The article is an Insight Paper on Mental Health, a lingering issue magnified by Covid-19 pandemic. Written for Health Ethics, MBA-H Ateneo Graduate School Business.

1. ADDRESSING MENTAL ILLNESS
FROM AN ETHICO-SOCIAL STANDPOINT
IN CURBING A FUTURE PANDEMIC
By
LILIA S. CHUA, MD
(MBEthics, AGSB, Term 2, SY2020-21)
Submitted in partial fulfillment of the requirements for
Business Ethics of the Ateneo Graduate School of Business
To
Prof. DENNIS O. TEMPORAL
June 02, 2021

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Mental health care is a big topic in the field of medicine that requires complex
strategy and high ethical standards to deal with. Concern for mental health issues
rise when stressful stimuli in the form of natural calamity, disaster, pandemic, or
psychosocial problems occur. The concept of mental health dates back in 1950
when the World Health Organization (WHO) first defined it as
A condition, subject to fluctuations due to biological and social factors, which
enables the individual to achieve a satisfactory synthesis of his own
potentially conflicting, instinctive drives; to form and maintain harmonious
relations with others; and to participate in constructive changes in his social
and physical environment. (Bertolote 2008)
The current definition of mental health by WHO is
A state of well-being in which every individual realizes his or her own
potential, can cope with the normal stresses of life, can work productively and
fruitfully, and is able to make a contribution to her or his community. (World
Health Organization 2019)
These definitions imply a functional capacity of a person to think, to become
productive, and to be able to adjust to his environment in a community. It is a state of
mind that allows a person to understand himself, to balance his inner conflicts, to be
in a healthy relationship with other people, and to engage in social activities
harmoniously. The state of mental well-being surmises that human behaviors and
actions are morally sound, following the ethical system of natural law to do good to
everyone (Donaldson 2002, 10-11).
The complexity of addressing the nursing care of persons with mental illness
comes with deep ethical balance between human right and autonomy against
coercive treatment and many more dilemmas. Deontological application of guidelines
set by international health organizations like the WHO is being adopted by member
countries like the Philippines. This paper calls for close monitoring on the
implementation of policy and management guidelines on mental health. By doing so,
there is hope of preventing the surge of mental illness to become the next pandemic.
The inevitable application of coercive treatment in extraordinary circumstances
aimed to stabilize a severely compromised mental patient must be based on strong
ethical rationalization.
Mental illness is a mental health condition that collectively encompasses the
diagnosis of mental disorders in a wide spectrum from neurological, substance

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disorder, anxiety, depression, attention-deficit hyper activity disorder (ADHD), post-
traumatic stress disorder (PTSD), bipolar behavior, to schizophrenia. A person’s way
of thinking, feeling, mood or behavior becomes a mental illness or interchangeably, a
mental disorder, when there is disruption in the functional capacity and in the ability
to relate to others. Numerous factors are involved in the development of mental
illness. Adverse childhood experience, substance abuse, genetic causes, long
standing medical conditions and social stressors are some of the risk factors (Center
for Disease Control ND). Mental disorders can be short in duration with lucid state, or
long standing and severe. The demographic distribution is global and heterogeneous
in age, gender and psychosocial status.
The Covid-19 global pandemic has tremendous impact psychologically,
socially and economically particularly in the poor-resource countries like the
Philippines. The first-ever experience of living in a condition of fear for a highly
infectious and fatal disease, shortage of food supplies, financial incapacity, grief and
stress from a disrupted life resulted in anxiety and depression of the majority. Sleep
disturbances, eating disorders, rising obesity came about as a result of the lock
down, sedentary life style and burn out. The limitation of access to health care,
delayed medical and mental treatment, loss of job, financial losses, absence of
human interaction and loss of loved ones are major trigger factors to the surge of
mental illness. Domestic violence, child abuse and traumatic stress resulted in
substantial increase in anxiety and depression. It is predicted that mental health is
likely to be the next pandemic (Rogers 2021, Brooks 2020).
There is significant rise in mental illness of those at risk and worsening of pre-
existing cases such that mental illness is tagged by the United Nations as a “Parallel
Pandemic” of Covid-19. Of particular interest is the deterioration of mental health
among the young population 18 to 19 years old (United Nation 2021).
On the socio-economic aspect, the millennials who are part of the working
class and the generation Z age groups comprise the future world leaders. The
pandemic greatly affects the psychosocial development of this generation. The
stages of moral development of a person as one grows to a mature adult can be
disrupted by emotional disturbances. Substance abuse, anxiety and depression
become the end points. Generation Z who are between 7 to 22 years of age during
the Covid pandemic are in the stage of learning the concept of relativity, respect for

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individualism, act of kindness, and social order in the society. The millennials who
are between 23 to 38 years of age, on the other hand, are in the last two stages of
moral development. Recognition of rights and logical thinking about democracy and
justice grow to a higher level. There is desire to work towards the good of the
society. Kohlberg relates the stages of moral development to cognitive function
coinciding with the level of education of a person. (Crain 1985, 3-6, 13-14)
Psychosocial dysfunction can impair one’s judgment and functional capacity.
Mental illness is gaining attention as a global issue that needs to be addressed.
Covid 19 pandemic has a tremendous impact on the relationship between mental
health, the workplace and productivity.
Depression is a silent illness that can just explode into suicide or homicide.
Mental illness is a serious and urgent social occurrence. Promotion, awareness,
early identification and intervention of psychological disturbances are important
measures to produce peace and harmony in the society. Behavioral patterns of
people are important factors in living around a safe environment where the four
pillars of ethical principles non-maleficence, beneficence, autonomy and justice are
voluntarily practiced (Heston 2019).
Mental health issues have serious repercussions in the family as well as the
society. It is a social problem! A study done in 2017 by Our World in Data estimates
that 792 million people lived with a form of mental disorder comprising 10.7% of
world population (Ritchie 2018).
WHO data further show that people with mental disorders suffer from 1 year
of disability for every 5 years of life. The productivity loss from mental incapacity
accounts for more than US$ 1 trillion per year in economic losses. More than 80% of
people with mental disorders are without any form of treatment due to the stigma and
financial barriers in seeking professional help. Suicide mortality is close to 800,000
deaths per year with tendency to affect young people and elderly women who have
experienced violence, and other humanitarian crises (World Health Organization
2019).
WHO acknowledges that poor mental health condition can have a negative
outcome on a person’s health. It can lead to premature deaths, human rights

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violations, national and economic loss. Mental health is incorporated in the
Sustainable Developmental Goals of WHO. The WHO Special Initiative for Mental
Health (2019-2023): Universal Coverage for Mental Health was launched in 2018
with a vision that all people achieve the highest standard of mental health and well-
being through Universal Health Coverage. The Philippines is included in the first 6
out of the 12 priority countries along with Bangladesh, Jordan, Paraguay, Ukraine
and Zimbabwe where the program will be implemented. WHO recognizes the
weakness of the Philippine health system and the need for international support to
provide quality and affordable mental health care program. An investment case
mission was jointly conducted by the WHO and the United Nations Development
Programme (UNDP) in February 2020. The culminating objective of the mission is to
work towards a mental health system reform by outlining the Philippines’ financial
and social burdens in mental health conditions; and by identifying the benefits and
cost-effectiveness for policy packages (“best buys”). In response to the WHO
Special Initiative for Mental Health, the Philippines is working towards policy
development to scale up affordable and quality care and to reform the existing
traditional mental health care. The WHO thrust is to shift from the long-stay
institutionalized facilities to community-based mental health care. (World Health
Organization 2019)
The Philippines as a developing country lags behind in prioritizing service
delivery in mental health. Based on the WHO Mental Atlas Country Profile, the total
mental health expenditure per person is Php12.19 which is equivalent to 0.22% of
the government’s total health expenditure. Majority of mental health services are
paid out of pocket by the service users. Mental health data reporting is compiled
together with the general health statistics instead of specific mental health report.
Accurate statistical report on the Philippine mental health status is not available.
There is shortage of workforce in adult and child psychiatrists, psychologists,
therapists, mental health nurses and social workers. Mental health policies are in
place but without specified indicators or targets to monitor its implementation. (World
Health Organization 2019)
The Philippine Mental Health Act was signed into law in 2018. The act aligns
with the vision of the WHO and the establishment of community-based mental health
care facilities (Department of Health 2018).

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The approach in addressing mental health care is a source of many
arguments and ethical dilemmas. Questions arise how the patients can best be
managed - observe respect for patient autonomy and rights, or control and
legitimacy of coercive treatment; conventional institutional confinement, or
community-based mental facilities. Crucial moments in psychiatric emergencies
frequently require paternalistic action by mental health care professionals. The
patient shows temporary or prolonged absence of intellectual capacity for moral
reasoning. Involuntary hospitalization, coercive treatment, restraints, and seclusion
require strong ethical deliberation for the protection of both the patient and the health
service provider. (Ventura et al. 2020)
Ethical dilemmas in the delivery of mental health care have no structured
resolutions that can be followed. Oftentimes ethical decisions are based on the best
interest of the patient and the safety of people around. The rice cooker casserole
(Appendix, Figure 1) was used by J.D., a 62 y/o male bipolar patient, to repeatedly
hit the television while in a quarantine facility in Angeles, Pampanga in April 2020.
He was in a state of delusional psychosis. He perceived that the dog in the movie
was coming out to bite him. (Dungca 2021)
According to Kant, autonomy as a fundamental ethical principle is a right and
a responsibility guided by reason. Individuals have responsibility by capacity of
reason to know what is morally expected of them. People cannot be questioned for
personal perceptions or beliefs but JD’s delusional behavior was outside reality and
showed compromised reasoning. Autonomy and decision-making can be revoked
from JD. Paternalism supports the utilitarian principle of control over decision-making
and behavior of mentally ill patients to benefit more people at stake. (Gray 2010, 84-
85)
The United States has been practicing deinstitutionalized care or community-
based mental health care for decades. Medical Ethics professor Dominic Sisti
believes that high quality and ethically administered psychiatric asylums are
necessary comprehensive part of treatment to stabilize and provide short term
recovery for the seriously ill mental patients. Social Psychiatry professor Tom Burns
believes that highly trained case managers like nurses and social workers within a
multidisciplinary team are crucial in providing a decent community care for long term

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recovery of patients. A seamless continuum in mental health treatment from
outpatient care, to supportive community facility, to in-patient care is necessary to
prevent relapse and achieve successful treatment of mental patients. Lack of budget
from the health care system, few psychiatric professionals to deliver care, and costly
mental health care are major obstacles to provide effective and affordable treatment
in a community setting. (The New York Times 2016)
The challenges for mental health care delivery are magnified by Covid 19
pandemic. Up scaling the method of delivery care through remote community-based
therapy is necessary adaptation to the new approach while focusing on infection
control. Telehealth consult can be done for monitoring and case follow-up. It will
ensure continuous medication and psychotherapy of patients. This tool should be
made available for both private and public services. Home-based therapy can be
successful through a supportive family and community stakeholders. (Moreno 2020)
Resistant and unmanageable patients at the community level of care pose
ethical challenges in containing the spread of Covid infection. Psychoeducation and
psychological training will equip care givers in instances where the patient lacks the
reasoning capacity. Architectural set up of facilities should provide space for social
distancing. (Russ 2020)
Many Filipino families have been fragmented for economic reasons.
Exchange in the role of the head of the family which goes either to the father, the
mother or sometimes the adult children is a common scenario. The bread winner is
often forced to seek greener pasture abroad. Brain drain of health care professionals
in the Philippines is phenomenal. The society is confused with the flow of state
governance in the way the pandemic and other urgent matters are dealt with. The
problems of family fragmentation and divided leadership of the state can be
obstacles to the success of community-based metal health care.
Deontology, utilitarian, consequentialist, paternalist ethical approaches in
mental health care are virtues-based. The principle of double effect in coercive
treatment of mental patients aims to achieve an overall beneficence despite
unintentional harm on the patient (Silva 2017). Stablishing the recommendations for
psychiatric care should aim towards delivery of psychiatric care that provides cost

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effective, quality and affordable treatment at the same time equitable for all service
users. The uniqueness of each mental case requires the individualized assessment
by the psychiatrists. The ethical review board must possess high level of integrity
and prudence in decision making.
Nursing care for the mentally challenged individuals is a complex process that
calls for intense consideration for the 4 ethical principles of autonomy, maleficence,
beneficence and justice. Decision making in special situations beyond the policy or
treatment protocol may arise. Different ethical systems should be balanced in
achieving the best outcome.
Human nature to seek for ethos in life has great influence on societal
behavioral patterns. Moral obligations and social responsibilities are focused on
wealth maximization through industrialization, neoliberal capitalism and free market.
Fragmentation of the family, commercialization and mental health conditions in the
twenty first century may well be taken as part the unforeseen long term outcome of
the Friedman Doctrine. Friedman was successful in scaling up the poor way of life
five decades ago by focusing on the shareholders’ interest rather than the
stakeholders’ benefit (Friedman 1970). The burden of financial capacity can be
challenging, frustrating and depressing.
Private mental health services are known to be costly and unaffordable for low
and middle income population which comprise majority of the cases. Government
support and funding from the national budget are much needed to curb a future
pandemic of mental illness. Compassionate care of the mentally ill cannot be left
alone to individual and voluntary submission for treatment. It requires a
comprehensive approach involving the stakeholders in the society, the government,
supportive public and private institutions, team of psychiatric health professionals,
and trained community care givers and family.
In summary, mental illness is a pressing social problem. The ethical
standpoints in addressing mental health disorders which is foreseen as a future
pandemic include conscientious decision-making in handling patients, judicious
policy implementation guided by distributive justice and outcome monitoring, and
financial accountability of the state under good governance and leadership.

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Seven: Kohlberg’s Stages Of Moral Development.
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2021.” CNN (Jan 5, 2021).

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_______ “WHO urges more investments, services for mental health.” (2019).
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_______ WHO Mental Health Atlas 2017 Country Profile.
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APPENDIX
Table 1. WHO Mental Health Atlas-2017 country profiles

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Figure 1. Photograph of casserole that JD used to hit a television in a quarantine
facility.