راهبردهای تدریس میان رشته ای برای قانون بهداشت روانی

The use of an inter-disciplinary teaching strategy in the context of mental health law is explored here as a means of balancing concerns for the patient's best interests and maximizing their autonomy. One law professor and one psychiatrist participated in joint teaching sessions in the Queen's University School of Medicine, and share their strategies for overcoming perceived conflicts between patient's legal rights and the practice of psychiatry.

Many mental health professionals perceive a ‘clash of cultures’ between law and medicine, believing that ‘law is at best irrelevant to, and at worst an insensitive brake upon, the therapeutic ends of mental health practice”.1 Traditionally, the role of the lawyer is to champion the individual rights of patients, acting on the liberal individualist principle that we are all fully capable and have a right to make our own choices, however suspect those choices may be to others. Lawyers thus fight to maximize patient autonomy by protecting the right to bodily integrity and self-determination. As an advocate, the job of the lawyer is to follow the client's instructions, even when those instructions might seem unwise or contrary to the client's own interests: “the lawyer has a duty to the client to raise fearlessly every issue, advance every argument, and ask every question, however distasteful, which the lawyer thinks will help the client's case and to endeavor to obtain for the client the benefit of every remedy and defense authorized by law.”2 The role of the physician requires that they act in the patient's best interests, to ensure their well-being and to provide the best care possible. According to the Ontario College of Physicians and Surgeons, “the patient must always be confident that the physician has put the needs of the patient first”.3 The emphasis here is on the needs and best interests of the patient, and these perceived needs may conflict with the patient's own expressed desires and choices in some circumstances. A need for treatment and care may then necessitate intervention where an individual is at risk, as physicians cannot abdicate responsibility where individuals are incapable and therefore unable to care for themselves. These conflicting values are a reality that must be addressed by lawyers and healthcare providers alike. The battle lines appear to be drawn where patient autonomy is seen as being at odds with health and well-being, and this conflict is often most acute where the state authorizes a forced intervention to assess, restrain or treat, contrary to the patient's own expressed choice.4 The power imbalance between the doctor and patient is exacerbated in such coercive circumstances, and adequate legal representation is often unavailable.5 The authors acknowledge that these tensions are often present, especially in situations where involuntary committal or treatment is required. In practice, however, we suggest that there are many shared views that underlie both the practice of medicine and law; ideally, psychiatrists should seek to respect and enhance patient autonomy alongside clinical care, and lawyers should be concerned about their client's health and well-being as well as their legal rights. Thus, both law and psychiatry tread a fine line, struggling to discern and respect patient self-determination while simultaneously respecting the concern for care and treatment. The goal of this paper is to explore those shared understandings and to describe how they have informed and facilitated our own experience in teaching mental health law to medical students. We describe our own efforts to craft a joint teaching session on law and psychiatry, beginning with the historical background and previous problems, followed by a description of the teaching method we used, and finally summarizing our observations and conclusions. We suggest that the struggle to balance these competing concerns may be fruitfully addressed via an inter-disciplinary approach in education. There is some evidence that this approach does help to overcome bias between different disciplines,6 and this was borne out in our own experiences, documented below, as we found that students were more receptive to both the clinical and legal dimensions of psychiatric practice. Multiple perspectives can also provide a more complete picture of the individual's life situation and concerns, ideally helping us to avoid the pitfalls of a medical model that risks reducing human experience to a clinical diagnosis. Instead, both faculty members utilize a social model that resists rigid diagnostic categories and recognizes the multi-dimensional nature of any finding of mental illness, as resulting from a complex interaction of various social and environmental factors as well as internal psychological states.7

In the past, emergency psychiatry and mental health law were taught by law professors and psychiatrists separately at Queen's University; psychiatrists emphasized the importance of a comprehensive risk assessment and the necessity of involuntary admission to protect patients' safety, while law professors focused on the protection of individual rights and autonomy. Such an approach created the perception of a conflict between law and psychiatry, leading to confusion amongst medical students. Co-teaching of law and psychiatry has helped to clear the confusion and to some extent dispel perceived conflicts, therefore enabling medical students to provide effective and timely medical care within the legal confines of the Mental Health Act in emergency psychiatry. We have observed that the struggle to balance these competing concerns may be fruitfully addressed via an inter-disciplinary approach in education and teaching strategies. Our joint teaching session enabled us to demonstrate to students that law and medicine may be seen as interlocking pieces of the same puzzle, as law demarcates the legitimate boundaries for intervention and care. This in turn helped to clarify and to some extent remove perceived conflicts, as students were able to understand the role and limits of involuntary admission and were more confident in decision-making.