Introduction
For nurses, their job is hard daily work requiring profound knowledge, skills, and dedication. The profession demands them to be sustainable and responsible, meet the requirements, and comply with the main work principles. With nurses, patients most often communicate, ask and answer, talk and listen. Hospitals, in particular those dealing with patients with mental illness, are considerably challenging places of work. Employees daily see human suffering, own limited capabilities, and face severe ethical dilemmas. Solving ethical problems also requires precise knowledge and professionalism, the ability to make the best decision in critical situations.
Psychiatry differs significantly from other areas of medicine, including in ethics. The field is gradually expanding as, in addition to clearly defined diseases, personnel also should deal with more hidden disorders. At the same time, society is still not tolerant enough towards patients with mental illness and has prejudices. Such an image affects the desire to seek professional help, provokes a pessimistic view on treatment, and makes patients even more vulnerable. Moreover, this image can affect the social and professional life of the patient. For this reason, ethical treatment has a critical significance in relations between patients and medical staff.
The most effective medical and psychiatric care is provided in a hospital. In their practical activities, doctors and nurses of the department should be guided by the principles of medical ethics. For example, among the main requirements that stand out: the actions aimed at the benefit of patients, respecting their interests, and medical confidentiality. Mentally ill people do not always realize that their condition is dangerous – for themselves or surrounding people. Therefore, the situation of providing them help in the psychiatric hospital is perceived as violent and often provokes resistance. In the hospital, such people often refuse treatment, the need to observe the regime, and taking drugs. Doctors and staff have to resort to coercion, which, however, should not contradict the humane approach to the patient.
The Scenario of Ethical Dilemma Case
The scenario presented and studied below is hypothetical, and similarities with real people are coincidental. However, considered ethical dilemmas might arise in actual nursing practice. The purpose of the presented case and analysis is to evaluate the ethical aspects of providing care to a patient in a psychiatric ward. Another objective of the paper is to provide recommendations for treatment in accordance with the moral and ethical principles of the profession of a mental health nurse.
Michael is a 28-year-old man who cannot continue his career as an athlete due to an injury – he lost his leg. The sport was the basis of his life, and the man devoted all his time and efforts to it. Besides sports, Michael had few activities and hobbies, and he sought to build a career only in this area. The incident during vacation, which led to an injury, happened two years and since then, Michael’s psychological condition has been deteriorating.
He is divorced, has no children, and does not maintain relations with his parents. At first, the man sought to survive only the loss of his leg, but then he felt confused and uncertain about what his life was worth. He is also always tired, annoyed and speaks of feeling ill. Since the primary basis in his life is destroyed, he does not see the goal before himself, feels the meaninglessness and pity of his situation. Due to lost opportunities and not seeing prospects for the future, Michael is experiencing depression.
Hospitalized after a suicide attempt, Michael does not want to take medication but still does, obeying the rules. Disability as a result of the trauma and hospitalization significantly depresses the man, and he sees no point in taking drugs. Besides resisting medication sometimes, Michael is apathetic to staying in the hospital, prefers being private, and does not participate in discussions. Although the man’s time in the hospital is relatively short, there is no sign of improvement, and even vice versa – he is very devastated.
Concerned about Michael’s condition, nurses seek extraordinary control – they check whether there are any things that can be used for harm. They also carefully monitor medication use and consider the option of adding medication to food fraudulently if Michael will refuse to take them. However, deception threatens to worsen relations with the patient and can provoke his resistance. Moreover, questions arise about how acceptable such actions are and whether they violate patient autonomy. This concept implies people’s freedom to make crucial decisions that concern them personally, including their treatment. However, the disease can disrupt the ability to think reasonably and push for wrong choices. At the time of arriving in the hospital, nurses can note the following characteristics of the patient:
- Risk of harm associated with feelings of inferiority and hopelessness.
- Ineffective coping with trauma and its consequences – disability.
- Grief related to irretrievable lifestyle changes and lost life values.
- Social exclusion related to family separation and non-communication.
Thus, Michael suffers from depression and requires treatment so that no new incidents occur. This condition is quite common and is often not taken with sufficient severity. People suffering from depression feel sad, hopeless, insecure, and experience many other negative emotions (“Depression,” 2020). Failing to provide Michael with timely care could lead to a new suicide attempt. However, with proper treatment, he has a chance to find and discover new opportunities for himself.
Scenario’s Ethical Conflicts
Nurses that usually communicate with patients much closer and more than doctors face the suffering and pain of their wards directly. At the same time, they have a crucial role in supporting the ethical treatment and preservation of human rights (Ventura et al., 2020). Ethical conflicts may arise when nurses are unsure which direction of the patient support to choose. While staff behavior should be consistent with the benefit of their patients, there may be different views on it. For example, actions will benefit in the future but violate patient autonomy. Moreover, sometimes nurses may disagree with the chosen course of action concerning a person, and, as a result, moral pressure arises (Ventura et al., 2020). For these reasons, stress tolerance and the ability to make decisions based on accepted ethical principles are essential.
Nurses exhibit paternalism in the described scenario, which is common in the field. This concept reflects the practice where people with specific power can restrict those who are subordinate or dependent on them (Ventura et al., 2020). Patients are obliged to respect the work of medical personnel and obey their instructions as they act in the interests of their wards (“When hospitalization is needed,” 2020). At the same time, nurses can limit autonomy while the patient is under supervision, hoping that he will be able to manage his freedom independently, adequately, and for good in the future.
One solution to the described situation is the option where Michael’s incompetence in solving issues of self-care and his health will be proved. The state of depression in which the man is in and the tendency to suicide indicate the possibility that he can choose a decision which he would not make without depression. Depression is characterized by impaired information processing and perceiving the world in a pessimistic view (Baruth & Lapid, 2017; LeMoult & Gotlib, 2019). Owen et al. (2018) study proves that people with depression have a broken vision of reality and projecting themselves into the future, which is critical for self-determination and decision-making. Proven incompetence solves the conflict of autonomy of the patient because he cannot act in the name of his well-being.
Incompetence in decision-making must be established officially, and a guardian must be appointed. Michael, as an adult, is considered competent if the opposite is not proven (Australian Law Reform Commission, 2010). The recognition process may take a long time, and since Michael currently has no relatives whom he would fully trust, there will also be problems in finding a guardian. A lengthy process will take time, which could be spent on treatment and not promote patient trust in the staff. Nevertheless, it is critical to consider Michael’s autonomy, as otherwise, nurses may face severe moral and legal complications.
If Michael is recognized as competent in decision-making, the conflict about how much his autonomy relates to his well-being remains open. Several additional factors are essential and influential for his case. His state of depression is reversible since, with proper treatment, he may see new prospects. Michael’s disability, although it may limit his freedom, still leaves him with many opportunities in life. In addition, the intervention of nurses is not violent, does not cause severe physical inconvenience, and is aimed at the patient’s benefit.
A potential violation of a patient’s autonomy may also contradict his right to dignity. Although some researchers argue that the concepts of dignity and autonomy are interchangeable, their differences are still crucial for ethical decision-making in healthcare (Simões & Sapeta, 2019). The researchers also note the fact that despite the importance of understanding dignity in medicine, no single definition has yet been inferred for it (Simões & Sapeta, 2019). Dignity refers to the practice when the individual is treated respectfully and honorably – patients whose dignity the staff respects feel they are worth as people and deserve a good attitude. Respect for human dignity is critical for treatment, as it is the basis for patient-centered care. In Michael’s case, excessive surveillance, he may perceive as disrespectful for him and as a violation of personal boundaries. However, the concept of dignity also includes self-respect, which in this case, is disrupted. Michael may temporarily not adequately perceive himself and his desires due to a depressed condition.
This case can also be considered from the point of view of such ethical principles, which should guide representatives of medical personnel in their actions as veracity and fidelity. They suggest that nurses should be honest with patients and loyal to them (Casale, 2017). The fact that nurses are considering the cheating option indicates a violation of integrity. At the same time, their actions, in their opinion, are probably aimed at improving the patient’s life. For this reason, the issue of fidelity is intertwined with the conflict of autonomy. Nurses are faithful to Michael’s interests because they think about his possible future – this is a manifestation of loyalty. At the same time, their actions against the patient’s will violate the trust which can be achieved between them.
Possible Action Plan based on Ethical Theories and Principles
As demonstrated in the previous section, the present case is characterized by several ethical conflicts. Nurses’ actions should be based on ethical concepts and theories. According to Casale (2017), utilitarianism involves achieving the common good – happiness for more people by any means. It may seem that this approach suggests the possibility of cheating or declaring Michael incompetent. However, in this case, the nurses will be under moral pressure. Kantianism is the opposite direction, which puts forward the path to achieving a specific goal and not the goal itself. As part of this approach, the principles of autonomy, beneficence, nonmaleficence, and similar are considered (Casale, 2017). Based on both of these approaches, nurses should choose more ethical actions instead of deception – they will bring more good and be more consistent with professional duties.
Michael’s autonomy and dignity are also critical for his recovery and must be respected. Trusting relationships with nurses can contribute to his sooner healing. Ignoring independence and dignity will also violate the principles of beneficence and nonmaleficence. Impaired by disability, Michael’s self-esteem may suffer even more if he learns about deception and disrespect by staff. Moreover, as indicated earlier, his possible incompetence in decision-making must be formally proven and may have destructive consequences for self-perception. Fraud by nurses is also excluded so that the principles of honesty and fidelity are respected. Based on all the arguments presented, nurses cannot give Michael drugs fraudulently, and it is necessary to focus on treatment – the effects of drugs and his moral support.
Conclusion
Thus, the proposed scenario of patient Michael suffering from depression and suicidal ideation raises several ethical conflicts. Nurses concerned about the condition of the man show excessive paternalism and consider deceiving the patient for his benefit. For this reason, the most crucial issue in the case is the question of the balance of the patient’s autonomy and well-being in the circumstances of a depressive condition. Staff fraud also involves a violation of the principles of fidelity and veracity. Nurses have the task of acting for Michael’s recovery while respecting the necessary ethical principles.
Based on existing ethical theories and principles, patient autonomy is preferred in this case. For his part, Michael as a patient, must respect the rules established in the hospital. Nurses must treat him with dignity and respect to provide patient-centered care. This approach is necessary for the patient as it will contribute to improving the emotional state. In the case, if the deterioration of the condition noticed by nurses continues to be observed, Michael’s doctors should consider the option of changing drugs. Thus, in this case, nurses should focus on a softer and more ethical approach.
Nurses’ actions should be based on attention and the ability to listen to the patient. Understanding a person in a depressed state, his thoughts, often not coinciding with reality and reacting correctly, is a very challenging task. For instance, it is especially critical to avoid condescension, neglect, and pity in the conversation in Michael’s case. Therefore, mental health care has high requirements for nurse professionalism and the development of patient communication skills.
References
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