Healthcare providers are increasingly expressing interest in the treatment of negative symptoms of schizophrenia, paralleling a growing concern over clinical and functional recovery as well as evidence relating to recuperation. Even so, these trends have been accompanied by the need for values in the field of medicine. One of the chief values that modern practitioners are expected to consider in their practice is truthfulness. There is a rising concern for whether healthcare providers should disclose information to patients who are suffering from potentially fatal illnesses like cancer. Today, healthcare providers believe that physicians should not withhold the truth from patients regardless of the status of their ailment. Some practitioners are even utilizing advance directives to forecast whether a patient will express interest in knowing the truth in future. The degree to which the healthcare sector has given priority to the value of truth is exhibited in the following moral accord; that clinicians should remain truthful to patients even if the situation may cause foreseeable, additional harm to patients. Evidently, there is a gap in knowledge about how the management of psychiatric complications like schizophrenia interact with the current ethical consensus. This paper aspires to explore situations in which the respect of autonomy of schizophrenia patients may conflict with the values of beneficence and non-maleficence.
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Review of Literature
Insight of Schizophrenia manifestation
The manifestation of schizophrenia is often in form of positive and negative symptoms (Keil et al., 2016). Positive symptoms are those that are not experienced by the individuals and normally include tactile, gustatory, olfactory, and visual hallucinations, as well as disordered speech and delusions. Such symptoms are typically associated with psychosis (Singh et al., 2017) and are generally responsive to medication (Lee et al., 2016). On the other hand, negative symptoms represent deficits in emotional responses or other body processes and do not respond to medication (Millan et al., 2014). They include the inability to experience pleasure, poverty of speech, diminished emotions, lack of motivation, and lack of the desire to build relationships. Because of their nature, negative emotions contribute more to shrunken quality of life, poor functional abilities, and burden to others (Andreasen, 1982). People who experience negative symptoms to a greater degree compared to positive symptoms usually have a history of poor adjustment before the inception of the complication, and are less likely to respond to drugs at all (American Psychiatric Association, 2006).
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Other studies have rejected the validity of the positive and negative classification of symptoms, particularly factor analysis studies that observe a three-dimension categorization of symptoms. The terminology may be different in both cases, but aspects of hallucination, disorganization, and negative symptoms are equally considered (Charney et al., 2013).
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Ethical implications in Treatment
Given the current ethical consensus, the treatment of schizophrenia is bound to raise a range of issues. The biggest challenge regards the complication’s nature as a form of psychosis. It is important to note that there are no current tests to validly determine whether one is psychotic or not. Additionally, there are no particular chemicals that seem to indicate the manifestation of schizophrenia or the degree of psychosis. Along with this, the management of schizophrenia in patients is challenging, acutely when it comes to the respect for patient autonomy. As seen from the manifestation of the disease, schizophrenia patients are more likely to have irrational thoughts. The following context reflect the need for exploring further into the case patient autonomy as far as the treatment of schizophrenia is concerned.
Truthfulness in Schizophrenia Treatment.
The conflict between the disclosure of truth and maleficence is a scenario that is likely to be encountered by any clinician who chooses to withhold facts as a result of a patient’s psychodynamics and underlying emotional needs. Indeed, psychiatrists normally withhold information from patients because of the potential implications it might have on the patient- the risk of patients not returning for further treatment is a common motivation for withholding the truth. The degree to which a practitioner withholds information can have potential ethical implications as far as patient autonomy is concerned. However, the ethical “tradeoff” can be warranted because of mutually exclusive and competing values that can benefit the patient. Such conflicts are common in the treatment of patients who suffer from paranoia – a symptom of schizophrenia.
A majority of psychiatrists believe that delusions should not be confronted. According to Andreason and Black (2014), patients with delusional disorders are more inclined to accepting treatment if it is presented as a remedy for tension, dysphoria, and concern that a patient experiences because of their delusion. Thus, the partial nondisclosure of facts may contribute to the general wellbeing of the patient, although some psychiatrists applied this approach beyond necessary levels. Havens (2004) uses a similar model to help develop an effective therapeutic alliance by requesting psychiatrists to explore and share symptoms in form of strengths with their patients. This approach may not be evidence based according to Stanard (1999), but Havens (2004) maintains that psychiatrists may obliterate patient fears through positive results. This creates an ethical dilemma of whether the principle of truthfulness should be consistently upheld in treatment of schizophrenia.
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“Risky” Ambitions of Schizophrenia Patients
There is an emerging school of thought that places greater emphasis on the quality of life rather than mere treatment of schizophrenia symptoms (Stanard, 1999; Kane, 2007). One way of improving the quality of life is allowing the patient to make their own choices. In this regard, some patients with schizophrenia are quite ambitious and this can lead to conflicts with their caregivers. A schizophrenia patient may wish to pursue a career that lies beyond their abilities, particularly intellectual capabilities, for instance. To achieve their desires, such a patient faces the risk of worsening their condition, yet to do otherwise would compromise with their quality of life. This, therefore, presents an ethical dilemma to the psychiatrist. Should they support their patient’s ambitious wishes to improve their quality of life or should they cancel the individual against following that course in order to evade the likelihood of exacerbation? The first option would be to be less authoritarian and protective and give preference to the patient’s desires. Although the complication could intensify, the psychiatrist would be supporting the patient in achieving his desires and gaining quality of life.
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In such cases, some psychiatrists employ shared decision-making approaches (Hudson et al., 2008). This approach provides patients with more truth and information concerning their treatment decisions. According to Harman et al. (2006), this approach bypasses the principle of informed consent by focusing on the power asymmetry between caregivers and patients. The application of the approach means that the psychiatrist will give more information and power over treatment decisions to the patient via use of directional aids among other means. Evidently, respect for the autonomy of a patient with schizophrenia is independent of actual implications of treatment, given that schizophrenia patients are more prone to losing decision-making abilities.
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Involvement of schizophrenia patients in formulation of psychiatric advance directives.
Advance directives are a necessary part of information disclosure. Correspondingly, a clinician can request a schizophrenia patient to express their opinion concerning modes of treatment should they lose decisional capabilities in future. This can only be done with patients who still have their decisional capacity in place. Such advance directives can assist psychiatrists to foresee future consequences encompassing the particular institutions the patient will attend, means of treatment, and medication (O’Reilly, 2008). By giving patients the chance to take part in critical decision-making procedures, the psychiatrist may be in a position to respect patient autonomy while regarding their wellbeing. Even so, Widdershoven & Berghmans (2007) and Hamann et al. (2006) are unwilling to pursue this course. This raises a complicated ethical dilemma that reverts decision-making to earlier stages. Another thing to consider is that the presentation of this option may cause exceptional fear in patients.
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In sum, clinicians face a range of ethical dilemmas when treating patients with schizophrenia. The biggest among them involves the observation of patient autonomy and regard for the values of beneficence and non-maleficence. As seen above, symptoms of schizophrenia manifest in terms positive and negative symptoms that are highly reminiscent of those experienced by psychosis patients. Hence, there is a noteworthy concern of whether schizophrenia patients are rationally adequate to make their own decision. This concern is further reflected in the support of risky” ambitions and the establishment of advance directives. It is clear that this is an area worth researching since the wellbeing of patients with schizophrenia is at stake.
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