Ethical Issues in Providing Behavioral Health Treatment to Vulnerable Populations
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Mental health vulnerabilities exist across the lifespan and involve numerous risk factors. Vulnerability involves these complex, interactive, and cumulative risk factors that result in adverse effects on health throughout the lifespan (WHO 2001). The US Surgeon General’s Report on Mental Health identifies that “even more than other areas of health and medicine, the mental health field is plagued by disparities in the availability of an access to its services.” These disparities are viewed readily through the lenses of racial and cultural diversity, age, and gender (DHHS 1999, P. vi). There are significant differences in “social, economic and educational contexts among many population groups which subsequently place them at greater risk for poor mental health” (Pearson et al. 2015, p. 14).
Braveman et al. (2011) defined health-care disparities as typically “plausibly avoidable health differences according to race/ethnicity, skin color, religion, or nationality; socioeconomic resources or position (reflected by, e.g., income, wealth, education, or occupation); gender, sexual orientation, gender identity, age, geography, disability, illness, political or other affiliation; or other characteristics associated with discrimination or marginalization (S150).”
Other factors characteristic of a population with behavioral health needs putting them at risk for care inequities and health disparities include degree of psychiatric illness impairing functioning, level of perceived dangerousness, and degree of stigma they experience, related to behavioral health. These terms and factors are in turn, conceptually part of the broader definitions of health disparity and health equity, terms discussed at length in the literature, particularly in the Healthy People 2020 movement identified by the US Department of Health and Human Services (USDHHS 2010). The National Institutes of Health defined health disparities as “differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist amount specific population groups in the United States.” Health disparities occur with populations having medical and behavioral health-care needs. Providing care to populations with health disparities is challenging.
These concepts are also reflected in a number of international ethics documents including the United Nations International Universal Declaration on Bioethics and Human Rights (UNESCO), the Belmont Report, the Declaration of Helsinki, and the Council for International Organizations of Medical Sciences (CIOMS) guidelines (Zagorac 2016). All emphasize the right to health and health services with the elimination of marginalization and exclusion of persons for any grounds. All of these documents focus on the need to protect the vulnerable in research and care models, while the manner of providing this protection is not elucidated in any of these guidelines (Zagorac 2016).
All policy makers and international agencies agree that vulnerable populations need protection without identifying the exact process occurring at an actual care level in a treatment setting. It is difficult to precisely define health disparity in a heterogeneous population. While this might be the first step in defining the behavioral health issues present in a disenfranchised population, it is muddied by the myriad of influencing factors on the concept of vulnerability. If vulnerability is a fluid concept, it potentially changes over the lifespan. Research has identified that racial minorities, those in underserved socioeconomic groups, and those with chronic psychiatric illness are vulnerable by static factors. Others can change, such as socioeconomic status, health status, and community of residence. Identifying the individual factors that make vulnerability and constant risk while being aware of the individual’s unique circumstances is essential to providing ethically balanced care.
Importantly, all of these categories reflect the individual’s or group’s status in a social hierarchy. Not all health disparities define health differences. Instead, they are relevant to “social justice because they may arise from intentional or unintentional discrimination or marginalization” and, in turn, “are likely to reinforce social disadvantage and vulnerability” (Braveman et al. 2011, p, S150). The major professional groups providing behavioral health treatment (physicals, nurses, psychologists, social workers) to all populations clearly state and endorse nondiscriminatory health-care practices aimed at minimizing health disparities. All mental health professionals encounter vulnerable populations in their work. “Mental healthcare professionals face numerous and difficult challenges” (Hem et al. 2014). Uncertainty about the right treatment, need for coercive treatment measures, and the individual’s competence are all influences.
The ethical issues inherent in providing behavioral health care are embedded in all levels of care provision beginning with the individual needing care and moving through the professional providing care, the setting of the care, the community where it is given, the philosophical model of the institution where the care is given, and the financial structure the society uses to pay for the care. Each of these entities has their own ethical challenges and dilemmas.
Applying Ethics to Specific Behavioral Health-Care Practices: Community Health Clinics
The Primary Health Care Behavioral Health model has been proposed and implemented as a model for community treatment in many health systems both in the United States and internationally. It focuses on a team-based model of care that integrates physical and behavioral health needs. It is population based and can accommodate a large number of patients within a community. The goal is continuity and longitudinal engagement with patients and families rather than being specific to one episode of illness (Reiter et al. 2018). Vulnerable populations tend to use the community health-care system for their care as it is affordable, available, and focused on the entire person or family requiring services.
In this model of care, the clinic is located in a community known to providers. Care is shared by a number of health-care specialities and is full service, i.e., involving medical, dental, adult and pediatrics, obstetrical, and behavioral health services in one location. The ethical issues presented by this model of integrated care reflect many of the ethical issues encountered by other providers, in other settings. They will be summarized here as an exemplar.
Runyan et al. (2018) identify the common ethical issues particular to the community health-care system. They note that the traditional model of ethical care has applicability to the single-episode model of treatment, with a clear beginning and ending point and one clinician in charge of the care. In this interdisciplinary model, several individuals are involved with the patient and might have various understandings on the ethical variances that are presented in this model. Reiter and Runyan (2013) note that while the primary health-care model focuses on the whole family, specialty mental health care typically looks at the care of the individual.
Ethical dilemmas require a view that is non-disciplinary related and pertains to the primary care environment. Issues of confidentiality, collaboration, and involvement of other family members can contribute to ethical dilemmas. The community health treatment model strives to decrease discrepancies in health status, services, or outcomes based on social inequalities among particular segments of a population. These differences comprise the factors noted early on. The concept of health equity involves the promotion and achievement of the highest level of health for all people and the absence, over time, of health differences related to age, gender, ethnicity, and underserved status.
Applying Ethics to Psychiatric Practices
Ethical psychiatric care involves providing the individual and family with care that fosters development and health. This involves providing support for individual/family/community strengths, development of collaborative partnerships to prevent and treat illness, enhancing public and professional education and awareness, and advocating for mental health promotion, treatment, and translation. Application of ethical practices means that the mental health professional adheres to the highest standards of behavior and respect toward individuals in their care, regardless of that person’s status or presentation.
- Hem MH, Pedersen R, Norvoll R, Molewijk B (2014) Evaluating clinical ethics support in mental healthcare: a systematic literature review. Nurs Ethics. Available via https://journals.sagepub.com/doi/full/10.1177/0969733014539783. Accessed 22 Aug 2019
- Reiter J, Runyon C (2013) The ethics of complex relationships in primary care behavioral health. Fam Syst Health 31(1):20–27. https://doi.org/10.1037/a0031855
- Reiter JT, Dobmeyer AC, Hunter CL (2018) The primary care behavioral health (PCBH) model: an overview and operational definition. J Clin Psychol Med S 25:109–126. https://doi.org/10.1007/s10880-017-9531-x
- US Department of Health and Human Serivces (1999) Mental health: a report of the Surgeon General. US Department of Health and Human Services, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, RockvilleGoogle Scholar
- US Department of Health and Human Services. Office of Disease Prevention and Health Promotion (2010). Health People 2020. Available at http://www.healthypeople.gov/. Accessed 21 Aug 2019
- World Health Organization (2001) The world health report 2001: mental health: new understanding, new hope. World Health Organization, GenevaGoogle Scholar