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Ethical Dilemmas in Psychiatric Nursing

Updated on February 13, 2011

Decision making - competent or not competent?

People who suffer from a severe and enduring mental illness may become so unwell that they are unable to decide on their treatment. Often they do not realise that they are ill because the nature of a psychotic illness can sometimes cause them to lose touch with reality. The dilemma when nursing a patient who has a mental illness is when acting in their best interests may cause a conflict between safeguarding the patient and taking away their autonomy and independence. A nurse is accountable for their practice and any decisions made whilst in their care. Sometimes the fear of repercussions may influence decision making.

Looking at risks versus benefits of decision making
Looking at risks versus benefits of decision making

Compliance with medication and iatrogenesis

The basis of nursing ethics is laid down in the NMC code of professional conduct (2010) that nurses act always in a manner to promote and safeguard the interests of patients and clients. P9. Tschudin (1993) suggested that caring is the ethical basis of nursing. The NMC further suggests that nurses are accountable for their actions; therefore failing to act in the best interests of the patient may be breaching the code of conduct. However, deciding what the patient's best interests are can be the subject of a dilemma.

A dilemma in nursing practice may be encountered in a variant of situations and has been defined as "a choice or situation between equally unsatisfactory alternatives or a difficult problem seemingly incapable of a satisfactory conclusion" (Gove 1961). Webster's Dictionary)

Some dilemmas may involve conflict between the professional responsibility of the nurse and the autonomous choice of the patient. (Sletteboe 1997). This may be illustrated in the dilemma encountered as a student nurse on placement at a Mental Health Rehabilitation centre which involved a psychiatric patient who had requested his medication to take with him while out in the community for the day. The example below is merely used to illustrate the ethical arguments which may be applied to many other situations.

Decision Making - A Dilemma

The ethical theory of Utilitarianism advocated by Bentham (1789) requires that an action may be judged right or wrong depending upon its consequences. (Johnson 1989) Therefore achieving the greatest good to the greatest number of people may be achieved by not allowing the client to self medicate, and would be acting in the clients best interests. However by acting in a paternalistic way, the psychiatric nurse was taking away the client's freedom and autonomy to be in control of his own life. Autonomy has been defined by Aiken and Catalano (1994) as "the right of self determination independence and freedom" p23.

It has been argued by Playle (1998) that non compliant behaviour may be considered irrational particularly in those patients diagnosed with a mental illness. Competence to make decisions may therefore be questioned, resulting in a loss of autonomy. This may reflect upon the philosophy of professional power and control, and the only option available to the client in order to prove rationality and competence is to comply with the treatment. The health professional may then interpret compliance as the client achieving insight into the condition.

It has been suggested by Waller and Altshuler (1986 that the nature and effects of an enduring mental illness interferes with the ability of the individual to make sound "rational judgements'. However it may be argued that even with the individual is not displaying behaviours considered irrational; their competence may still be questioned by health professionals. There is clearly a moral dilemma between respect for autonomy and benficence in mental health care. It has been suggested by Aiken and Catalano (1994) that it is important for the health professional to accept the patient's decisions even if they do not agree with them.

Ethics and mental capacity - paternalism

At the time the medication was prescribed, the client was considered to be incompetent to make such a decision, having been diagnosed as having paranoid schizophrenia and was detained in hospital under Section 3 of the MeConflict arose when the client asked a staff nurse for his 2pm medication to take out with him while he was on leave. This consisted of one tablet of Chlorpromazine, a neuroleptic drug. (which is rarely used these days, but this incident was a while ago. The patient also had Olanzapine an antipsychotic drug and one Procyclidene while helps to control the side effects of medication.

The risks of giving someone responsibility for their medication must balance favourably against the benefits.

Risks - the person may not take the medication, as he was unsure whether it helped him, didn't think he was ill, didn't like putting on weight

and blamed he medication. The patient also had a history of self harm, therfore he may have stored up the medication on this andsubsequent leaves if he took his medication out with him each time. If he were to subsequently overdose, the decision of allowing him to take responsibility for the medication would have repercussions for the nurse.

The benefits to the person would be increased self esteem, autonomy, being given responsibility for his own care, and increasing independence, rather than enforced dependence,

Risk of Relapse versus Competence to Understand Treatment and Risks

The staff nurse was faced with a dilemma. Should he allow the client to take his medication out with him and risk the client's non compliance which may result in a relapse or should he insist that he returns back to the centre for it, therefore denying his autonomy and self determination and reinforcing the belief that he is not considered to be competent (Breeze 1998) suggests that paternalism may be considered justifiable if it is felt that the patient is not making a rational choice. An alternative view is to consider the client's competence in making a decision.

Beauchamp and Childress (1994) suggest that it is difficult to assess competence of patients with mental health problems owing to their fluctuation mental states. In this client's case there seems to be a conflict regarding competence. On the one hand he is considered competent enough to go out unescorted, on the other he is not considered competent to self medicate. The Mental Capacity Act 2005 suggests that a person may be competent in one area but not in another. Ie the person may be able to decide what to have for dinner but not be able to manage to deal with his finances, or decide on his medical treatment.

By law, no person has the right to give consent for medical treatment on behalf of another adult, whether considered incompetent or not. Irrationality does not in itself amount to incompetence. Under Section 3 of the Mental Health Act 1983) Compulsory treatment is permissible following the opinion of two doctors who agree that this proposed treatment is in the patients best interests and that "some impairment or disturbance of mental functioning rendered the person unable to make a decision whether to consent or refuse treatment (Dimond 1997) p137.

Risks of Chlorpromazine and typical antipsychotics

The benefits of the medication in taking a way his psychotic symptoms were helping the client to regain his autonomy and lead an independent life. Although research has shown that long term use of neuroleptic medication could ultimately lead to irreversible side effects such as Tardive Diskenesia if not monitored closely. In this case the principle of non malevolence therefore may be challenge (Breeze 1999)

Risk of weight gain and diabetes with some medications
Risk of weight gain and diabetes with some medications

Risk of relapse versus risk of weight gain and diabetes

The client had a previous history of self harm and common compliance with medication and was not considered to have a great deal of insight into his illness. A pattern had developed whereby he had been stabilised on medication, and discharged from hospital only to be re-admitted when his symptoms recurred, due to non compliance. The client had recently said that he did not feel he needed his tablets any more as he felt much better and blamed Olanzapine for his recent weight gain, which is a document side effect. It is clear therefore that the client was basing his reluctance to take medication on a rational argument.

Making an Informed Choice?

Olanzapine had caused the client to gain weight which had an effect on his physical health and his self esteem. Procycledine was given to counteract the side effects of the neuroleptic medication (Chlorpromazine). However the proven benefits of the medication in alleviating the distressing psychotic symptoms of the illness were considered to outweigh the minimal risks of the side effects, which were closely monitored.

Is Paternalism Justified?

In this case study the psychiatric nurse considered that the client was not competent to take his medication with him and self medication and informed the client that he could have it on his return to the Centre. By acting in a paternalistic way, the psychiatric nurses decision to refuse to allow the client to self medicate may effectively increase the client's dependence and reduce independence. This may have a detrimental effect on his self esteem and consequentially, his mental health.

Kant, in the 1700's advocated the theory of Deontology and considered that moral actions and decisions must be performed out of a sense of duty, and in doing what they feel ought to be done (Reiser, Burszatjn, Appelbaum and Gutheil 1987)

So in preventing the client from taking his medication with him he would be observing a duty of care in ensuring the client's compliance with the medication, thereby preventing his relapse and potential risk of self harm If the client were to save up his medication over a period of time, - i.e. daily and subsequently overdose, the consequences of either scenario would have an effect on other people in the community and the client's family.

Barker and Baldwin (1995) suggest that the argument for rationality is based on the value judgement and that rational people will want to be well and when offered treatment which aims to make them well, a rational person will comply with treatment. However, a person with a severe and enduring mental illness may not recognise that he is ill. Paternalism could therefore ensue if the patient with mental health problems did not agree with the health professional.

The Greatest Good for the Greatest Number?

Kelly (1997) suggests that ensuring a patient compliance not only ensures the best outcome for the patient, but also has a role in maximising resources and reducing health care cost. As resources are limited in the NHS the concept of justice and fairness may be an issue in this case. The implications of relapse due to non compliance would put a further train on resources in the acute care setting.

In reaching a decision, the psychiatric nurse relied on his experience of the client and the wish to protect himself against accusations of neglect under the NMS Code of Conduct. He may also have been seen to act according to the utilitarian principle of the greatest good for the greatest number, in considering the consequences of his decision and deontological values which include the duty of care. The way in which this dilemma was resolved complied with the recommendations of the NMC 2010 which states that not only should the patients interests be promoted as safeguarded but that no action or omission on the part of the nurse is "detrimental to the interests, condition or safety of the patient. Therefore, the psychiatric nurse acted in a way to ensure the clients compliance with the medication and therefore prevented a relapse. However it is important that the reasons for the decision making are constantly reviewed and evaluated in order to restore autonomy and independence in the long term and that each case is considered individually.

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    • TillyMint LM profile image

      TillyMint LM 7 years ago

      @reasonablerobby: I suppost that it depends on the way you evaluate the problem, using a sedative may not be good for the patient and some "sedatives" can be addictive if used in the longer term. I suppose it depends upon what would alleviate distress caused by the condition versus the risks. I hope your father is doing well. Thanks for the comment

    • TillyMint LM profile image

      TillyMint LM 7 years ago

      @aesta1: Yes it can be very difficult to make decisions on behalf of another person, acting in their best interests whilst also being accountable for your decisions, thanks for the comment.

    • aesta1 profile image

      Mary Norton 7 years ago from Ontario, Canada

      You must face these as you are a community psychiatric nurse. Must be difficult.

    • profile image

      reasonablerobby 7 years ago

      A difficult topic of course. I have recently had a glimpse of this because my father has suffered a serious stroke and there are signs of dementia too. The decision at his nursing home has been to calm him down due to shouting out using a sedative. Another home we have spoken to does not advocate this. Definitely a dilemma.

    • joanv334 profile image

      joanv334 7 years ago

      Hello, thanks for sharing!