Case Study

Case Study #2
The patient is a 27-year-old man who has severe schizophrenic illness and type-I
diabetes. Before treatment in your secure treatment unit, he was treated
successively in different settings with good success. He had been brought to your
secure treatment unit after a near-fatal assault on a patient in another hospital.
His stay has been characterised by periods of relative health alternating with
periods of withdrawal and aggression, at which time he would become very
depressed. During these periods, he talks about hearing “voices” which he claims
were the reason he attacked others physically, including staff, in the past.
He also refuses to accept his insulin during periods of depression but agrees to
his schizophrenia medication; this is appropriately managing the illness, despite
the periods of withdrawal and aggression. The only treatment that helps him to
recover to some degree from his depressive episodes is electroconvulsive
therapy (ECT), even though he had once expressed his wish to not receive it
when he was capable. Although he has been found incapable of consenting to
treatment during depressive episodes, he refuses ECT each time it is presented,
and he has to be forcibly restrained while his insulin is administered.
The staff find it distressing to have to forcibly restrain the patient so often, and to
inject him with insulin against his will. They feel that restraining him
compromises their caring relationship with him. Also, they feel uncomfortable in
having to inject him with insulin, which he needs for his type-I diabetes, since he
is adamantly refusing. Unfortunately, this is the only way to keep him from
ketoacidosis until he recovers from his depression after a few weeks of ECT.

What are some of the ethical issues in this case?
• Which of the treatments (if not all) should/should not be administered?
• When capable, what did the patient refuse exactly? What did his refusal
mean?
• What documentation is available?

•Do prior expressed capable wishes apply only to somatic disease or do

they also apply to mental health conditions?

• Does the patient have the right to refuse psychiatric intervention in prior
expressed wishes from a mental health point of view? If so, what if he
becomes violent?
• Would this only apply to mental health patients with periods of stability?
What if the patient became permanently incapable?
• What alternatives are available to this patient (to the ECT) and were these
provided to him as options when capable and deciding?

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