Volume 2, Issue 12 - February 2000

Ethics and the Stigma of Mental Illness

"By our very attitude to one another, we help to shape one another's world."
- The Ethical Demand.

There are grave moral consequences to receiving a psychiatric diagnosis: it has the power to transform an individual into "a crazy person." With such a designation, the possibilities for enacting one's vision of a "good life" are significantly impaired. A recent inquiry in Britain by Mind found that when people - secretaries, managers, office workers, and doctors - received a psychiatric diagnosis their world changed. "Not because of their condition but because they had suddenly been marked as different." One witness to the inquiry stated: "unemployment, social isolation, poverty, homelessness, stigma, contempt and fear surround people with mental health problems like a shroud. It is easier to live in society with a prison record than a psychiatric record." ¹ The stigma that comes with the diagnosis of a mental disorder can "spoil" the identity of persons and their way of being in the world.

What is Stigma?

Stigma disqualifies an individual from full social acceptance. Its origins reveal its power to marginalize: in Ancient Greece stigma was a sign cut or burnt into a person's body to designate low moral status, such that of a slave or criminal. Once stigma is attached to a person, everything changes. Respect and empathy are no longer found in the interconnectedness with others. These are replaced, not merely with indifference, but with fear, rejection and exclusion. Stigma's effects spread beyond stigmatized persons to those with whom they are connected, marking them as well. It creates difficulties for existing relations and prevents the establishment of new ones.² It opens the way for injustice.

Stigma and Health Professionals

The realization that the mentally ill experience exclusion and prejudicial responses is not new. Until recently, psychiatric treatment was situated in asylums on the outskirts of communities, ensuring those deemed mentally ill stayed away from the rest of society. What is new, however, is the revelation that health professionals are a significant source of stigma and discrimination.

In Australia, research by the National Community Advisory Group on Mental Health (1994) shows consumers and careers³ "overwhelmingly" believe that they experience more stigma and discrimination from mental health professionals than from any other sector of society. Closer to home, focus groups conducted by the Alberta Mental Health Board also identified health practitioners as a significant source of stigma. ⁴ Clients and their families in this province say that more than a few caregivers fail to treat them with respect.

Sources of Stigma

Paternalistic attitudes seem to be a significant source of the problem. The dominant paradigm for psychiatric care is the medical model -- the physician is expected to be an expert and practitioners from other disciplines to complement that expertise. ⁵ Johnson, the author of Users and Abusers of Psychiatry,⁶ suggests that this model can lead professionals to see their patients as illnesses. People with schizophrenia become "schizophrenics," as if that is their defining attribute. Although health professionals may assume that they are acting responsibly and with benevolence, client and family perspectives are often ignored in the development of service systems, programs and even individual care plans. Actor Margot Kidder recently described her psychiatric hospitalization to the Canadian Mental Health Association: "You're completely invalidated as a human being. You're treated like a naughty child who must be taught a lesson." ⁷ Rather than being considered as a true partner in their health care, persons with a psychiatric diagnosis may find themselves unusually vulnerable or stripped of their dignity. Their right to dignity -- "the right to be treated in a way that affirms the distinct importance of their own lives"⁸ -- is a clear one, stipulated explicitly in professional codes of ethics.

The system itself can be a source of stigma if it is designed to meet the needs of administrators and practitioners rather than patients and families. Further, organizational factors and the professional or clinical culture can affect the openness of staff to the moral dimension of their practice. ⁹ The dehumanizing aspects of mental health care can be institutionalized and "routinized" out of awareness.¹⁰

Stigma: An Ethical Issue

Stigma is fundamentally an ethical issue. Individuals are part of a network of moral relations upon which their well-being and self-realization depend. There is both ethical and practical import to these relations.¹¹ As beings inescapably dependent on one another, we have derived ways of living in community. A moral community presupposes a basic trust existing in all interactions between human beings. Mistrust exists, especially in some circumstances, but social life could not exist if mistrust was preeminent. ¹² Respect, justice, fairness, faithfulness: these are moral claims one human being can rightly make of another. Such moral claims are foundational to the covenant between health professionals and their clients, where more than expertise is demanded. Health professionals need to be able to identify with those in their care, to be touched by their suffering. ¹³ No one should be humiliated or treated in a way that diminishes them. Health professionals must be vigilant about the ethics of their practice with individual clients, and about the way their attitudes and actions impact the client's life.

Responsibility to Act

Their ethical obligation, however, goes beyond this. There is a responsibility to act if the system itself is disrespectful of persons. There is a role to play in addressing societal barriers to human flourishing. In its 1996 Madrid Declaration, the World Psychiatric Association stipulated that psychiatrists must advocate for fair and equal treatment of the mentally ill and for social justice and equity for all. Combating stigma has become a top priority of the mental health division of the World Health Organization and of the World Federation for Mental Health. Here in Alberta, the Provincial Mental Health Promotion Committee has targeted "changing public attitudes regarding mental illness" and "developing communities that will accept and include people who live with mental disorder" as a core area for change. ¹⁴ As bodies committed to promoting the wellbeing of humanity, health professionals, institutions and organizations need to actively support this agenda. It is the ethical thing to do; indeed it is a moral imperative.

References

1. Mind Press Release, 4/11/99.
2. Goffman, I. (1963). Stigma: Notes on the management of spoiled identity. Englewood Cliffs, NJ: Prentice Hall Inc.
3. People who use psychiatric services and the family and friends who support them.
4. Personal communication, Beth Evans, Member of the Provincial Mental Health Promotion Committee, Alberta Mental Health Board.
5. Gallop, R. (1997). Caring about the client: The role of gender, empathy and power in the therapeutic process. In S. Tilley (Ed.), The mental health nurse: Views of practice and education. ( pp.28-42). Oxford: Blackwell Science Ltd.
6. Johnson, L. (1989). Users and abusers of psychiatry. London: Routledge.
7. Moore, D. (1999, August 20), Actor urges pople to take control of their mental health. Edmonton Journal, p.A12."
8. Dworkin quoted in Shotton, l. & Seedhouse, D. (1998). Practical dignity in caring. Nursing ethics, 5 (3), p. 252.
9. Holm, S. (1997). Ethical problems in clinical practice: The ethical reasoning of health care professionals. Manchester, UK: Manchester University Press.
10. Brody, E. (1995). Editorial: The humanity of psychotic persons and their rights. Journal of Nrevous and Mental Disease, 183(4), 193-194.
11. Selbourne, D. (1994) The principle of duty. London: Sinclair-Stevenson.
12. Fink, H. & MacIntyre, A. (1997). Introduction. In K. Logstrup, The ethical demand. Notre Dame: University of Notre Dame Press.
13. Gastmans, C. (1999). Care as a moral attitude in nursing. Nursing ethics, 6(3), 214-223.
14. Mental Health Promotion Strategy, Alberta Mental Health Board, August, 1998, p.3.

Announcements and News

• Representatives of the PHEN board and staff will be meeting with Deputy Minister of Health and Wellness Lynne Duncan in March to provide an update on PHEN's activities and progress, and solicit input from the Ministry on health ethics issues that PHEN may help to address. For information, please contact Al-Noor Nathoo or Campbell Miller through a PHEN office.

• The Alberta Congress Board held a one-day Health Forum on February 5^th, 2000 to discuss the role of public and private health care delivery in Alberta. Speakers included Minister Halvar Jonson, health economists Bob Evans and Richard Plain, MLA Ron Stevens, UNA President Heather Smith, consumer advocate Wendy Armstrong, and opthamologists Ian MacDonald and Harold Climenhaga, among others. For a report on the forum, please visit www.yourhealth.ab.ca.

• The U of C Faculty of Medicine Office of Medical Bioethics is seeking to fill the position of Bioethicist. The deadline for application is March 3^rd, 2000. For more information, please visit www.bioethics.ca/english/misc/jobs/omb.html.

• The PHEN user fund application deadline has been moved from May 1st, 2000 to April 10th, 2000. This is to enable members to apply to the fund to help offset the cost of attending PHEN's Conference and Annual General Meeting. To request an application package, please contact Colette Mooney at info@phen.ab.ca, or by phone at (780) 492-8239 or (800) 472-4066.

Views offered in this article are those of the author and do not necessarily reflect the position of the Provincial Health Ethics Network.