Ethical issues in community mental health: cases and conflicts

Ethical issues pervade community mental health yet, surprisingly, the field has been virtually ignored in the academic realm of medical ethics. In the past decade, the ethical questions in psychiatry which have attracted the most scrutiny are derived from the "dramatic" issues of psychiatrist-patient sexual relationships, the tradition's practice of involuntary commitment, and the therapist's duty to warn potential victims at the expense of breaching a client's confidentiality (Eth, 1990; Dyer, 1988; Bloch, Chodoff, 1991). Yet the "pragmatic," and more pervasive, ethical tensions which arise in the daily practice of community psychiatrists have warranted little attention. Both medical ethics and community psychiatry suffer as a result. Nonetheless, ethical reasoning is intricately entwined in the decisions and relationships which make up the community mental health setting. For example, trying to determine what is the "right" thing to do for a client inevitably entails judgments about moral, social and legal matters. In other words, no decision in the clinical setting is purely psychiatric (Perlin, 1989).