When shared decision making breaks down and parents and medical providers have developed entrenched and conflicting views, ethical frameworks are needed to find a way forward. This article reviews the evolution of thought about the best interest standard and then discusses the advantages of the harm principle (HP) and the zone of parental discretion (ZPD). Applying these frameworks to parental refusals in situations of complexity and uncertainty presents challenges that necessitate concrete substeps to analyze the big picture and identify key (...) questions. I outline and defend a new decision-making tool that includes three parts: identifying the nature of the disagreement, checklists for key elements of the HP and ZPD, and a “think list” of specific questions designed to enhance use of the HP and ZPD in clinical decision making. These tools together will assist those embroiled in complex disagreements to disentangle the issues to find a path to resolution. (shrink)

Professional providers of mental health services are motivated to help people, including, or especially, vulnerable people. We analyse the ethical implications of mental health providers accepting employment at detention centres that operate out of the normal regulatory structure of the modern state. Specifically, we examine tensions and moral harms experienced by providers at the Australian immigration detention centre on the island of Nauru. Australia has adopted indefinite offshore detention for asylum-seekers arriving by boat as part of a deterrence strategy that (...) relies on making detainment conditions harsh. This has known deleterious mental health effects. As a token to fiduciary care obligations, Australia employs mental health professionals to work on Nauru. These providers are often motivated to make a positive difference for detainees’ lives. We examine the overall impact of the providers’ work with detainees and the implications of their presence. The strongest evidence supports that the small mitigation of harms offered by these providers does not outweigh the harms of supporting a system designed to perpetuate human suffering. For mental health professionals considering working in offshore detention, we offer specific topics to scrutinise and weigh prior to employment. Because optimising detainee’s mental health is beyond the capacity of individual providers, we call for the organisations standardising and supporting mental health professionals to oppose employment of their associates in offshore detention. Lessons from this case study are generalisable to other jurisdictions to help inform organisations that licence and support mental health providers and individual providers considering work in similar settings. (shrink)

Downie and Schuklenk1 provide a clear narrative of the development of Canadian policy on medically assisted dying. This is very helpful for considering specific aspects of the continuing deliberations in Canada. This commentary presents an alternative perspective on the authors’ argument that narrow eligibility criteria for medical assistance in dying are discriminatory and unjustified. I argue that disability or mental illness as sole reason for accessing MAiD removes protections for all people who have times in their life when they have (...) mental illness or disability combined with intolerable suffering. I claim that individuals do not make their best, self-actualising decisions at those times and the supposed protections of vague terms such as incurable, advanced and decline are not clinically useful for evaluating eligibility for individuals with chronic health conditions. Within discussion of the impact of social determinants of health on access to MAiD, the authors present the argument that decisionally capable people with mental illness or disabilities as their sole underlying condition should be allowed to access MAiD. The authors state that opposing this access sacrifices patient rights and strips people of their agency. To support their argument, they embrace the idea that people with mental illness or disabilities belong to an identifiable cohort. They claim that …. (shrink)