Advertisement

Ethical Issues Arising from the Prescription of Antipsychotic Medication in Clinical Forensic Settings

  • Harriet Hunt-GrubbeEmail author
Chapter
  • 12 Downloads

Abstract

This chapter covers ethical issues requiring consideration when prescribing antipsychotic medications, with particular focus on prescribing that involves high-dose antipsychotics or polypharmacy.

Prescription of antipsychotic medication currently holds a central place in the treatment of many with psychiatric disorders and it at times tends to dominate much of what psychiatrists do—certainly within secure settings where a major arm of the treatment options comprises use of these agents. Medications are prescribed in an attempt to treat mental illness but also to modify the behaviour of patients, both in terms of ameliorating internal distress and in reducing actual and potential violence. Psychiatrists can often find themselves the deliverers of care by virtue of the drugs at their disposal and this is where ethical mindfulness and sensitivity need to play a part in the decisions made.

This chapter offers a debate on considering the overriding principles of medical ethics, namely, autonomy, beneficence (to seek to do good), non-maleficence (to do no harm) and respect for justice when prescribing antipsychotics to forensic patients. As the issues are complex, it is discussed how these principles should be weighed against each other and hardly ever be considered in isolation. Pertinent issues in prescribing within forensic settings such as capacity and informed consent are also discussed.

Forensic psychiatrists quite often need to be able to balance and weigh up the ethical obligations they have to the patients in their care and the ethical obligations they have to the wider society in terms of management of risk. Dr. Hunt-Grubbe in this chapter argues that this dual role is never more apparent than when prescribing and administering high doses or complex regimes of antipsychotic medication to detained patients when consent to do so has been refused or revoked.

Keywords

Ethical issues in prescribing Ethical issues in high dose antipsychotics Ethical issues in antipsychotic polypharmacy Polypharmacy in forensic psychiatry Polypharmacy in forensic mental health High dose antipsychotics in forensic psychiatry Ethical issues in antipsychotic prescribing Ethical issues in antipsychotic prescribing in forensic settings 

References

  1. Applebaum PS (2007) Clinical practice. Assessment of patients’ competence to consent to treatment. N Engl J Med 357:1834–1840CrossRefGoogle Scholar
  2. Beauchamp TL, Childress JF (2001) Principles biomedical ethics, 5th edn. Oxford University Press, OxfordGoogle Scholar
  3. Cahn C (1982) The ethics of involuntary treatment: the position of the Canadian psychiatric association. Can J Psychiatry 27:67–74. Available from http://journals.sagepub.com/doi/abs/10.1177/070674378202700113?journalCode=cpabCrossRefGoogle Scholar
  4. Carrier F, Banayan D, Boley R, Karnik N (2017) Ethical challenges in developing drugs for psychiatric disorders. Prog Neurobiol 152:58–69.  https://doi.org/10.1016/j.pneurobio.2017.03.002CrossRefPubMedGoogle Scholar
  5. College Report (2014) CR190. Consensus statement on high-dose antipsychotic medication. Available from https://www.rcpsych.ac.uk/usefulresources/publications/collegereports/cr/cr190.aspxGoogle Scholar
  6. Goedhard LE, Stolker JJ, Heerink ER, Nijman HL, Olivier B, Egberts TC (2006) Pharmacotherapy for the treatment of aggressive behaviour in general adult psychiatry: a systematic review. J Clin Psychiatry 67(7):1013–1024CrossRefGoogle Scholar
  7. Insel T (2010) Psychiatrists’ relationships with pharmaceutical companies: part of the problem or part of the solution? JAMA 303:1192–1193CrossRefGoogle Scholar
  8. Längle G, Steinert T, Weisner P, Schepp W, Jaeger S, Pfiffner C, Frasch K, Eschweiler GW, Messer T, Croissant D, Becker T, Kilian R (2012) Effects of polypharmacy on outcome in patients with schizophrenia in routine psychiatric treatment. Acta Psychiatr Scand 125(5):372–381.  https://doi.org/10.1111/j.1600-0447.2012.01835.xCrossRefPubMedGoogle Scholar
  9. Levine DF, Bleakley A (2012) Maximising medicine through aphorisms. Med Educ 43:156–162Google Scholar
  10. McKinnon J (ed) (2007) Towards prescribing practice. John Wiley & Sons Ltd., New York, NYGoogle Scholar
  11. Michel A (2011) Psychiatry after virtue: a modern practice in ruins. J Med Philos 36(2):170–186CrossRefGoogle Scholar
  12. Moncrieff J (2008) The myth of the chemical cure: a critique of psychiatric drug treatment. Palgrave Macmillan, BasingstokeGoogle Scholar
  13. Seemüller F, Schennach R, Mayr A, Musil R, Jäger M, Maier W, Klingenberg S, Heuser I, Klosterkötter J, Gastpar M, Schmitt A, Schlösser R, Schneider F, Ohmann C, Lewitzka U, Gaebel W, Möller HJ, Riedel M, German Study Group on First-Episode Schizophrenia (2012) Akathisia and suicidal ideation in first-episode schizophrenia. J Clin Psychopharmacol 32(5):694–698CrossRefGoogle Scholar
  14. Sen P, Gordon H, Adshead G, Irons A (2007) Ethical dilemmas in forensic psychiatry: two illustrative cases. J Med Ethics 33(6):337–341CrossRefGoogle Scholar
  15. Sokol DK (2013) “First do no harm” revisited. BMJ 347:f6426.  https://doi.org/10.1136/bmj.f6426CrossRefPubMedGoogle Scholar
  16. Strous RD (2011) Ethical considerations in clinical training, care and research in psychopharmacology. Int J Psychopharmacol 14(3):413–424.  https://doi.org/10.1017/S1461145710001112CrossRefGoogle Scholar
  17. Swanson JW, Swartz MS, Van Dorn RA, Volavka J, Monahan J, Stroup TS, McEvoy JP, Wagner HR, Elbogen EB, Lieberman JA, CATIE Investigators (2008) Comparison of antipsychotic medication effects on reducing violence in people with schizophrenia. Br J Psychiatry 193(1):37–43.  https://doi.org/10.1192/bjp.bp.107.042630CrossRefPubMedPubMedCentralGoogle Scholar
  18. Tandon R, Jibson MD (2002) Extrapyramidal side effects of antipsychotic treatment: scope of problem and impact on outcome. Ann Clin Psychiatry 14:123–129CrossRefGoogle Scholar
  19. Taylor DM, Paton C, Kapur S (2015) Maudsley prescribing guidelines, 12th edn. Wiley-Blackwell, Hoboken, NJ. ISBN: 978-1-118-75460-3Google Scholar
  20. Warburton K (2014) The new mission of forensic mental health systems: managing violence as a medical syndrome in an environment that balances treatment and safety. CNS Spectr 19(5):368–373CrossRefGoogle Scholar
  21. Wilkie A, Preston N, Wesby R (2001) High dose neuroleptics – who gives them and why? Psychiatrist 25:179–183Google Scholar
  22. Williams JR (ed) (2005) WMA medical ethics manual. The World Medical Association, Ferney-VoltaireGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Barnet Enfield and Haringey Mental Health TrustLondonEngland

Personalised recommendations