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Consequently, a duty of respect towards the incapable patient is imposed, which has to provide the necessary action as far as society is concerned in order to safeguard the incapable patient's integrity. In fact, all the theoreticians of the principle of "indirect voluntary act" which constitutes the theory of the double effect mixed actions with a possitive effect and other negative effect consider that it is necessary to fulfil four conditions: 1. When we speak about natural or de facto capacity of the patient with SMI, we refer to his or her aptitude to receive, understand or keep the relevant information about his or her clinical situation, with the possibility of making a choice among the possible options and their alternatives according to the personal system of values Coercion and pressure in psychiatry: lessons from Ulysses. The use of CTO and other forms of mandatory outpatient treatment has been controversial. The second group tend not to have any other defenders apart from the associations of mentally ill patients whose weight in the community is relative. It is implemented by a mental health facility that has developed an appropriate treatment plan for the individual person. JAMA ;

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    Possibly, its non implementation will entail the risk of causing avoidable harm to the patient, e. This prescription must ultimately be based on a bioethical exercise of responsibility by the psychiatrist, judiciously weighing up the classic principal prima facie duties which must necessarily be translated into a real duty referring to a specific patient and context.

    Mental capacity is the term used to describe the cluster of mental skills that people use in their everyday lives. O'Reilly R.

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    Psychiatry has a high ethical profile and in it, more than in other branches of medicine, both sciences and humanities converge. Legal security measures are to post-crime social dangerousness what the sentence by a court of law is to the punishment of a crime.

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    Principles of biomedical ethics.

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    Guardianship of people with mental disorders. The effectiveness and ethical justification of psychiatric outpatient commitment.

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    Dresser R. It sets out the terms under which a person must accept medication and therapy, counselling, management, rehabilitation and other services while living in the community. To cause harm is always wrong prima facie.

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    E., Wiley, E.O, Carpenter, K.E, López, J.A., et al. numerous on dorsal fin and anal fins, many of the spots merging; pale FAO names: En – Bigeye scad; Fr – Selar coulisou; Sp – Chicharro ojón.
    Justice Discussion on CTOs and deinstitutionalisation has occurred at the interface of ethical values and contexts in conflict There is, however, a clear clash of interests between the majority of patients with less severe mental disorders such as adjustment disorder and the minority with SMI such as schizophrenic disorder.

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    A retrospective examination of outpatient commitment in New York. The positive aim benefit for the patient by applying the treatment has to be simultaneous to the negative court coertion ; 2.

    The main negative criticisms to CTO centre around the fact that the evidence of efficacy is not conclusive, that it might tend to substitute integral community treatments for SMI, that it could become an exaggerated and generalized measure applied with too broad criteria and to patients who do not need it.

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    The decisions about giving and refusing consent to certain therapeutical interventions such as CTO are at the third level. There is also the risk of an excessive or extra-limited exercise of medical paternalism 25both of a positive and conservative type, which could lead to an unnecessary application of CTO.

    It is the duty of the State to exercise parens patriae in a fair and equitable way in accordance with certain economically feasible and effective public health options 8.

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    The influence of SMI on these behaviours may vary in intensity over time. A CTO seeks as its ultimate goal to both restore freedom to certain patients with SMI and enable the best possible integration and social interactions, and it is effective in some of these patients In no way should this be answered, since society has the right and duty to exercise democratic constructive pressures that seem appropriate to influence the legislator, and the State has the duty to implement appropriate and coherent criminal and civil policies.

    Chicharro-Merayo, Mar.

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    Aside from the obligation of not causing harm, it is perceptive not to subject the others to the unnecessary risk of suffering it.

    Regarding the Aristotelian principle of "composite actions" in two directions, in which the direction of the intended purpose prevails 30,33it is inferred that an action or intervention such as a CTO will be morally acceptable if there is proportionality between the negative consequences limitation of individual freedom, if only to restore it and the positive which is directly expected.

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    Summary A CTO is an extraordinary means of intervention, applicable only in the absence of less restrictive care alternatives and when the patient's self-governance is severely compromised, whether or not there is court-ordered incapacity to act. If we were referring to non-paternalistic beneficence, the free and informed consent of the patient would always be required; however, when this is not possible as it is the case with some patients with SMI, the moral imperative of promoting beneficent actions entails seeking the greatest good for the patient in all circumstances 26 such as, for example, by means of CTO.

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    Its welfare counterparts are the mental health courts, that is, the forced inpatient or outpatient treatment alternative to serving a sentence.

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    The first of these claim their right to be assisted by community mental health services satisfactorily in terms of time and manner, and have more weight as they are more numerous.

    Principles of biomedical ethics. Although the international regulation of CTOs is extremely irregular, it is broadly comprised of three different forms: as an alternative to involuntary admission, as a supplement or continuation of an involuntary admission, and as a preventive measure of involuntary admission.

    Moreover, the diagnosis of SMI itself is not free from bioethical problems 2. Both are totally applicable both to patients who are de facto incapable some SMI, although they are not incapacitated and those declared by law patients incapacitated by court order.

    2 Comments

    1. When prescribing a CTO, open communication between the clinician, the patient and the family or legal guardian is crucial. Both are totally applicable both to patients who are de facto incapable some SMI, although they are not incapacitated and those declared by law patients incapacitated by court order.

    2. This conflict, which is determined by the rules of professional authority 13inescapably obliges them from the factual normativism of principlism; and, from the complementary narrative perspective of virtue, this obligation is tied to the personal idea of practical wisdom, moral consciousness and experience, and the excellence in character of the responsible clinician who advocates the measure There is, however, a clear clash of interests between the majority of patients with less severe mental disorders such as adjustment disorder and the minority with SMI such as schizophrenic disorder.