Chapter: Psychiatric Mental Health Nursing : Legal and Ethical Issues

Ethical Issues

Ethics is a branch of philosophy that deals with values of human conduct related to the rightness or wrongness of actions and to the goodness and badness of the motives and ends of such actions.



Ethics is a branch of philosophy that deals with values of human conduct related to the rightness or wrongness of actions and to the goodness and badness of the motives and ends of such actions (King, 1984). Ethical theories are sets of principles used to decide what is morally right or wrong.


Utilitarianism is a theory that bases decisions on “the greatest good for the greatest number.” Decisions based on utilitarianism consider which action would produce the greatest benefit for the most people. Deon-tology is a theory that says decisions should be based on whether or not an action is morally right with no regard for the result or consequences. Principles used as guides for decision-making in deontology include autonomy, beneficence, nonmaleficence, justice, verac-ity, and fidelity.


Autonomy refers to the person’s right to self-determination and independence. Beneficence refers to one’s duty to ben-efit or to promote good for others. Nonmaleficence is the requirement to do no harm to others either intentionally or unintentionally. Justice refers to fairness; that is, treat-ing all people fairly and equally without regard for social or economic status, race, sex, marital status, religion, eth-nicity, or cultural beliefs. Veracity is the duty to be honest or truthful. Fidelity refers to the obligation to honor com-mitments and contracts.


All these principles have meaning in health care. The nurse respects the client’s autonomy through patient’s rights, informed consent, and encouraging the client to make choices about his or her health care. The nurse has a duty to take actions that promote the client’s health (beneficence) and that do not harm the client (nonmaleficence). The nurse must treat all clients fairly (justice), be truthful and honest (veracity), and honor all duties and commitments to clients and families (fidelity).



Ethical Dilemmas in Mental Health


An ethical dilemma is a situation in which ethical principles conflict or when there is no one clear course of action in a given situation. For example, the client who refuses medica-tion or treatment is allowed to do so based on the principle of autonomy. If the client presents an imminent threat of danger to self or others, however, the principle of nonmalefi-cence (do no harm) is at risk. To protect the client or others from harm, the client may be involuntarily committed to a hospital, even though some may argue that this action vio-lates his or her right to autonomy. In this example, the utili-tarian theory of doing the greatest good for the greatest num-ber (involuntary commitment) overrides the individual client’s autonomy (right to refuse treatment). Ethical dilem-mas are often complicated and charged with emotion, mak-ing it difficult to arrive at fair or “right” decisions.


Many dilemmas in mental health involve the client’s right to self-determination and independence (autonomy) and concern for the “public good” (utilitarianism). Exam-ples include the following:


·    Once a client is stabilized on psychotropic medication, should the client be forced to remain on medication through the use of enforced depot injections or through outpatient commitment? Are psychotic clients necessarily incompetent, or do they still have the right to refuse hospitalization and medication?


·    Can consumers of mental health care truly be empow-ered if health-care professionals “step in” to make decisions for them “for their own good”?


·    Should physicians break confidentiality to report clients who drive cars at high speeds and recklessly?


·    Should a client who is loud and intrusive to other clients on a hospital unit be secluded from the others?


·    A health-care worker has an established relationship with a person who later becomes a client in the agency where the health-care worker practices. Can the health-care worker continue the relationship with the person who is now a client?


·    To protect the public, can clients with a history of vio-lence toward others be detained after their symptoms are stable?


·    When a therapeutic relationship has ended, can a health-care professional ever have a social or intimate relationship with someone he or she met as a client?


·    Is it possible to maintain strict professional boundaries (i.e., no previous, current, or future personal relation-ships with clients) in small communities and rural areas where all people in the community know one another?


The nurse will confront some of these dilemmas directly, and he or she will have to make decisions about a course of action. For example, the nurse may observe behavior between another health-care worker and a client thatseems flirtatious or inappropriate. Another dilemma might represent the policies or common practice of the agency where the nurse is employed; the nurse may have to decide whether he or she can support those practices or seek a position elsewhere. An example would be an agency that takes clients with a history of medication noncompliance only if they are scheduled for depot injections or remain on an outpatient commitment status. Yet other dilemmas are in the larger social arena; the nurse’s decision is whether to support current practice or to advocate for change on behalf of clients, such as laws permitting people to be detained after treatment is completed when there is a potential of future risk for violence.



Ethical Decision-Making


The ANA published a Code of Ethics for Nurses (2001) to guide choices about ethical actions. Models for ethical decision-making include gathering information, clarifying values, identifying options, identifying legal considerations and practical restraints, building consensus for the decision reached, and reviewing and analyzing the decision to determine what was learned (Abma & Widdershoven, 2006).


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