9 LEGAL ANDETHICALISSUES 185
deontology include autonomy, beneficence, non-
maleficence, justice, veracity, and fidelity.
Autonomyrefers to the person’s right to self-
determination and independence. Beneficencerefers
to one’s duty to benefit or to promote good for others.
Nonmaleficenceis the requirement to do no harm to
others either intentionally or unintentionally. Jus-
ticerefers to fairness; that is, treating all people fairly
and equally without regard for social or economic sta-
tus, race, sex, marital status, religion, ethnicity, or
cultural beliefs. Veracityis the duty to be honest
or truthful. Fidelityrefers to the obligation to honor
commitments and contracts.
All these principles have meaning in health care.
The nurse respects the client’s autonomy through pa-
tient’s rights, informed consent, and encouraging the
client to make choices about his or her health care.
The nurse has a duty to take actions that promote the
client’s health (beneficence) and that do not harm
the client (nonmaleficence). The nurse must treat all
clients fairly (justice), be truthful and honest (verac-
ity), and honor all duties and commitments to clients
and families (fidelity).
Ethical Dilemmas in Mental Health
An ethical dilemmais a situation in which ethical
principles conflict or when there is no one clear
course of action in a given situation. For example,
the client who refuses medication or treatment is
allowed to do so based on the principle of autonomy.
If the client presents an imminent threat of danger
to self or others, however, the principle of non-
maleficence (do no harm) is at risk. To protect the
client or others from harm, the client may be invol-
untarily committed to a hospital, even though some
may argue that this action violates his or her right
to autonomy. In this example, the utilitarian theory
of doing the greatest good for the greatest number
(involuntary commitment) overrides the individual
client’s autonomy (right to refuse treatment). Ethi-
cal dilemmas are often complicated and charged
with emotion, making it difficult to arrive at fair or
“right” decisions.
Many dilemmas in mental health involve the
client’s right to self-determination and independence
(autonomy) and concern for the “public good” (utili-
tarianism). Examples include the following:
- Once a client is stabilized on psychotropic
medication, should the client be forced to
remain on medication through the use of
enforced depot injections (Armstrong, 1999;
Svedberg, Hallstrom & Lutzen, 2000) or
through outpatient commitment (Torrey &
Zdanowicz, 2001)?- Are clients who are psychotic necessarily
incompetent, or do they still have the right to
refuse hospitalization and medication
(Chamberlin, 1998; Barrett, Taylor, Pullo &
Dunlap, 1998)? - Can consumers of mental health care truly
be empowered if health care professionals
“step in” to make decisions for them “for
their own good” (Breeze, 1998)? - Should physicians break confidentiality to
report clients who drive cars at high speeds
and recklessly (Niveau & Kelley-Puskas,
2001)? - Should a client who is loud and intrusive to
other clients on a hospital unit be secluded
from the others (Terpstra, Terpstra, Pettee &
Hunter, 2001)? - A health care worker has an established
relationship with a person who later becomes
a client in the agency where the health care
worker practices. Can the health care worker
continue the relationship with the person
who is now a client (Cutcliffe, Epling,
Cassedy, McGregor, Plant & Butterworth,
1998)? - To protect the public, can clients with a
history of violence toward others be detained
after their symptoms are stable (Dickenson,
1997)? - When a therapeutic relationship has ended,
can a health care professional ever have a
social or intimate relationship with someone
he or she met as a client? - Is it possible to maintain strict professional
boundaries (i.e., no previous, current, or
future personal relationships with clients) in
small communities and rural areas where all
people in the community know one another
(Roberts, Battaglia & Epstein, 1999; Simon
& Williams, 1999)?
The nurse will confront some of these dilemmas di-
rectly, and he or she will have to make decisions about
a course of action. For example, the nurse may observe
behavior between another health care worker and a
client that seems flirtatious or inappropriate. Others
might represent the policies or common practice of the
agency where the nurse is employed, and the nurse
will have to decide if he or she can support those prac-
tices or decide to seek a position elsewhere. An exam-
ple would be an agency that takes only clients with a
history of medication noncompliance if they are sched-
uled for depot injections or remain on an outpatient
commitment status. Yet other dilemmas are in the
larger social arena; the nurse’s decision is whether to
support current practice or to advocate for change on
- Are clients who are psychotic necessarily