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The COVID-19 Pandemic presents unique challenges for patients with mental disorders, their care givers, mental healthcare professionals, and bioethicists. Professor John Z. Sadler and Professor Şerife Tekin engage in a productive exchange pertaining to ethical issues in psychiatric care in the time of the COVID-19 pandemic.

In what follows you will read a psychiatric case shared by Professor Sadler based on his recent experience at his hospital and Professor Tekin’s reflections on the ethical issues involved in the case. It is important to note here that this exchange occurred on April 1, 2020, in Texas, US, in the midst of a lockdown. We believe that the historical moment counts for a lot in this case. We welcome our readers to join the conversation in the comments.

Case for AAPP Blog, April 1, 2020*
By John Z Sadler, MD, University of Texas at Southwestern

*Details have been changed to preserve anonymity of the family.

As are clinics across the USA, our clinic has converted all of our visits to virtual ones. Our clinic is part of a safety-net healthcare system, so our patient population is of limited means. For this reason, we offer currently only telephone-call based tele-psychiatry, without video.

Mr. B is a 62 year-old man with chronic undifferentiated schizophrenia who lives at home on disability, assisted by his 83 year-old mother, while aged, is in relatively good health. At our last tele-psychiatry audio visit with Mr. B, he showed evidence of clinical deterioration compared with his last visit in-person with us 6 weeks ago. On his consented-to tele-psychiatry visit, he described persecutory delusions involving the “X-people” who were “stalking us” (referring to mother). He expressed some intent to retaliate violently against the X-people but has not actually confronted them, or anyone, as both the patient and mother are complying with the community order to stay at home except for essential activities (e.g., health care, grocery, exercise outdoors). Moreover, Mr. B was quite stable on medications six weeks ago, but now the patient has discontinued medications for unclear reasons. The mother, Mrs. B, who spoke over the speakerphone connection, said that Mr. B was getting worse: more pacing, hearing more voices, ranting about the X-people, but Mrs. B did not feel threatened by the patient and said the patient had never been violent with anyone.

The clinic resident, Dr. S, and attending physician (me) were concerned nevertheless about the patient’s relatively-rapid deterioration, especially in the face of meeting him for the first time in the prior visit. Dr. S advised Mrs. B about how to take out a mental-illness warrant if she needed assistance. (A mental-illness warrant is a Texas court-ordered emergency-psychiatry involuntary evaluation not to exceed a 3 day period.) The patient was, perhaps surprisingly, unperturbed by this advice. After discussing quickly offline, Dr. S and I decided that the balance of risk and benefit did NOT favor us recommending, at this time, the mother take the patient to the emergency department, given both members of the family were at high-risk for serious complications from COVID-19 infection, and had no protective gear of their own. Instead, Dr. S would follow up with the family frequently over the phone, and continue to encourage Mr. B to resume his medications.

This case, for us, raises ethical questions about managing the unstable patient over tele-psychiatry when usual clinic resources are not available, and while increasing the level of personal-contact care poses its own serious risks from COVID-19. Moreover, we suspect that this problem, writ large over the community, poses community risks as unstable individuals with psychosis may increasingly not be able to adhere to safe-distancing and other public infection-control steps, while at the same time have limited mental health in-person support.

A commentary, April 1, 2020
By Şerife Tekin, PhD, University of Texas at San Antonio

Thank you, Professor Sadler for sharing this case with us. It is pertinent that we address and engage with ethical issues pertaining to individuals with mental disorders during this difficult time. There is a long list of problems that all members of the society are faced with during the COVID-19 pandemic, e.g., trying to avoid contexts in which one can get infected with the virus, continuing to work in jobs that contain high risk (healthcare workers, workers at the grocery stores, home delivery agents), increased unemployment, facing with financial insecurities, confronting food insecurity, etc. In addition to these, individuals with mental disorders are vulnerable to exacerbation of their symptoms under the pandemic, such as increased insomnia due to loss of daily routines, increased volatility in mood, and as in the case of Mr B, disruptions in medical treatment and increased persecutory delusions. Such problems further deteriorate or even pose threats to individuals around the patients, including their caregivers; in this case increased risk of violence against others.

I would like to focus on two themes that emerge in this case. The first is the evaluation of advantages and disadvantages of tele-medicine. A big problem in contemporary healthcare, and mental health care in particular, is the gap between the needs of individuals with mental disorders and the resources dedicated to care. For example, in 2016, 18.3% of all US adults were diagnosed with a mental disorder, and of these, only 43.1% received some kind of treatment, e.g., inpatient or outpatient counseling or prescription medication (Substance Abuse and Mental Health Services Administration 2017). Among other things, reasons for not receiving help include the lack of available services, inability to recognize symptoms, and the cost of treatment. Advances in computer technology, the applications artificial intelligence, and the use of data analytics in biomedicine are creating optimism, however, as many believe these technologies will fill the need-availability gap by increasing resources for mental health care. While tele-medicine, and in this context, tele-psychiatry offers tremendous resources, they are not without significant limitations. This case illustrates both.

On the one hand, in circumstances like those presented in the COVID-19 pandemic, tele-psychiatry enables treatment of patients with mental disorders without having to expose them and their caregivers to increased risks of getting sick, or community spread. As it is recently reported, there has been an increase in virtual psychotherapy during the COVID-19 pandemic, enabling individuals to receive the mental health counseling they need. Professor Sadler’s case, however, also calls into question of how fit mental disorders are for being treated remotely. While I do not want to overstate the differences between mental and physical disorders, the very nature of some mental disorders are so that what is recommended and effective in treating physical disorders may actually make the experience of mental disorders worse. Take social distancing. It is a good guide for preventing and treating patients with COVID-19. Using tele-medicine, patients can get advice on whether they should stay at home or see a healthcare practitioner. What usually comes out through this interaction over the phone is that even if the individual has the symptoms of the COVID-19, as long as they do not require intensive care, they could and should stay at home. However, staying home may make the symptoms of some mental disorders worse: Added isolation through social distancing, the loss of routines that help regulate mental health may all exacerbate the person’s condition. Or, as in the case of Mr. B, the patient may need more hands-on or emergent care at a health institution. While my observation does not solve the problem in the current situation it will perhaps caution tele-medicine and tele-psychiatry optimists to recognize the intrinsic limitations of these technologies in treating mental illness.

The second theme is how must healthcare professionals navigate the potential risks involved in different decision scenarios? In this case Dr. S is conflicted between the decision to remain to monitor the apparently deteriorating mental health of a patient through tele-psychiatry and the decision to recommend in-person care, due to scarcity of personal protective equipment available for patients, their caregivers, and the healthcare professionals. Mainstream bioethics often recommends a medley of ethical guidelines in such scenarios. Following the main principles of bioethics may be one option, i.e., avoidance from causing further harm to the patient (non-maleficence), aiming to improve the condition of the patient (beneficence), respecting patient’s autonomy, and a fair treatment of the patient in question. None of these principles are straightforwardly helpful here. Take the non-maleficence and beneficence principles: On the one hand, Mr. B might be worse off by staying at home due to increased risk of self-harm and harm to others; he may also be worse off by being hospitalized, due to increased risk of exposure to COVID-19. It is not obvious which of these decisions would make the patient worse or better off. The power of principle of autonomy as a guide is limited as well. In this case, arguably, the patient has limited agency and thus autonomy. His caregiver, who is in a position to make decisions regarding Mr. B’s care is also unsure about the right course of action to follow, as neither hospitalization nor continuing to be cared for at home through tele-psychiatry seem to offer straightforward solutions. So, the healthcare professional cannot just straightforwardly follow the caregiver’s wishes. The principle of justice, which encourages healthcare professionals to treat patients fairly, also does not offer any concrete solutions in the time of a pandemic when medical resources are scarce.

In these situations, it is wise to turn to virtue ethics or feminist ethics as potential guides; which is what I take Dr. S has followed. Unlike the principle-based guidelines of mainstream bioethics, both virtue ethics and feminist ethics take seriously the context of the medical case in question. Instead of chasing after the universals, they value the particulars. Virtue ethicists promote healthcare professionals to develop virtues and be guided by those virtues in caring for the patients. Some of these virtues include being compassionate, thoughtful, attentive to the patient’s identity and relationships in determining their needs, and being aware of and sensitive to social and cultural norms. In this case, in consultation with her colleague, Dr. S. seems to have acted virtuously, in so far as she was (i) compassionate, (ii) decided to seek collaborative decision-making, (iii) took the individual context of Mr. B seriously – as a person with increased risk of negative outcome if gets sick with COVID-19, with a caregiver who is also part of the similar risk group. After this process, she decided to increase the frequency of her follow ups with the family to continue to monitor the situation and continue to encourage Mr. B to resume his medications.

Feminist bioethicists are committed to understanding persons not as solitary agents living independent from each other but, rather, as intrinsically relational beings that exist and flourish through interconnected relationships. Dr. S’s attention to the relationship between the patient and his caregiver is illustrative of feminist commitments. For instance, she prepared for a possible worse-case scenario and advised Mrs. B, Mr. B’s caregiver, on how to get a mental-illness warrant if she needed assistance. She also took cues from patient’s “surprisingly, unperturbed” response to this advice and recommended that him to not be hospitalized at this time. Her attention to the relationship between her and Mr. B, as well as her seriousness about explicitly communicating with the patient’s caregiver exemplifies what feminist bioethicists strive for in making tough decisions.