Community psychiatry

Abstract

Ethical dilemmas in community psychiatry are not novel, but they present in sufficiently different guises to warrant reconsideration in a new context. The models of care and the social climate in which they have developed are reviewed, as well as the key ethical challenges that have emerged. These include concerns about privacy, confidentiality, coercive practices (the range of treatment pressures, ‘involuntary outpatient commitment’ or ‘community treatment orders’), and conflicts of duty to the patient versus others. Approaches to dealing with these issues are presented. These include increasing patients’ involvement in their care (e.g., ‘crisis cards’, ‘joint crisis plans’, and advance directives), clarifying grounds for coercive interventions in the health interests of the patient (e.g., a decision-making-capacity-based approach, the influence of the UN Convention on the Rights of Persons with Disabilities), and considerations concerning the risk of harm to others, including duties to carers.