Ethical Issues in Person-Centred Care

For the purpose of this assignment the student will be discussing and analysing the professional, legal and ethical issues that influenced how person-centred care was delivered to a patient in an acute psychiatric hospital where the student was working. In accordance with the Nursing and Midwifery Council (NMC) (2010) the patient will be referred to as Sarah to uphold confidentiality. During a shift at the hospital the student attended a manager’s ward review. The student listened as approved mental health professionals (AMHP) discussed the wellbeing of patients who were being cared for in the hospital.

AMHP’s are mental health professionals who have specialist training in mental health assessment and legislation (Barcham, C (2008) The first patient to be reviewed was Sarah, a thirty two year old female who suffered from schizophrenia.

Sarah was an informal patient who had agreed to be admitted into hospital to be treated. As an informal patient Sarah has the same rights as a person being treated with a physical illness (NHS, (2010) meaning Sarah had the freedom of choice to refuse treatment and could self-discharge.

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However, doctors and nurses have the power to prevent patient’s from leaving if it is felt that there is a serious concern that the patient or public could be at risk of harm (Choa, O (2007) If this is the situation then the staff should respect the patient’s wishes by attempting to explain the concerns in the hope that the patient makes a decision to stay. If the patient still insists on leaving, it is then that detainment under the Mental Health Act 1983 (MHA) must be considered.

(Department of Health (2005) (DH) The student heard how Sarah’s mental state had deteriorated in the past week due to her refusing to take her medication.

Sarah had demonstrated auditory hallucinations and paranoid delusions about being poisoned. It was also mentioned that on a number of occasions Sarah had become physically aggressive towards staff and other patients. This was also witnessed by the student when Sarah was brought into the ward review. Due to this Sarah’s doctor decided that it would be in Sarah’s best interest to enforce treatment in form of a depot injection under section two of the MHA. If treatment was to be enforced on Sarah without a detainment under the MHA it could constitute as an assault (Choa, O (2007) This is classed as negligence and the patient could go on to seek legal advice, which could lead to criminal or civil proceedings (Harpur, C (2009) The MHA is a law that allows people with a mental illness to be detained and treated in hospital without consent. This may be to protect the patient from self-harm or from inflicting harm on others.

The decision to detain Sarah under the MHA was deemed necessary as the doctor felt that Sarah no longer had the mental capacity to consent to, or refuse treatment due to the severity of the mental illness. Mental capacity is a person’s ability to make their own decisions (NHS Choices (2012) Consent is based on an understanding of the patient’s autonomy (Tschudin, V (1993) and autonomy is a fundamental ethical principle in health care. The implication of enforcing treatment on a patient without consent is that it can breach a patient’s right to be autonomous. However, to challenge this Barker, P et al (1992) p111 argues that it is the biological changes in the brain caused by mental illness that undermine a person’s autonomy, so imposing treatment on a person without consent may restore autonomy. It is then Sarah may start to realise that the medication is beneficial. Therefore, more good would be achieved by administering medication.

To respect Sarah’s autonomy the doctor informed her of all the risks and benefits about treating her illness, this was an act to try to help Sarah take some control over what decision to make. However, because of the delusional thoughts of being poisoned Sarah did not understand or believe what the doctor was saying as this contradicted all self-beliefs. It was this inability to understand that made it clear to the doctor that Sarah’s mental illness removed the capacity for autonomous control to choose whether or not the treatment would be beneficial. Before treating Sarah without consent there are certain guidelines that are provided within the MHA what the doctor must follow. These are called ‘codes of practice’ (DH, (2005) and relate to anyone who is working with adults who are believed to lack the capacity to make decisions.

For example, has the doctor tested Sarah’s capacity before making the decision to administer treatment without consent? The MHA says capacity can be tested by answering these four questions (DH, (2005) Can Sarah understand, retain and weigh up the information that is being given about the illness and treatment, and can Sarah communicate with the doctor whether it be verbally or non-verbally. It was clear to the student that the answer to these questions was ‘no’ because schizophrenia affects the way a patient thinks, feels and behaves which makes it more difficult to distinguish between what is real and unreal. (National Institute of Mental Health (NIMH) (2012) Sarah’s doctor also have a professional duty to adhere to the ethical principles of beneficence and non-maleficence (Wilmot (2003)

Beneficence is the act to ‘To do good’ whereas; non-maleficence is the act ‘To do no harm’. However, this may not always be possible, especially in mental health. For example; giving Sarah depot injections would help to control the schizophrenia and alleviate its symptoms, but, administering the injections may be unpleasant and painful for Sarah. The ethical dilemmas the doctor has is weighing up the benefits against the risks (Beauchamp and Childress (1994)

In conclusion, professionals need to ensure that each patient has the sufficient information and understanding to make informed choices about treatment because the principles of gaining consent apply equally to those who suffer mental illnesses. However, in a situation where the patient is deemed incompetent to make such decisions it is important to ensure that the ethical, professional and legal issues are considered to achieve the best outcome for the patient. Also it is important to understand that people with schizophrenia do not always need to be detained in hospital. Many people lead a stable life, work and have relationships.

References

1. Barcham, C (2008) Understanding the Mental Health Act changes – Challenges and opportunities for doctors. British Journal of Medical Practitioners. 1 (2) pp13 – 17
2. Barker, P. and Baldwin, S. (1992) Ethical Issues in Mental Health. 1st ed. London.
3. Chapman & Hall Beauchamp, T, L and Childress, J, F. (1994) Principles of Biomedical Ethics, 4th ed. New York: Oxford University Press
4. Burnard, P. and Chapman, C. (1993) Professional and ethical issues in nursing: the code of professional conduct, Scutari.
5. London Choa, O. (2007) Compulsory treatment within the Mental Health Act 1983: A Legal Review. Nursing Times. 26 August, p7
6. Department of Health (DH) (2005) Mental Capacity Act 2005 – Summary [Online] [Accessed 8th August 2012] Available at: http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Bulletins/theweek/Chiefexecutivebulletin/DH_4108436 Harpur, C.