric rehabilitation (Anthony, Cohen, Farkas, & Gagne, 2002).

Psychiatric rehabilitation aims to improve the functioning and quality of life of individuals with severe psychiatric disorders, so that they achieve and maintain lives that are satisfactory and meaningful to them, thus facilitating recovery. It consists of enhancing the living skills and environmental supports of individuals with mental illness, enabling them to achieve goals that, preferably, they set themselves. Yet such individuals may set goals reflecting values that conflict with those held by mental health practitioners or by society at large, and that are induced by mental impairment, such as stalking another person due to erotomanic delusions (i.e., the mentally ill individual thinking that the other person is infatuated with him or her).

Psychiatric rehabilitation practitioners have reported difficulty, due to this problem, in working toward goals set by their clients (Hendrickson-Gracie, Staley, & Morton-Neufeld, 1996). Goals set by individuals with mental illness that involve harm to self or to others are suspect, such as in the case of the stalker with erotomanic delusions. In such cases, a client-centered approach that endorses patient goals at all cost runs into ethical trouble, because it rigidly compromises acceptable values such as preservation of life and fairness to others. If so, others—such as legally appointed guardians or substitute decision makersmay be required to set goals for individuals with mental illness. Yet rehabilitation goals set by others are problematic, because if the goals of the individual prior to the psychiatric disorder are not known (as frequently occurs), then best interests, not patient goals, are considered. This may preserve an aspect of the client-centered approach in that best interests can be claimed to address patient needs. But this is conceptually problematic, because there is no—and probably cannot be—consensus on what a person needs to achieve and maintain a satisfactory and meaningful life and, arguably, that is so subjective that it can only be determined by the person, mentally ill or not.

Thus, client-centered mental health care, at least in the area of psychiatric rehabilitation, may not be ethically and conceptually sound in some cases. In such cases, alternative approaches may be required, with the recognition that forced or coerced psychiatric rehabilitation may not be ethically acceptable with regard to achievement of goals, and to maintenance of goals (the latter would probably require continuous and possibly increased coercion or force). An alternative could be a dialogical approach, where all involved parties engage in structured dialogue to establish mutually acceptable goals in an ethically sound manner (Rudnick, 2002a). Schizophrenia, with its various symptoms and impairments, may challenge this approach, but there may be ways to overcome this challenge within a dialogical approach by facilitating communication and accommodating for such psychiatric symptoms and cognitive impairments (Rudnick, 2007). For instance, impairments in executive functions may disrupt the ability to predict consequences of actions, and hence to discuss relevant utilitarian considerations, but cognitive rehabilitation and support strategies (Twamley, Jeste, & Bellack, 2003) may be helpful in overcoming this challenge, therefore facilitating such dialogue with cognitively impaired individuals who have schizophrenia. Future study may explore this approach in detail.

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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