Ethics in community psychiatry.
OBJECTIVE
The aim of this paper is to clarify the ethical challenges resulting from new models of community psychiatry and to examine practical approaches aimed at meeting them.


METHODS
Review of the literature and observations both as clinician and medical director of community services.


RESULTS
Assertive community treatment presents ethical dilemmas relating to privacy, confidentiality, 'coercion' and conflicts of duty to the patient versus others, including carers and the wider community. Their acuity is influenced by the context in which services are provided, especially community fears of the consequences of care in the community for the severely mentally ill. Approaches to resolving ethical problems include increasing patient involvement in their care, clarifying the grounds for'paternalistic' interventions, and re-examining grounds for acting to reduce the risk of harm to others.


CONCLUSIONS
The ethical dilemmas are not new, but they present in sufficiently different guises to warrant reconsideration in their new context. There has been a reluctance to face them, but if community psychiatric practice is to survive, it must rest on a sound ethical base.
Szmukler
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Bethlem and Maudsley NHS Trust, Denmark Hill, London, United Kingdom.
D019090:Case Management / Q000592:standards*; D003068:Coercion; D003156:Community Mental Health Services / Q000592:standards*; D003158:Community Psychiatry / Q000592:standards*; D003159:Community-Institutional Relations; D003219:Confidentiality; D016265:Conflict of Interest; D004992:Ethics, Medical; D006801:Humans; D007258:Informed Consent; D001523:Mental Disorders / Q000628:therapy*; D010344:Patient Advocacy; D010819:Physician's Role; D012941:Social Responsibility