Consider, for example, the following case (personal communication). [emphasis original]. This chapter explores mental health nursing practice within an ethics context. discuss critically the possible risks and benefits of psychiatric advance directives. The Code of Ethics identifies … Mental Health Ethics: The human context. 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). For example, as Buchanan and Brock (1989 : 318) comment: It is precisely in situations such as these that attending health care professionals need a reliable framework within which to decide how best to act – notably: (1) whether to respect a patient’s preferences even though the patient is deemed ‘incompetent’, or (2) whether to override patients’ preferences in the interests of protecting or upholding what has been deemed by others to be in the patient’s overall ‘best interests’. In mental health nursing, autonomy is sometimes overridden in the interests of promoting the principle of beneficence (Lakeman 2009). 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. 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 fifth and final competency test is that of actual understanding . 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. To this end, the document addresses the following eight domains: Inherent dignity and equal protection – encompassing the right of all people to respect the human worth and dignity of people with mental illnesses, and to support people who are mentally ill or intellectually disabled to exercise their rights when their own capacity to do so is impaired. 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). in clinical contexts) usually refer to a person’s competence to do something , in this instance, to choose and make decisions ; according to this view, competence is, therefore, ‘choice and decision-relative’. These and like criteria remain problematic, however. In other words, competence is always ‘task specific’ and determining or measuring competence is thus always ‘context dependent’. It has long been recognised at a social, cultural and political level that people suffering from mental illnesses and other mental health-related problems need to have their moral interests as human beings protected from abuse and neglect, which, for a variety of reasons, are especially vulnerable to being violated. Other barriers that have been identified include: concerns about the ‘legal and ethical issues relating to the liability for implementing or overriding (PAD) statements’. Currently almost two-thirds of the states in the USA have legal processes in place for allowing and managing PADs (Zelle et al 2015b). In short, those who did not support PADs placed more importance on clinical outcomes than on upholding patient autonomy. 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. 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. Gillon (2003) argued that a model of understood ethical principles can help in avoiding the two polar dangers – moral relativism and moral imperialism. 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). Variously named ‘psychiatric wills’, ‘self-binding directives’ (SBDs), ‘advance directives’, ‘advance statements’, ‘advance agreements’, ‘advance instructions’, ‘crisis cards’ and ‘Ulysses contracts’, the idea of notifying treatment preferences in advance, or making a ‘psychiatric will’ (a term that is analogous to ‘living wills’), is credited with originating in the work of the eminent American psychiatrist, Thomas Szasz (1982) , and the identified need for psychiatric patients to have an instrument that enabled them to refuse unwanted treatment. community treatment order (CTO) contexts) ( Corring et al 2017 ; Nagra et al 2016 ; Molodynski et al 2014 ). https://nursekey.com/ethical-issues-in-mental-health-care-2 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. According to media reports, this act led to a psychiatrist certifying him as rationally incompetent, thereby enabling John McEwan to be treated (fed) against his will. There is, however, one notable caveat to this stance: because the rights of people with mental illness are disproportionately vulnerable to being infringed in health care contexts (both psychiatric and non-psychiatric), a more nuanced approached to the issue is required. Specifically, Buchanan and Brock (1989 : 84–6) suggest that the whole issue hinges on: setting and applying accurately standards of competency to choose and decide; and. 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. 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. 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 less experienced staff members on the ward disagree with this reasoning, however, and argue that, even though the patient’s psychiatric condition is deteriorating, and this is a preventable harm, the patient is nevertheless able to make an informed decision about this and therefore his wishes should be respected. One response is to insist on the development of reliable (research-based) criteria for deciding these sorts of problematic issues. [1] Ethical problems demand a morally rigorous response, be-cause they often involve making difficult choices. Enforced treatments in such cases may, however, compound their distress and make future treatment difficult, especially if the patient later feels (i.e. the capacity to communicate the decision made (after Kerridge et al 2013 : 384–6). The incidents were assessed for typicality by asking representatives of nursing staff, psychiatrists and consumers of acute mental health services to rate each story on a scale from one to five (one being “this would never occur” and five being “this sort of incident is common”). ISBN: 9780730344612. Psychiatric advance directives have been defined as ‘documents that allow users with severe and chronic mental illnesses to notify their treatment preferences for future crisis relapses and to appoint a surrogate decision-maker for a period of incompetence’ ( Nicaise et al 2013 : 1). 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). (Whether or not the risk of suicide does provide strong grounds for overriding a patient’s decision to refuse hospitalisation and treatment is another question, and one which is considered shortly in this chapter.). There is, however, still work to be done, noting that provisions for PADs have not yet been incorporated in the mental health legislation of all Australian jurisdictions and that, even where it has been (e.g. The Ethics Of Mental Health Nursing 1596 Words 7 Pages In order to address the moral theory and moral principles that underpin the ethics of mental health nursing, I intend to demonstrate how clinical decision making mental health nursing is formulated based on the chosen moral principles of beneficence, non-maleficence and ‘respect for autonomy’ (NHS, 2015). 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. 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). 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. The primary objective of the 2012 revised version of the Mental health statement of rights and responsibilities document is to inform stakeholders of the rights of people experiencing a mental illness to have access ‘to timely assessment, individualised care planning, treatment and support’ and the related rights and responsibilities that consumers, carers, support persons, service providers and the community all have in relation to these rights ( Australian Government Department of Health 2012 : 3). ECT), or ‘opting-in’ (consenting to services as well as to specific treatments) ( Atkinson et al 2003 ; Swartz et al 2006 ). With reference to the ethics of suicide prevention, intervention and postvention: discuss the distinction between suicide, suicidal behaviour and parasuicide and why making this distinction is important, examine critically at least five criteria that must be met in order for an act to count as suicide rather than some other form of death (e.g. Explore ways in which the nursing profession might improve its advocacy of people with mental health problems and severe mental illnesses. Commenting on the moral standards which should be met when deciding whether to respect or override the expressed preferences of a patient deemed ‘incompetent’, Buchanan and Brock (1989) have classically argued in their foundational text that it is important to be clear about what statements of competence refer to. While drawing primarily on the Australian experience, this discussion nonetheless has relevance for nurses working in other countries. Here objections can be raised concerning just how sophisticated a patient’s understanding needs to be. 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. 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. For example, a fully comatose patient would be unable to evidence a choice, unlike a semi-comatose patient or a brain-injured person, who could evidence a choice by opening and shutting their eyes or by squeezing someone’s hand to indicate ‘yes’ or ‘no’. Discuss critically the notions of ‘surrogate / substitute decision-making’ and ‘supported decision-making’ in the case of people deemed to be rationally incompetent. 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 ). 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). One problem with this test, however, is whether, say, the blinking of a patient’s eyelids can be relied upon as evidencing a choice; in a life-and-death situation one would need to be very sure that a patient’s so-called ‘evidencing a choice’ is more than just a reflex. This test asks how well the patient has actually understood information which has been disclosed. By taking these steps, Ulysses was able to investigate the power of the Sirens without being seduced to his death by them as well as ensure the safety of his ship and his crew as they sailed past them. Early proponents of PADs in the US expected that their use would spread ( Appelbaum 1991 ). 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 ). In Australian, New Zealand and other common-law jurisdictions, legislative provisions also enable psychiatrists to override a person’s will and preferences and admit (‘commit’) them involuntarily to hospital for treatment, which, in effect, grants psychiatrists the authority to ‘act as substitute decision-makers, rather than as advisers and service providers’ ( McSherry 2012 : 1). do NOTrepresent obligations and should NOTform the basis for imposing sanctions. Like Gert and colleagues (1997) , cited earlier, they argue that statements of competence (i.e. The claim of a moral right usually entails that another person has a corresponding duty to respect that right. 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. 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. In 2013, the cost for treating mental illness in the US topped the list for all medical conditions. These views have been underscored in an insightful essay by Stier (2013) who explores the fundamentally normative nature generally of assessing, diagnosing and treating mental illness – including determining whether something is a mental illness (which relies on normative judgments about ‘normal’ versus ‘deviant’ behaviour), irrational (which includes judgments about ‘impaired reality testing’), or harmful and distressing (which relies on value-laden judgments about whether something is ‘bad and dysfunctional’). 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. She further suggested that, at most, rationality should be regarded as a value , rather than a property that all ‘normal’ people have ( Gibson 1976 : 193). The health care professional in turn could be judged, criticised and possibly even censured on grounds of having infringed the patient’s rights. The quality of the patient’s choice in this instance is irrelevant. 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 ). Before his accident he had been a committed sportsman and for him the life of a helpless quadriplegic was intolerable. One reason for this is the systemic barriers to their use including a ‘lack of resources deployed to assist patients in preparing PADs (unless assistance is provided, completion rates for PADs tend to be low), and a lack of “buy-in” and acceptance of PADs by clinicians’ ( Swanson et al 2007 : 78). Although practised under the rubric of benevolent paternalism, the tenets of involuntary treatment have nonetheless seriously challenged and, in many instances, infringed the rights of mentally ill persons – particularly those whose decision-making capacity has been seriously compromised by their illness – to make informed and self-determining decisions about their care and treatment. oral or intramuscular psychotropic medication, or electroconvulsive therapy). A short case-study highlights potential solutions to those challenges. irrevocability during a crisis (also known as a ‘Ulysses contract’ – see below) ( Swartz et al 2006 : 67). This is because there is no substantial agreement on the characteristics of a ‘competent person’ or on how ‘competency’ should be measured. Governance – encompassing the responsibility of governments and other stakeholders to ensure that mental health initiatives (including service provision, mental health legislative reform, and other forensic matters) are appropriately resourced and supported. 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.