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Psychiatric ethics: a critical introduction for mental health

nurses

Author details:

Marc Roberts RMN RNT DipHE BA(Hons) PGCE PGCRM MA PhD

Email: [email protected]

Published paper available on request or at:

https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2850.2004.00764.x

Roberts M (2004) Psychiatric ethics; a critical introduction for mental health nurses.

Journal of Psychiatric and Mental Health Nursing 11: 583-588.

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Abstract

Drawing upon the author’s experience as a mental health nurse lecturer, this paper

suggests that many mental health nurses seem to have difficulty engaging with the ethical

issues in psychiatry, and appreciating the relevance of those issues to their everyday

practice. In an attempt to address this difficulty, this paper will present a framework that

can serve as an accessible introduction to the ethical issues in psychiatry. Reflecting upon

general, clinical examples from psychiatric practice, it will be suggested that many

ethical issues in psychiatry are concerned with acts of paternalism and with the common

justification for those acts. Having presented this framework, the paper will then subject

it to a preliminary critique by drawing upon contemporary, critical approaches to health

care ethics. It is hoped that this will serve to stimulate both a deeper appreciation of the

relevance of ethics to the practice of mental health nursing and an ongoing critical

consideration of the ethical issues in psychiatry.

Keywords: autonomy, care, communitarianism, mental illness, paternalism, power

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Introduction

An initial encounter with ethics can be both a confusing and discouraging experience.

The variety of ethical approaches, technical terms and critical discussions may lead to the

conclusion that ethics is somehow too ‘abstract’, ‘philosophical’ or, worse still,

‘irrelevant’ for mental health nurses. In an attempt to highlight the relevance of ethics to

the practice of psychiatry, this paper will adopt an approach that is commonly referred to

as ‘principlism’, the consideration of ethical issues in terms of general principles such as

respect for autonomy, beneficence, non-maleficence and so on (Beauchamp & Childress

2001).

Although principlism remains the dominant approach in medical ethics today

(Widdershoven 2002), it has been, and continues to be, the target of criticism. Despite its

limitations, however, one of its strengths is to provide a framework in which the ethically

relevant features of a situation can be drawn out. By doing so, principlism can provide

mental health nurses with a valuable thinking skill to identify, explore and respond to

ethical issues in psychiatry (Fulford et al. 2002).

In order to present such a framework, significant points of discussion and

criticisms of principlism will be temporarily ‘put to one side’. However, once the

framework has been presented, these points and criticisms will be introduced and

discussed by drawing upon contemporary, competing approaches to health care ethics.

Paternalism

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A useful place to begin for an understanding of the ethical issues in psychiatry is with the

concept of paternalism. Paternalism can be defined as: ‘The policy or practice on the part

of people in positions of authority of restricting the freedom and responsibilities of those

subordinate to or otherwise dependent on them’ (Pearsall 1998). So defined, it can be

seen that the everyday practice of psychiatry contains many examples of paternalism.

Compulsory admission and treatment of people under the Mental Health Act 1983, the

use of ‘control and restraint’, ‘seclusion’, locked wards, ‘special observations’ and the

covert administration of medicines could all, to varying degrees, be said to constitute a

restriction of a person’s freedom and responsibilities and, therefore, could all be

considered to be acts of paternalism.

Autonomy

An act of paternalism raises ethical concerns because it can be seen to conflict with or

override a person’s autonomy where autonomy is defined as: ‘The right or condition of

self-government’ (Pearsall 1998).

PATERNALISM V AUTONOMY
(Figure 1)

In so far as autonomy is understood as the freedom to govern one’s own life and acts of

paternalism involve a restriction of a person’s freedom to do precisely that, then

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paternalism can be considered ethically problematic because it conflicts with or overrides

a person’s autonomy (Fig. 1).

Mental Illness

Respect for a person’s autonomy has come to be one of the most important principles of

contemporary medical ethics and Western society generally (Blackhall et al. 2002). In so

far as acts of paternalism conflict with or override a person’s autonomy, then those acts

demand ethical justification. Commonly, acts of paternalism are justified by invoking the

concept of ‘mental illness’ (Fig. 2) and suggesting that mental illness diminishes, to

varying degrees, a person’s capacity to act in an autonomous manner (Fulford 1995).

PATERNALISM V AUTONOMY

Mental Illness

(Figure 2)

Hallucinations, delusions, depression, anxiety, dementia and so on, are commonly

thought to diminish, to varying degrees, a person’s capacity to govern themselves and,

therefore, act in an autonomous manner (Beauchamp 2000). As such, it is often suggested

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that acts of paternalism in psychiatry are sometimes necessary to govern a person who,

because of mental illness, is currently unable to govern themselves.

Beneficence and Non-maleficence

However, invoking the concept of mental illness alone is not sufficient to justify an act of

paternalism in psychiatry. Commonly, it is suggested that the act of paternalism should

also be beneficent, that is, it should ensure ‘good’ and/or it should be non-maleficent, that

is, it should prevent ‘harm’ (Fig. 3).

PATERNALISM V AUTONOMY

Beneficent Mental Illness

Although ‘control and restraint’, ‘seclusion’, locked wards and so on could be said to

conflict with or override a person’s autonomy, it is commonly suggested that those acts

of paternalism would alleviate a person’s ‘mental distress’ and/or prevent harm from

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occurring to that person and/or prevent that person from harming others (Thompson et al.

2001).

Therefore, an act of paternalism in psychiatry is commonly justified by suggesting

that the person who is subject to it has a mental illness and cannot act autonomously and

that the act ensures good - that is, it is beneficent - and/or prevents harm - that is, it is

non-maleficent (Fig. 3).

Discussion

Although it may be advantageous to adopt principlism in order to present a framework in

which the ethically relevant features of situation can be drawn out, this approach also has

significant limitations. These limitations will now be introduced through a discussion of

the ethics of care, virtue ethics and communitarianism, the issue of power and finally, the

concept of mental illness.

The Ethics of Care

By analysing ethical issues in terms of general principles, principlism (and indeed ethical

theory since the Enlightenment) is commonly criticized for prioritizing rational, universal

and detached ethical reasoning. This approach is said to be inappropriate for health care

in which the interpersonal relationships between practitioners and clients are all

important and impact upon our ethical decision-making (Allmark 1995). As an alternative

to principlism, the ethics of care is an approach that stresses the importance of care and

caring within practitioner-client relationships. As such, it is said to be of particular

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relevance to mental health nursing in which interpersonal relationships play such a

central role and are themselves the vehicle of treatment (Adshead 2002).

The ethics of care originated primarily from feminist writings with Carol Gilligan

(1982) emerging as one of its major exponents. Gilligan suggests that there exists a

difference between how men and women approach and consider ethical issues. In

particular, she maintains that while men have a tendency to employ universal rights in a

detached manner, women view ethics in terms of responsibilities of care within

meaningful relationships.

Building upon this, the ethics of care stresses the importance of attending to

particular contexts rather than general principles, highlighting that an appropriate ethical

response in one situation may be inappropriate in another. Accordingly, each situation

within mental health nursing is said to call for a unique response that cannot be summed

up by a universal principle to respect autonomy, beneficence, non-maleficence and so on

(Allmark 1995).

In order to provide a unique and appropriate ethical response in a given situation,

the ethics of care calls for ‘engaged involvement’ with clients. Mental health nurses build

relationships with clients who are vulnerable and in need of care; therefore, an

appropriate ethical response to those clients is said to be engaged involvement with their

needs rather than a detached consideration of general principles (Allmark 1995).

To achieve engaged involvement with clients, the ethics of care highlights the

importance of ‘emotional responsiveness’ within practitioner-client relationships

(Beauchamp & Childress 2001). Rather than focusing exclusively on the use of reason,

an intertwining of both reason and emotion is said to be essential for appropriate ethical

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decision-making. An awareness of how a client feels about a proposed health care

intervention will introduce significant considerations into our ethical reasoning that can

easily be ignored by principlism (Adshead 2002).

Virtue Ethics and Communitarianism

By approaching ethical issues in terms of general principles, principlism (and again,

much ethical theory since the Enlightenment) is concerned with what a person should do

in a given situation. For virtue ethics, however, this focus is too narrow and fails to take

account of other relevant features of ethical decision-making, most importantly, a

person’s character. Therefore, rather than focusing upon what a person should do in a

given situation, virtue ethics focuses upon what a person should be in order to make

ethically appropriate decisions.

Accordingly, rather than asking what mental health nurses should do, virtue ethics

suggests that our guiding question should be ‘…what type of person must the mental

health nurse be in order to make ethically correct decisions?’ (McKie & Swinton 2000

p.41). In particular, it suggests that mental health nurses adopt and develop virtues (such

as trust, commitment, empathy and so on) in order to cultivate a character that will ensure

ethically appropriate decisions are made (McKie & Swinton 2000).

A mental health nurse cannot, however, simply choose for herself what virtues to

adopt and therefore what character to cultivate. Such an approach is grounded in the

conception of a person as an individual unit, free to decide which values to adopt for

themselves. Although the conception of the person as a self-contained unit has a strong

philosophical tradition (Descartes 1641/1993) and is the political foundation for liberal

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democratic societies, it has been repeatedly criticized (see, for example, Foucault 1982,

Merleau-Ponty 1996, Lyotard 1997, Levinas 1999, Heidegger 2000, Deleuze 2001 and

Lacan 2001) and is commonly identified as being the cause of many of modern life’s

problems (Taylor 1992).

Against such an individualistic conception of what it is to be a person,

communitarianism suggests that people are inextricably bound up with the communities

of which they form a part (Parker 2002). For communitarians, a ‘community’ is

understood as any form of communal life in which we play a part; therefore, society at

large, an institution or profession or even the family to which we belong can all be

understood as ‘communities’. Rather than forming their own identity and choosing their

values in isolation, communitarianism suggests that a person’s identity, responsibilities

and much of what a person ought to do is determined by the roles that they acquire as a

member of a community (Beauchamp & Childress 2001).

Mental health nursing can be seen to be such a community in so far as it possesses

standards of conduct and excellence that determine what it means to be a good mental

health nurse. For communitarians, these standards can only be achieved by adopting the

virtues that a community identifies as important (MacIntyre 1997). Therefore, a person

has to adopt and develop the virtues (trust, commitment, empathy and so on) that the

mental health nursing community identifies as leading to those standards of conduct and

excellence that determine what it means to be a good mental health nurse.

Power
It has been suggested that principlism does not address the issue of power or if does so,

does so insufficiently (Feenan 1997). However, since the work of so-called ‘post-

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modern’ theorists such as Foucault (1977), Lyotard (1997), Deleuze & Guattari (2000)

and Derrida (2001), the issue of ‘power’ has gained increased importance within

psychiatry, psychotherapy and mental health nursing generally. In contemporary

psychiatric ethics, special attention has been paid to an analysis of the existence and

exercise of power within practitioner-client relationships and the way in which a client’s

gender, age, race, socio-economic class and education may contribute to their

powerlessness.

Sherwin (2002) has suggested, however, that simply being identified as a ‘patient’

is enough to disempower a person. As a ‘patient’ a person is required to submit to

medical authority, to learn to listen and accept medical instruction and also to respond

with gratitude for any attention given. This experience may be compounded in psychiatry

where a person may have a history of being a ‘patient’ and of experiencing negative

consequences following attempts to exercise power and autonomy (Feenan 1997).

Threats of being ‘sectioned’, treatment without consent and generally having others

decide what is in one’s best interests may all be factors in the development of a state of

disempowerment and learned helplessness (Seligman 1975).

An important and subtle feature of the maintenance of the dominant power

positions of practitioners is the possession of a body of knowledge or theory that

structures how ‘mental illness’ is to be understood and treated. Foucault (1980) has

suggested that knowledge is so intimately bound up with power that he fuses the two

together and speaks instead of ‘power/knowledge’ as a unitary concept.

While clients may now have a greater degree of say in how they are treated, being

subject to a practitioner’s body of knowledge may mean that they have little power to

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determine how their problems are understood (Fulford et al. 2002). For example, it has

been suggested that psychotherapeutic interventions involve a ‘covert’ and hence,

ethically problematic replacement of how a client understands their problems. In so far as

all psychotherapies possess a theory of how mental health problems are to be understood

then the client’s account of their problems is said to be either ‘…destroyed or

incorporated – but in any event replaced - by the professional account’ (Kaye 1999 p.26).

Mental Illness

As highlighted above, paternalism in psychiatry is commonly justified by invoking the

concept of mental illness that is said to diminish, to varying degrees, a person’s capacity

to act in an autonomous manner (Fig. 2). However, of all the concepts introduced in this

paper, mental illness is arguably the most contested. There exists a variety of critical

discussions surrounding the concept of mental illness from biological, cultural,

existential, feminist, historical, phenomenological, psychological and social perspectives

(see, for example, Laing 1960, Szasz 1960, Foucault 1965, Scheff 1966, Sedgwick 1982,

Littlewood & Lipsedge 1989, Kitwood 1990 and Kendell 1996).

Although all of these perspectives cannot be discussed in detail here, a central

debate that is common to many of them is whether mental illness is to be understood as

an ‘objective fact’ or a ‘subjective value judgment’ (Fulford 2000). The former position

is encapsulated within what is commonly known as the medical model of mental illness

and despite sustained criticism, remains the dominant model within psychiatry today

(Fulford 2000).

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For the medical model, psychiatry is continuous with the natural sciences and

human biology in particular in so far as it is concerned with accumulating ‘objective

facts’ about bodily dysfunction (Fulford 2000). Accordingly, mental illnesses are seen as

fundamentally the same as bodily illnesses. In particular, they are said to be ‘diseases of

the brain’ and as such, neuropharmacological intervention is considered to be the most

appropriate treatment (Kendell 1996).

Those opposing the medical model suggest that mental illness is not some

‘objective fact’ that is discovered by value-free observations but rather, always involves

drawing upon a set of values and norms. Diagnosing a person as mentally ill is said to

involve judging that person against what a particular culture considers to be

psychologically, socially and ethically ‘normal’ (Fee 2000). For a so-called ‘anti-

psychiatrist’ such as Thomas Szasz (1960), people deviate from a culture’s values and

norms in so far as they are struggling with the problems inherent in living with other

people. As such, Szasz suggests that ‘mental illness’, understood as some form of bodily

illness, is a ‘myth’ and that the term is used as a ‘social tranquilizer’ that serves to

disguise the very real ‘problems in living’ that people experience within human

relationships.

How we understand the concept of mental illness will impact upon how we

identify, explore and respond to ethical situations in psychiatry. If mental illness is

understood as some form of bodily disease, as an ‘objective fact’, then paternalistic acts

can be presented as interventions that aim to alleviate the human suffering of those

‘afflicted’ with that disease. However, if mental illness is understood more as a term that

is applied to those who deviate from a culture’s values and norms then acts of

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paternalism begin to seem more like attempts to maintain a cultural status quo and

therefore, become inherently political acts.

Conclusion

It has been suggested that many mental health nurses seem to have difficulty engaging

with the ethical issues in psychiatry and appreciating the relevance of those issues to their

everyday practice. By drawing on principlism’s approach to ethics, a framework has been

presented that it is hoped will serve as an accessible introduction to psychiatric ethics.

However, although principlism has its strengths it also has significant limitations. These

limitations and further points of discussion have been highlighted through a consideration

of the ethics of care, virtue ethics and communitarianism, the issue of power and finally,

the concept of mental illness.

In the light of principlism’s limitations, however, this paper also raises a series of

broader, interconnected considerations for psychiatric ethics. One such consideration is

whether principlism can help us make ethical decisions in psychiatry and mental health

nursing, or whether it should be understood solely as a framework that is useful for

drawing out the ethically relevant features of a given situation. If, as is now commonly

suggested, principlism has little prescriptive power, we may think it is necessary to

replace that approach with another (such as the ethics of care, virtue ethics or

communitarianism); however, we then face questions about which approach to adopt and

why. Alternatively, we may consider the possibility of some form of ‘unified ethical

approach’ that incorporates the various approaches to psychiatric ethics, or we may

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conclude that we are faced with the difficult challenge of having to draw from a variety

of seemingly conflicting ethical approaches in order to make our ethical decisions.

Thus, by highlighting the limitations of principlism and, on the basis of those

limitations, raising a series of broader, interconnected considerations for psychiatric

ethics, it is hoped that this paper will serve to stimulate both a deeper appreciation of the

relevance of ethics to the practice of mental health nursing and an ongoing critical

consideration of the ethical issues in psychiatry.

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