ethical dilemmas in mental health


For the last month, you have been working on ... › Url: Go Now. The following are several common ethical dilemmas that nurses face while on the job. 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. 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. Alternatively, a depressed and so-called ‘irrational’ person might refuse a particular psychiatric treatment, such as psychotropic drugs, electroconvulsive therapy or psychosurgery, out of a very ‘rational’ and well-founded fear of what undesirable effects these treatments might ultimately have. Ten facts on mental health: fact 2. The claim of a moral right usually entails that another person has a corresponding duty to respect that right. 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. This prompted the general practitioner who was medically responsible for him to inform the senior nursing assistant that: During one incident, while at home, John McEwan was observed to be angry at having been reconnected to the ventilator against his wishes. › Url: Go Now, Health Details: Hale, B. The dilemmas are derived from a discussion of the results of a qualitative research project that took place in five countries of the European Union. For example, in Australian jurisdictions, ascertaining whether a patient has the capacity to make informed decisions requires that the following processes be examined and shown: the comprehension and retention of information about the treatment, the capacity to formulate a reasonable belief about the information that has been given, the capacity to weigh up that information in the balance so as to arrive at a prudent choice. 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. But what are PADs, and are they capable of achieving the outcomes that their proponents anticipate and expect? Self-determination, personal responsibility, empowerment, and self-advocacy are expected outcomes of WRAP. Ethical dilemmas in community mental health care is the focus of this article. Ethical Dilemmas in Mental Health Nursing | Healthfully. The promotion of mental health and the prevention of mental illness – encompassing the responsibilities of governments and health service providers to: promote mental health; support, develop, implement and evaluate programs for preventing mental health problems and illnesses; support the ongoing development of comprehensive, flexible, integrated, and accessible community, primary health and hospital-based social support, health and mental health services. In many instances, people with serious mental illnesses might not comply with, and might even refuse altogether to accept, recommended psychiatric treatment (e.g. 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. It teases out the ethical challenges that mental health nurses can face on a daily basis. This is especially likely in cases where involuntary or non-voluntary hospitalisation involves unconsented, coercive institutional procedures such as seclusion, restraints, forced medication and forced feeding ( Borckardt et al 2007 ; Cusack et al 2018 ). 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 ). Also, although some studies have suggested that clinicians are broadly supportive of the ‘advance-consent’ function of PADs (termed ‘prescriptive function’), clinicians are more reticent about their ‘advance-refusal’ function (termed ‘proscriptive function’) – especially if used to refuse all future treatment ( Swartz et al 2006 ). Published. In seeking to redress the implications of these considerations, mental health advocates have increasingly sought to emphasise and champion a suite of rights and responsibilities that are specific to the context of mental health care. 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. Health Details: One way to improve our ethics is to example arguments on both sides of common ethical dilemmas.. Health Details: Ethical issues in counseling generally fall on the therapist. 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. Nevertheless, Buchanan and Brock (1989) provide an important basis for identifying the following three factors which need to be taken into consideration when deciding whether to override a mentally ill person’s decisions, namely: (1) whether the person is a danger to herself or himself, (2) whether the person is in need of care and treatment, and (3) whether the person is a danger to others. › Ethical considerations in mental health, Health Details: Mental Health Ethical Dilemmas Examples. Early proponents of PADs in the US expected that their use would spread ( Appelbaum 1991 ). The mental health profession is not exempt to this. This month's issue explores critical social, cultural, and ethical dimensions of mental illness. Examples of Ethical Dilemmas that Nurses Deal with on a Regular Basis •Dealing with the pro-life and pro-choice debate. These risks may be accentuated in cases where the PADs are ‘competence-insensitive’ and service providers wrongly judge the point at which a PAD applies and apply it prematurely ( Bielby 2014 ). The … Enforced treatments in such cases may, however, compound their distress and make future treatment difficult, especially if the patient later feels (i.e. As Gert and colleagues (p 132) go on to explain, we need to appreciate that persons as such are ‘not globally “competent” but rather “competent to do X”, where X is some specific physical or mental task’. Ethical Issues in Mental Health Nursing Pages: 8 (1835 words) Ethical Principles in Nursing Pages: 3 (721 words) Legal and Ethical Issues for Mental Health Professionals Pages: 11 (2560 words) Legal and Ethical issues in nursing Pages: 13 (3092 words) The different stakeholders are confronted with the following dilemmas: c … The need of a highly nuanced approach to upholding the rights of persons with mental illness and related problems in health care rests on at least three considerations. It is perhaps easy to think of competency in cases such as this in purely medical or psychiatric terms. A review of the literature has found that the information and options most frequently cited by users when preparing a PAD are: contact details of the user, the consultant, the general practitioner, the psychiatric nurse and the nominee (trusted person nominated by the user). Comparable studies conducted in Australia and New Zealand have had similar findings. Fulfilling a corresponding duty can involve either doing something ‘positive’ to benefit a person claiming a particular right or, alternatively, refraining from doing something ‘negative’ which could harm a person claiming a particular right. The mental health profession is not exempt to this. 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’. In a 2013 systematic review of the literature on the subject, Nicaise and colleagues (2013) identified three main theoretical frameworks or rationales for PADs: improvement in the therapeutic alliance between the users and clinicians. Moreover, there is little evidence showing that PADs have, in fact, achieved their intended purpose ( Campbell & Kisely 2009 ). cessation of medication, remaining out of hospital and not being the subject of an involuntary admission to a psychiatric facility) ( Sellars et al 2017 ). 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. A little over a year after his accident, and despite still being ventilator dependent, John McEwan was discharged home. The researchers reported that, although most (93%) of both clinicians and users supported the idea of PADs, they differed significantly on the preferred content of such directives – particularly with regard to the use of seclusion as a method of de-escalation. In the weeks following his discharge from hospital, John McEwan continued to express his wish to be allowed to die ( Social Development Committee 1987 : 310–11). Non-discrimination and social inclusion – encompassing the rights to: privacy and confidentiality; health, safety and welfare; equal opportunities to access and maintain health and mental health care, and other social goods; contribute to and participate in the development of social, health and mental health policy and services. In defence of their position, they argue that the patient’s complaints are justified – the adverse side effects of his psychotropic drugs have indeed been ‘awful’, and are commonly experienced by other patients as well; and that he has experienced a decline in his psychiatric condition before, and hence knows what to expect. 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. Discuss critically the notions of ‘surrogate / substitute decision-making’ and ‘supported decision-making’ in the case of people deemed to be rationally incompetent. Only a few countries (e.g. In a later appraisal and application of this test, Appelbaum (2007 : 1835) reiterates that legal standards for assessing the decision-making capacity of patients still generally embody ‘the abilities to communicate a choice, to understand the relevant information, to appreciate the medical consequences of the situation, and to reason about treatment choices’. Health Details: Mental health practitioners working with children and families must attend to several ethical concerns that do not typically come into play with adult clients. Because one of the most ethically confronting issues in mental health care is the coercive treatment 2 of persons admitted as involuntary or non-voluntary patients to a psychiatric facility or program, particular attention will also be given to the issues of informed consent and competency to decide, and ongoing proposals to develop and operationalise ‘psychiatric advance directives’ (PADs) in jurisdictions around the world. Psychiatry has always been an area of medicine with unique ethical challenges. The ethical dilemmas encountered are centred on issues of care and control within the realm of mental health. Rights and responsibilities of the community – encompassing the responsibility of communities to be adequately informed and educated about mental health issues, and to uphold the rights of mental health consumers and their carers. In short, those who did not support PADs placed more importance on clinical outcomes than on upholding patient autonomy. The social work code of ethics are … With reference to the idea of psychiatric advance directives in mental health: define what a psychiatric advance directive is, discuss critically the different theoretical frameworks and forms that psychiatric advance directives can take, discuss critically the different functions that psychiatric advance directives might serve, examine the purpose of ‘Ulysses contracts’. Health Details: Counselling Dilemmas, Ethics & Legal Issues, Relationship & Families; Read More; Counselling Dilemma: Dual Relationship Boundaries. 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). John McEwan, a former Australian water-skiing champion, was left a ventilator-dependent quadriplegic after a diving accident at Echuca, Victoria. A New Zealand survey of 110 mental health service users and 175 clinicians had similar findings ( Thom et al 2015 ). 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. 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’). Some examples of ethical dilemma examples include: Taking credit for others’ work; Offering a client a worse product for your own profit; Utilizing inside knowledge for your own profit . November 13, 2014. A patient could without contradiction ‘rationally’ choose suicide as a means of escaping an intolerable life characterised by suffering intractable and intolerable pain. Consider, for example, the following case (personal communication). There is room to speculate that, had a PAD been in force at the time for this patient, a very different outcome might have resulted in this case. The test of ability to understand , on the other hand, asks whether the patient is able to comprehend the risks, benefits and alternatives to a proposed medical procedure, as well as the implications of giving consent. 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 . oral or intramuscular psychotropic medication, or electroconvulsive therapy). The idea of a Ulysses contract derives from Homer’s story of the mythological character Ulysses (known as Odysseus in Greek mythology) who escaped being seduced to his death by the ‘sweet songs’ of the Sirens, the magical women of Cyrene, who cast spells on the sailors of ships so that their vessels would be wrecked and subsequently could be scavenged. The course will also describe ethical principles and skills required in the delivery of mental health services. Health Details: In this session, we will explore this emerging challenge by discussing the behavioral health ethical codes that apply to virtual interactions and share common challenges and recommended best practices. › Url: Go Now. Often they arise because the presence of mental disorders causes many patients to lack capacity to make decisions for themselves and to depend on clinicians to attend to their best interests in ethics and law. This need of protection has also been recognised at an international level as evident from the United Nations General Assembly’s adoption in 1991 of the Principles for the protection of persons with mental illness and for the improvement of mental health care and, a decade later, by the World Health Organization’s release of The world health report 2001: mental health: new understanding, new hope ( WHO 2001a ). Published. We describe the ethical issues that arose in relation to a significant difference of opinion between team members about using nasogastric clozapine in the treatment of a severely ill patient. Despite this reticence, the PAD is increasingly being regarded as an important instrument that enables respect of not only the patient’s wishes, but also their values (i.e. Access to care poses difficult ethical and legal dilemmas for health care professionals, who sign an oath not to harm their patient. Attention will also be given to the vexed issue of the ethics of suicide prevention, suicide intervention and suicide postvention. The fifth and final competency test is that of actual understanding . Given this, determining competence in health care contexts fundamentally involves determining a person’s ability to make particular choices and decisions under particular conditions ( Buchanan & Brock 1989 : 311–65; see also Light et al 2016 )). 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). This question becomes even more problematic when it is considered that persons deemed ‘rationally incompetent’ (or, at least, cognitively impaired) can still be quite capable of making ‘reasonable’ self-interested choices, and, further, that the choices they make – even if ‘irrational’ – are not always harmful ( Williams 2002 ; see also Light et al 2016 ; Stier 2013 ). Distinguished by unique jargon, knowledge bases, and historical traditions, the mental health professions are united in the aim of assisting clients and patients with problems that often cannot be categorized within the confines of one professional discipline, › Url: Go Now. › Url: Go Now. ethical concerns in mental health, › Url: Go Now, › Get more: Ethical concerns in mental healthShow List Health, Health Details: Colleagues and Ethical Dilemmas in the Mental Health Profession . Prior to 2014 there seemed to be little optimism that PADs will be formally adopted in Australian jurisdictions as a legal mechanism for promoting and protecting the rights of mentally ill people to participate effectively in decision-making concerning their psychiatric care and treatment. Ethical issues in mental health care. This chapter explores mental health nursing practice within an ethics context. irrevocability during a crisis (also known as a ‘Ulysses contract’ – see below) ( Swartz et al 2006 : 67). Mental Health Ethical Dilemmas Facing Mental Health Social Workers. The author outlines that any ethical problems be identified at an early stage so that such problems do not rise to the point of having harmful impacts…, › Url: Go Now. 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. Discussions of key ethical dilemmas in mental health care, including consent, trauma and violence, addiction, confidentiality, and therapeutic boundaries. 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. All rights reserved | Email: [email protected]. Ethical dilemmas in mental health resources for college students: A reflective case study Kangkana Bhuyan, Bhavishya Kalyanpur, … Assessing risk and permitting choices of patients deemed ‘rationally incompetent’, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), United Nations General Assembly’s adoption in 1991, Australian Health Ministers Advisory Council (AHMAC) 2013, Australian Government Department of Health 2010, Australian Government Department of Health 2012, Australian Law Reform Commission (ALRC) 2014, Ethics, dehumanisation and vulnerable populations, Moral theory and the ethical practice of nursing, Nursing ethics futures – challenges in the 21st century, Ethics, bioethics and nursing ethics : Some working definitions. What else then should health care professionals do? › Url: Go Now. 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 ). Further, they argue, if he is given the medication against his will, an even greater harm will follow: specifically, he will trust the nursing staff even less than he does already, and will be even less willing to comply with his oral medication prescription than he is now.

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