CLINICAL HANDBOOK OF SCHIZOPHRENIA

61. Ethics 625on two important ethical issues that are not directly addressed by other chapters in thisbook, and that are important enough to deserve separate consideration. These are the issuesof the ethics of client-centered care for people with schizophrenia and of research onpeople with schizophrenia. The section on client-centered care is primarily authored byRudnick, and the section on research is primarily authored by Weijer.ETHICS OF CLIENT-CENTERED CARE IN SCHIZOPHRENIAClient-centered care, also termed patient-centered care and person-centered care, isnowconsidered a mainstay of acceptable health care, both in mental health care and in physicalhealth care (Stewart et al., 2003). It is commonly characterized as health care thatserves the goals and the needs of the patient. It guides health care in the sense that clinicalassessments and interventions are directed by the goals and needs of patients, rather thanby those of others, including caregivers such as family members and clinicians. Thus, client-centeredcare clearly manifests the principle of autonomy or self-determination. Indeed,the recent rising of the recovery movement in mental health largely revolves aroundclient-centeredness and self-determination. Yet schizophrenia challenges the notion of(purely) client-centered care and the underlying principle of self-determination, and requiresthe consideration of additional ethical principles in the provision of care.People with schizophrenia demonstrate various psychiatric symptoms and cognitiveimpairments, some of which undermine self-determination. For instance, impaired insightinto illness, which is common in schizophrenia, disrupts decision-making capacity, leadingto the determination of incompetence to consent to or refuse treatment (Grisso &Appelbaum, 1998). Another example is that of delusions, which are very common inschizophrenia and by definition disrupt reality testing, leading to involuntary commitmentif risk of harm to self or others is also involved. Both examples illustrate how impairmentsand symptoms of schizophrenia undermine self-determination. So how doesthis impact on client-centered care for people with schizophrenia?The mental health care area that attempts to be most client-centered is psychiatric rehabilitation(Anthony, Cohen, Farkas, & Gagne, 2002). Psychiatric rehabilitation aims toimprove the functioning and quality of life of individuals with severe psychiatric disorders,so that they achieve and maintain lives that are satisfactory and meaningful to them,thus facilitating recovery. It consists of enhancing the living skills and environmental supportsof individuals with mental illness, enabling them to achieve goals that, preferably,they set themselves. Yet such individuals may set goals reflecting values that conflict withthose held by mental health practitioners or by society at large, and that are induced bymental impairment, such as stalking another person due to erotomanic delusions (i.e., thementally ill individual thinking that the other person is infatuated with him or her). Psychiatricrehabilitation practitioners have reported difficulty, due to this problem, in workingtoward goals set by their clients (Hendrickson-Gracie, Staley, & Morton-Neufeld,1996). Goals set by individuals with mental illness that involve harm to self or to othersare suspect, such as in the case of the stalker with erotomanic delusions. In such cases, aclient-centered approach that endorses patient goals at all cost runs into ethical trouble,because it rigidly compromises acceptable values such as preservation of life and fairnessto others. If so, others—such as legally appointed guardians or substitute decision makers—may be required to set goals for individuals with mental illness. Yet rehabilitation goalsset by others are problematic, because if the goals of the individual prior to the psychiatricdisorder are not known (as frequently occurs), then best interests, not patient goals,are considered. This may preserve an aspect of the client-centered approach in that best