Further, although PAD instruments should not ‘replace deliberation about possible future changes in the patients’ condition’ ( Widdershoven & Berghmans 2001 : 93), they are nonetheless seen as having an important role to play in eliciting and guiding communication about such matters (see also Spellecy 2003 ). 3 Basic rights Fundamental Legislation. This is so even in jurisdictions which have progressive legislative provisions enabling patients to determine in advance their ‘will and preferences’ apropos care, treatment and supported decision-making options ( Callaghan & Ryan 2016 ; Hem et al 2018 ; Molodynski et al 2014 ; Tingleff et al 2017 ). Progress has been slow, however. The psychiatrist’s judgment was revoked a few days later, however, when John McEwan ‘agreed to end his hunger strike and accept a course of antidepressants’ (p 2). First published in 1991, with a 2012 revised edition of the statement launched in early 2013, this document stands as an influential guide for other public policy initiatives and statements such as the National mental health policy (released in 2008 and committed to by all Australian governments), and successive national mental health plans (including the most recent Fifth national mental health and suicide prevention plan released in 2017 , the National standards for mental health services 2010 and the National carer strategy in 2011 ( Australian Government Department of Health 2010 , 2011 , 2017 ) and other documents (e.g. For example, contrary to popular medical opinion, there is nothing to suggest that a person’s decision to suicide is always the product of mental disease or depression. Victoria), patient preferences can still be overridden under defined circumstances ( Callaghan & Ryan 2016 ; Maylea & Ryan 2017 ). In mental health nursing, autonomy is sometimes overridden in the interests of promoting the principle of beneficence (Lakeman 2009). they help to remind all stakeholders (patients / consumers, service providers, caregivers and the community at large) that their relationships with each other are ethically constrained and are bound by certain correlative duties. An instructive example of this can be found in the much-publicised Australian case of John McEwan that occurred in the mid 1980s and which sparked an unprecedented public inquiry into the so-called ‘right to die with dignity’ ( Social Development Committee 1987 ). This paradigm shift in mental health is challenging traditional evaluation criteria and conventional justifications for involuntary treatment. Consider, for example, the following case (personal communication). during a moment of restored competency to decide) that the fiduciary nature of the professional–client relationship has been violated. In an early work on the subject, Roth and colleagues (1977) argue, however, that the concept of competency is not merely a psychiatric or medical concept, as some might assume, but is also fundamentally social and legal in nature. integrations of care through health providers working in partnership with clients and families. It should be noted that competency is a key issue not just in psychiatric care, but in any health care context where judgments of competency are critical to deciding: (1) whether a patient can or should decide and / or be permitted to decide for herself or himself, and (2) the point at which another or others will need to or should decide for the patient – that is, become what Buchanan and Brock (1989) term surrogate decision-makers and what is variously referred to in Australian jurisdictions as involving ‘substitute decision-making’ and ‘supported decision-making’, with the latter placing the person who is being supported ‘at the front of the decision-making process’ ( Australian Law Reform Commission (ALRC) 2014 : 51). The more experienced staff members in this case insist that the patient should be given his medication forcibly by intramuscular injection. instruments provided for by this legislation can only be used to refuse rather than to give consent to treatment) ( Meredith 2005 : 9; Swartz et al 2006 ). Mental health nurses face ethically‐difficult situations when administering these medications. Also, in another incident shortly before his death, he talked openly with his general practitioner about ‘hiring someone to blow his [John McEwan’s] brains out or kill him as he felt his wish to die was being frustrated’ ( Social Development Committee 1987 : 316). They go on to warn that there is no magical definition of competency, and that the problems posed by so-called ‘incompetent’ persons are very often problems of personal prejudices and social biases, or of other difficulties associated with trying to find the ‘right’ words. Nonetheless PADs have been touted as having the capacity to realise a number of benefits including: ‘decrease hospitalizations, reduce coercion in treatment, and improve relationships between consumers, families and clinicians’ ( Peto et al 2004 ; Sellars et al 2017 ; Zelle et al 2015a ), and destigmatising patients with mental illness on account of giving them the same rights to refuse psychiatric treatment as patients who wish to refuse general medical treatment ( Atkinson et al 2004 ). A number of objections can be raised here. Brisbane: Wiley. https://nursekey.com/ethical-issues-in-mental-health-care-2 These and like criteria remain problematic, however. The moral force of the right’s claim in this instance is such that if an attending health care professional does not uphold or violates the patient’s decision in regard to the treatment options considered, that patient would probably feel wronged or that an injustice had been done. At one point, desperate to achieve his wish, he went on a hunger strike and instructed his solicitor to draw up a ‘living will’, which stated ‘that he did not wish to be revived if and when he fell into a coma’ ( Bioethics News 1985 : 2). With regard to setting and applying accurately standards of competency to choose and decide, Buchanan and Brock suggest that, among other things, ethical professional decision-making in this problematic area should be guided by the following considerations (1989: 85): In other words, the extent to which an attending health care professional is bound morally to respect the choices of a person deemed ‘rationally incompetent’ depends primarily on the severity of the risks involved to the patient if her or his choices are permitted. For mental health nurses having the power to control and being expected to control people diagnosed with a mental disorder can be morally distressing, especially where situations do not always have clear outcomes. The test of reasonable outcome of choice is again as it sounds, and focuses on the outcome of a given choice, as opposed to the mere presence or absence of a choice. Canadian Psychological Association Ethics Code. As noted earlier, SDM places the person who is being supported at the front of the decision-making process ( ALRC 2014 ). The objective test here is similar to that employed in law, and involves asking the question: ‘What would a reasonable person in like circumstances consider to be a reasonable outcome?’ The reliability of this measure is, of course, open to serious question – as might be objected, what one person might accept as reasonable another might equally reject. A New Zealand survey of 110 mental health service users and 175 clinicians had similar findings ( Thom et al 2015 ). 1 2 Essential … For people using health services For the health professional For healthcare organisations For communities. As Dresser (1982 : 842) cautioned over three decades ago, if insufficiently informed persons enter into commitment contracts ‘only to please their psychiatrists, the contracts would become an avenue for the abuse of psychiatric paternalism, thus decreasing individual liberty’. Underpinning this caveat is the reality that in most jurisdictions around the world there are legislative provisions that enable people with severe mental health illness to be detained, restrained, coerced and / or treated without their consent . Determining whether a person has the competency to make an informed decision about whether to accept or reject a recommended treatment is not a straightforward matter, however. This can sometimes mean that, rather than providing a ‘psychiatric sanctuary’, an involuntary admission to a psychiatric facility may sometimes be experienced as a ‘psychiatric sentencing’ – akin to a penal incarceration. Lurch et al (2010) cites Florence nightingales (1859) nursing notes, where she discusses ethical duties of confidentiality, communication, and the centrality of meeting patients’ needs, this reflects the same moral and ethical issues nursing professionals face today. Arguably the most profound change (described as an ‘evolving revolution’ by Callaghan and Ryan 2016 ) has occurred in Australian jurisdictions. the capacity to communicate the decision made (after Kerridge et al 2013 : 384–6). ECT), or ‘opting-in’ (consenting to services as well as to specific treatments) ( Atkinson et al 2003 ; Swartz et al 2006 ). We have benefited from teaching by renowned academics with insight into the historical development of the law and its social and international context. Throughout his hospitalisation, he repeatedly asked to be allowed to die. discuss critically the possible risks and benefits of psychiatric advance directives. Mental health nurses seem to have difficulty engaging with the ethical issues in mental health, and generally are dealing with acts of paternalism and with the common justification for those acts. Since then a substantive paradigm shift has occurred, which has seen PADs incorporated into mental health legislation in the Australian Capital Territory (2015), Queensland (2016), Victoria (2014) and Western Australia (2014), with the Australian Capital Territory legislation regarded by commentators as the most progressive (see comparative table in Ouliaris & Kealy-Bateman 2017 : 576). The inability to get ‘quick determinations’ of illness and competency – and hence healing treatment – has also been identified as a risk that could serve ultimately to undermine the effectiveness of PADs ( Cuca 1993 : 1178; see also Nicaise et al 2013 ). Here objections can be raised concerning just how sophisticated a patient’s understanding needs to be. Some studies have suggested that, overall, clinicians are broadly supportive of the ‘advance-consent’ function of PADs (termed ‘prescriptive function’); however, clinicians are more reticent about their ‘advanced-refusal’ function (termed ‘proscriptive function’) – especially if used to refuse all future treatment ( Swartz et al 2006 ). Also of critical concern is finding a competency test which is comprehensive enough to deal with diverse situations, which can be applied reliably and which is mutually acceptable to health care professionals, lawyers, judges and the community at large. nurses caring for their own mental health), evaluation and research, legal and ethical issues (including understanding the rights of people with mental disorders), management of emergencies (e.g. Moreover, despite the efforts of mental health consumer groups and other mental health advocates, people with mental health problems and psychosocial disabilities continue to experience the infringement of many of their basic human rights (including the right to mental health and to mental health care). Underpinning this search has been the commensurate pressing need to find a balance between promoting autonomy and preventing harm and, equally important, finding a way to advance a genuine ‘ “supported decision-making” model in which a person makes treatment decisions for themselves, with support where required’ ( Ouliaris & Kealy-Bateman 2017 : 574). Only a few countries (e.g. irrevocability during a crisis (also known as a ‘Ulysses contract’ – see below) ( Swartz et al 2006 : 67). In defence of his refusal, the patient argues ‘reasonably’ that the adverse side effects of the drugs he is being expected to take are intolerable, and that he would prefer the pain of his mental illness to the intolerable side effects of the drugs that have been prescribed to treat his mental illness. Which can make the nurses ethical dilemma difficult to manage due to balancing the two valid ethical principles of autonomy (respecting and supporting decisions making) and beneficence (relieving or minimising harm in the best interest of the patient) (Hendrick 2004, … While Buchanan and Brock’s (1989) ‘sliding scale’ framework is useful, it is not free of difficulties. An important question to arise here is: ‘If statements on mental health rights and responsibilities fall short of providing clear-cut guidance in cases of this nature, is there any point in having them?’ The short answer to this question is, yes. Like Gert and colleagues (1997) , cited earlier, they argue that statements of competence (i.e. Whatever the faults, weaknesses and difficulties of such statements, they nevertheless achieve a number of important things; like bills and charters of patient rights generally, they help to remind mental health patients / consumers, service providers, caregivers and the general community that people with mental health problems (including mental illnesses and mental health problems) have special moral interests and entitlements that ought to be respected and protected, they help to inform stakeholders (patients / consumers, service providers, caregivers and the community) of what these special entitlements are and thereby provide a basis upon which respect for and protection of these can be required, they help to delineate the special responsibilities that stakeholders (patients / consumers, service providers, caregivers and the community) all have in ensuring the promotion and protection of people’s moral interests and entitlements in mental health care and in promoting mental health generally. instructions to follow at the beginning of a crisis ( Nicaise et al 2013 : 10). Roth and colleagues (1977) suggest that competency tests proposed in the literature basically fall into five categories: The test of evidencing a choice is as it sounds, and is concerned only with whether a patient’s choice is ‘evident’; that is, whether it is present or absent . In regard to the consideration of being a danger to self, Buchanan and Brock (1989 : 317–31) correctly argue that what is needed are stringent criteria of what constitutes a danger to self ; in the case of the need for care and treatment, that what is needed are stringent criteria for ascertaining deterioration and distress ; and in the case of harm to others, that what is needed are stringent criteria of what constitutes a danger to others . The Code of Ethics articulates ethical principles, values and standards to guide all members of the psychiatric nursing profession. They make the additional value judgment that it would be ‘better’ for the patient if his psychiatric condition were prevented from deteriorating, and that their decision to administer his prescribed medication forcibly against his will is justified on these grounds. The rights and responsibilities of people who seek assessment, support, care, treatment, rehabilitation and recovery – encompassing the right of people (including children) to ‘participate in all decisions that affect them, to receive high-quality services, to receive appropriate treatment, including appropriate treatment for physical or general health needs, and to benefit from special safeguards if involuntary assessment, treatment or rehabilitation is imposed’ (p 12). According to the American Nurses Association (ANA), the nursing code of ethics is a guide for “carrying out nursing responsibilities in a manner consistent with quality in nursing care and the ethical obligations of the profession.”Ethics, in general, are the moral principles that dictate how a person will conduct themselves. Significantly the issue of competency rarely arises in contexts where the patient agrees with and consents to a doctor’s recommended or prescribed treatment. This is because there is no substantial agreement on the characteristics of a ‘competent person’ or on how ‘competency’ should be measured. The emphasis of contemporary mental health nursing practice is to be evidence-based and to be ethical, which includes abiding by the nursing profession’s ethical rules (Smith 2012; NMC 2015). Explore ways in which the nursing profession might improve its advocacy of people with mental health problems and severe mental illnesses. Also, although applying the criteria developed may inevitably result in a health care professional assuming the essentially paternalistic role of being a surrogate decision-maker for a given patient, this need not be problematic provided the model of surrogate decision-making used is patient centred – that is, committed to upholding the patient’s interests and concerns insofar as these can be ascertained. injuries sustained as a result of a road traffic accident, an acute appendicitis, complications of diabetes, renal failure, etc.). Findings: The results indicated that nurses needed additional education in psychiatric ethics. Ethical dilemmas in community mental health care is the focus of this article. In either case, timely and effective psychiatric treatment and care are imperative. Of those who reported they did not support PADs, the key rationale was concern for the ‘clinical profile of the patient and the professional imperative regarding the psychiatrist’s duty of care’ ( Sellars et al 2017 : 70). Enforced treatments in such cases may, however, compound their distress and make future treatment difficult, especially if the patient later feels (i.e. This is so despite what Callaghan and Ryan (2016 : 601) describe as a ‘revolutionary paradigm shift’ that is occurring as a result of Article 12 of the UN Convention of the Rights of Persons with Disabilities (CRPD) 1 ‘objecting to the automatic use of substituted decision-making whenever a person fails to meet a functional test of decision-making capacity’. Given the emphasis on interpersonal process within PMH nursing practice and changing cultural mores, the ANA Joint Task Force broadened the focus and elaborated in depth on ethical issues involved in PMH nursing practice (ANA, 2014). As Gibson (1976) pointed out in an early article on the subject, rationality cannot escape the influences of the social patterns and institutions around it and, for this reason, any value-neutral account of rationality is quite inadequate. Gillon (2003) stated: ‘A set of universal moral norms – even merely prima facie moral norms – that can be interculturally and internationally accepted is surely to be celebrated in a world where the possibility of such agreement is too often contemptuously … However, if these practices are used in an unethical way mental health nurses … Email: [email protected] Search … Depending on the legal regulations governing a given PAD, a directive can contain provisions for either ‘opting-out’ (refusing) treatment (both general and specific – e.g. achieving a balance between (i) protecting and promoting the patients’ wellbeing (human welfare), (ii) protecting and promoting the patients’ entitlement to and interest in exercising self-determining choices, and (iii) protecting others who could be harmed by patients exercising harm-causing choices. The Code of Ethics identifies … Insufficient personnel, excessive workload, working conditions, lack of supervision, and in-service training were identified as leading to unethical behaviors. Despite the expectations reflected in the stated purposes and theoretical frameworks of PADs, their overall acceptance and uptake remain patchy. The claim of a moral right usually entails that another person has a corresponding duty to respect that right. They argue in defence of this decision that the patient’s condition is deteriorating rapidly, and that if he does not receive the medication prescribed he will ‘spiral down into a psychiatric crisis’ (in other words a total exacerbation of his condition), which would be even more intolerable and harmful than the unpleasant side effects he has been experiencing as a result of taking the psychotropic drugs in question. For instance, there remains the problem of how to determine what is a harm, what is a low / minimal and high / maximal risk of harm, and who properly should decide these things – the answers to which involve complex value judgments. Mental Health Care: An introduction for health professionals, 3rd Edition. Just what these criteria should be, however, and how they should be applied, is an extremely complex matter, and one that requires much greater attention than it is possible to give here. Roth and colleagues (1977 : 282), for example, cite the case of a 49-year-old psychiatric patient who was informed that there was a one-in-three-thousand chance of dying from ECT. Ethical discourse about mental health treatment has typically focused on paradigmatic concepts of individual autonomy, competence, paternalism, and appropriate justifications for overriding individual decision-making and restricting individual liberty. A patient-centred model of surrogate decision-making, in this instance, would have as its rationale preventing harm to patients , and would embrace an ethical framework which is structured ‘for deciding for patients for their benefit ’ ( Buchanan & Brock 1989 : 327, 331). It should be noted, however, that these two models are not necessarily mutually exclusive and indeed could, in some instances, be mutually supporting (a man contemplating a violent suicide involving others is a danger not only to himself but also to the innocent others he plans to ‘take with him’). In relation to these criteria, he goes on to clarify that the patient’s task in consent situations is to: clearly indicate their preferred treatment options; grasp the fundamental meaning of the information being communicated by their attending doctor (apropos the nature of patient’s condition, nature and purpose of proposed treatment, possible benefits and risks of that treatment, and alternative approaches (including no treatment) and their benefits and risks); acknowledge (have insight into) their medical condition and likely consequences of the treatment option available (noting that ‘delusions or pathologic levels of distortion or denial are the most common causes of impairment’); engage in a rational process of manipulating [sic] the relevant information (this criterion focuses on the process by which a decision is reached, not the outcome of the patient’s choice, since patients have the right to make ‘unreasonable’ choices). Specifically, an approach is required that places strong emphasis on consolidating the mental health interests of those who have or who are at risk of developing mental illnesses and which also emphasises the ‘special’ responsibilities that health care providers have towards this vulnerable group. In the case of suicide risk, the grounds for not honouring a patient’s decision do seem at least prima facie stronger than possible grounds for overriding the decision of a patient who is only moderately depressed. Of these four functions, the Ulysses contract is arguably the most reflective of the moral justification of PADs. Although ‘gold standard’ evidence is lacking, the authors of a 2009 Cochrane Database Systematic Review on ‘Advance treatment directives for people with severe mental illness’ nonetheless concluded that advance directives were ‘well suited to the mental health setting for the purpose of conveying patients’ treatment preferences should they become unable to articulate them in the future’ ( Campbell & Kisely 2009 : 10). People with mental illness tend to be warmer to nurses … Basically, it asks whether a given choice is the product of ‘mental illness’ or whether it is the product of prudent and critically reflective deliberation. There was no reason to suspect that John McEwan’s wishes were irrational. Coercive measures commonly used in mental health care contexts have been classified as basically involving four types: ‘seclusion, mechanical constraint, physical restraint / holding, and forced medication’ ( Krieger et al 2018 ; Tingleff et al 2017 ); these can be imposed in either institutional or community health care settings (e.g. The higher and more severe the risks involved, the higher and more rigorous should be the standards for determining the patient’s decision-making capacity, and the more certain attending health care professionals should be that the patient has met these standards. Rights and responsibilities of people who provide services – encompassing rights and responsibilities in regards to upholding the highest possible standards of mental health care, including the development and implementation of social, health and mental health policy and service delivery policies and guidelines. For example, an elderly demented resident may be deemed competent to eat his / her evening meal alone, but deemed not competent to refuse treatment – for example, surgery for a fractured hip. For example, if a patient with severe mental illness decides to refuse hospitalisation, the extent to which an attending health professional is obliged morally to respect this decision will depend on how severe the risks to the patient are of not being hospitalised – for instance, whether a failure to hospitalise the patient will result in her or him suiciding, or will result only in her or him being left in a state of moderate, although not life-threatening, depression. The fifth and final competency test is that of actual understanding . First, as discussed previously in Chapter 6 , people with mental illness are among the most stigmatised, discriminated against, marginalised, disadvantaged and hence vulnerable individuals in the world. In such instances, because of the psychiatric imperatives to treat their conditions (particularly if extremely distressed and ‘out of control’), the mentally ill are vulnerable to having medical treatments paternalistically imposed on them against their will. Earlier in this chapter, under the discussion of competency to decide, the case was given of an involuntary psychiatric patient who was held down and given an intramuscular injection of psychotropic medication against his will (see pp 213–14 ). Historically the critical issue in developing tests of competency is how to strike a contented balance between serving a rationally incompetent person’s autonomy and also serving that person’s health care, nursing care and medical treatment needs . The question remains, however, of how these things can be decided in a morally sound and just way. The enactment of formal legislation regulating PADs has a protracted history dating back to the USA, which has the longest history of their use, with Minnesota in 1991 becoming the first American state to enact legislation giving recognition to the ‘advance psychiatric directive’ allowing its citizens to ‘draft directives for intrusive mental health treatments’ ( Cuca 1993 : 1165). On closer examination, however, the practical guidance that this statement can offer is also limited – like other codes and statements, they cannot tell people what to do in particular cases . do NOTrepresent obligations and should NOTform the basis for imposing sanctions. In summary, the notion of ‘rational competency’ is problematic because there is no precise definition of, or agreement on, what it is. Background: Ethical challenges are common in clinical nursing practice, and an infectious environment could put nurses under ethical challenges more easily, which may cause nurses to submit to negative emotions and psychological pressure, damaging their mental health. However, in compliance with the provisions contained in the CRPD, there is now recognition that ‘persons with disabilities enjoy legal status on an equal basis with others in all aspects’ and that this requires recognition that competent persons, at least, have the right to refuse psychiatric treatment ( Maylea & Ryan 2017 : 88). On the basis of educated skill and past experience, the health professional is usually able to ascertain the level at which the patient has understood the information received and what data gaps or misunderstandings remain. Ethics in Mental Health examines some of the most common ethical issues and dilemmas involved in providing mental health services, on both an individual and societal level. To put this more simply, PADs stand to serve the basic functions of: prescription (advance consent to treatment options), proscription (advance refusal or rejection of treatment options), surrogate decision-maker designation 4 (identification and advance nomination of substitute decision-makers). Since first being proposed in the early 1980s, PADs have evolved and tend to take one or both of the following two forms, notably: an instructional directive ‘that provides specific information about a patient’s treatment preferences’. The need to do this becomes even more acute when the problem of determining and weighing harms is considered in relation to the broader demand to achieve a balance between protecting and promoting the patient’s wellbeing, protecting and promoting the patient’s autonomy, and protecting others who could be harmed if a mentally ill person is left free to exercise harm-causing choices (as happened in the Tarasoff case, considered in Chapter 7 ).
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