Ethical, Legal, and Clinical Considerations when Disclosing a High-Risk Syndrome for Psychosis
Ethical, Legal, and Clinical Considerations when Disclosing a High-Risk Syndrome for Psychosis
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DOI：
10.1111/bioe.12155
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发表时间：
2015-10-01
期刊：
影响因子：
2.2
通讯作者：
Saks, Elyn R.
中科院分区：
文献类型：
--
作者：
Mittal, Vijay A.;Dean, Derek J.;Saks, Elyn R.
当计划披露减少性精神病综合征(APS)的诊断时，有复杂的考虑因素。在这篇综述中，我们评估了伦理、法律和临床视角，以及与完全、非和部分披露策略相关的警告，讨论了社会影响，并提供了临床建议。每一项披露战略都与收益和成本/考虑因素有关。全面披露有助于促进自主性，允许对其他风险因素进行最明确的心理教育，有助于澄清和/或纠正以前的诊断/治疗，促进早期干预，并加强提供者之间的沟通，但有涉及遗传性、共病、文化和耻辱的重要考虑因素。保密通过限制耻辱和压力(这可能会无意中加剧病情)和混乱(与快速演变的诊断有关)来促进非恶意，但由于患者偏好的变化，以及随着没有不良影响的新治疗方法的出现，假阳性的风险不再证明随之而来的自主性丧失是合理的，这一点变得更加复杂。部分披露通过关注症状而不是标签来平衡伦理考虑，但有证据表明，外行人可能会将这些信息解释为伪诊断，而且症状本身也会导致污名，这限制了这种方法的有效性。此外，在涉及监护、保险公司的影响范围和歧视的披露方面，还有一些值得注意的社会考虑因素。我们提倡一种混合的方法来披露信息，并推荐未来的研究，旨在了解污名对临床病程的影响，并重新关注那些没有过渡但仍具有临床相关性的求助病例。
There are complex considerations when planning to disclose an attenuated psychosis syndrome (APS) diagnosis. In this review, we evaluate ethical, legal, and clinical perspectives as well as caveats related to full, non- and partial disclosure strategies, discuss societal implications, and provide clinical suggestions. Each of the disclosure strategies is associated with benefits as well as costs/considerations. Full disclosure promotes autonomy, allows for the clearest psychoeducation about additional risk factors, helps to clarify and/or correct previous diagnoses/treatments, facilitates early intervention and bolsters communication between providers but there are important considerations involving heritability, comorbidity, culture, and stigma. Non-disclosure advances nonmaleficence by limiting stigma and stress (which may inadvertently exacerbate the condition), and confusion (related to the rapidly evolving diagnosis) in a sensitive developmental period but is complicated by varying patient preferences and the possibility that, as new treatments without adverse effects become available, the risk with false positives no longer justifies the accompanying loss of autonomy. Partial disclosure balances ethical considerations by focusing on symptoms instead of labels, but evidence that laypersons may interpret this information as a pseudo-diagnosis and that symptoms alone also contribute to stigma limits the efficacy of this approach. In addition, there are notable societal considerations relating to disclosure involving conservatorship, the reach of insurance companies, and discrimination. We advocate a hybrid approach to disclosure and recommend future research aimed at understanding the effects of stigma on clinical course and a renewed focus on those help-seeking cases that do not transition but remain clinically relevant.