Consideration of Major Ethical Theories and Principles in ...



Consideration of Major Ethical Theories and Principles in Psychiatric NursingTrina SkinnerStenberg CollegeConsideration of Major Ethical Theories and Principles in Psychiatric NursingIn regards to the subject of ethics in health care, there are a considerable number of major approaches that must be examined and implemented in order to ensure effective and ethically sound resolutions to ethical and moral dilemmas one may encounter within psychiatric nursing. Some of the major ethical theories that will be addressed in this paper include Deontology, which encompasses Kantianism, Natural law theory, and Prima facie duty as well as Utilitarianism, and will also define and discuss the four major ethical principles in health care; autonomy, beneficence, non-maleficence, and justice (Butts & Rich, 2005), and how these parallel the Code of Ethics and Standards of Psychiatric Nursing Practice.Deontology can be defined as an ethical theory “based on dutiful actions, not actions based on rewards, happiness, or consequences” (Hill & Zweig, 2003, as cited in Butts & Rich, 2005), and envelopes Kantianism, Natural law theory, and Prima facie duties. According to Butts & Rich (2005), St. Thomas Aquinas (1225-1274) had a great influence on the natural law theory of Roman Catholic writers throughout the 13th century. Aquinas “was himself influenced by the works of Aristotle and Cicero” (Munson, 2004, as cited in Butts & Rich, 2005, p. 7). Aquinas played a pivotal role in contemporary natural law theory, as most versions of this theory in use today are based on his philosophy. Natural law theorists assert that ‘right’ action is self-evident and determined by nature, as opposed to by custom and human preference (Butts & Rich, 2005, p. 7). The law of reason is said to be engrained in the order of nature. An example of an ethical dilemma related to psychiatric nursing care that relates to the Natural Law Theory is the phenomenon of genetically predisposed diagnoses, such as schizophrenia. A person with such a diagnosis acquires the disorder naturally, according to this ethical theory, in which case it is arguable as to whether or not to treat such an illness for which nature intended and there is no cure. I personally would argue that a lack of treatment is unethical if the schizophrenic person is determined to be at risk for self harm or harm to others. It is debatable whether treatment merely prolongs the inevitable or enhances otherwise diminished quality of life; the definition of quality life is in itself a new example of an ethical dilemma nursing professionals face in regards to ethics and law in healthcare. “Natural law theory accepts that law can be considered and spoken of both as a sheer social fact of power and practice, and as a set of reasons for action that can be, and often are, sound as reasons and therefore normative for reasonable people addressed by them” (Finnish, 2011). Natural Law Theory professes that “use of the highest right reason and rationality guide human beings in their goals and their ends” (Butts & Rich, 2005, p. 7). It is fair to assume that psychiatric nurses utilize their most sound individual reasoning and rationale in determining the goals and outcomes of case management in caring for the mentally ill.Immanuel Kant, 18th century German born philosopher is likely considered the most influential to deontological theory. Kant declared that “a person is morally good and admirable if actions are done from a sense of duty” (Butts & Rich, 2005, p. 7). Kantianism is founded on the belief that human beings are rational, and therefore possess the freedom to make moral judgments. Thus, stated Kant, humanity should follow a “universal framework of moral maxims or rules to guide right actions and duties because it is only through dutiful actions that people have moral worth” (Butts & Rich, 2005, p. 7). Founded on this premise, Kant constructed a system of moral imperatives deemed categorical imperatives “where moral actions are concerned duties and laws are absolute, unconditional, and universal” (Butts & Rich, 2005, p. 8). In accordance with Kant’s philosophy no action could be declared right unless that action maintained the potential to “become a binding law for all people” (Butts & Rich, 2005, p. 8). One example of Kantianism that proves extremely relevant in regards to psychiatric nursing is the ethical implications surrounding commission of suicide: under Kant’s categorical imperatives suicide is not acceptable under any circumstance. “A person when committing suicide cannot rationally wish that all people should feel free to commit suicide”; the universe would lie in chaos according to Kant (Butts & Rich, 2005). In this respect I personally experience difficulty relating to Kantianism, as a future psychiatric nurse I do believe in cases of rational suicide as Mayo, (1986) explains “…it has been held that circumstances might befall a person in which suicide would be a perfectly rational course of action, in the same sense that any other course of action could be rational…”. I feel that people should have the freedom to decide whether not they wish to end their own life. As a mental health nurse caring for a suicidal patient, I would do everything within my scope of practice to prevent them from harming themselves; however, I would be honest and forthcoming of my intentions and reasoning for interfering with that person’s choice to end their life..Next this paper will address the significance of W.D. Ross’s seven Prima Facie Duties. Ross authored a book focused on his perceived connection of ethical intuitionism to prima facie (conditional) duties (Brannigan & Boss, 2001, as cited in Butts & Rich, 2005, p. 8). Although Ross’s ethical theory proved to be deontological (rule-based) in nature, opposed to Kant, he “considered consequences to have value in his theory of prima facie duties” (Butts & Rich, 2005, p. 8). Ross valued to moral principles above all else: rightness and goodness. “Actual duties are those real duties that a person is obligated to perform. Prima facie duties are morally significant duties as they relate to individual circumstances at first sight” (Butts & Rich, 2005, p. 9). The Code of Ethics developed by the RPNC demands that all registered psychiatric nurses “Conduct one’s self in a manner that reflects honesty, integrity, reliability, impartiality, and diligence” (RPNC, 2010, p. 4). All of the qualities listed above are crucial to the ability to appropriately implement Ross’s theory of prima facie duties. If any of these core values are compromised, so is the RPN’s ability to discern between prima facie (conditional) and unconditional duties (such as those presented in Kantianism). One such example of this theory occurred during my cohort’s clinical rotation in the Acute Psychiatric setting. I had made a commitment to meet a patient to play a board game immediately after breakfast. However, there was a potential medical emergency with another patient that was necessary for me to attend. In this case I made the decision to postpone my commitment to the gentleman I had promised the game with in order to provide appropriate medical treatment to a patient in distress. In this situation I was able to exercise my personal sense of prima facie duties. I did eventually come back to keep my word and engage in the planned game with the original patient and explained while maintaining patient confidentiality why I had not been available to play at the time we agreed upon. Utilitarianism upholds the value of promoting “the highest good that is possible in every situation”, or the greater good for the general population of individuals. (Butts & Rich, 2005, p. 9). A very controversial example of proposed utilitarianism in psychiatric nursing today is the use of seclusion rooms in the acute psychiatric care setting. Cutcliffe (2005), brings to light the fact that “questions remain concerning the morality of secluding (or threatening to seclude) a client- to the extent that such practices have been likened to a form of Fascism” (p. 17). When nursing staff feel that a patient’s behavior has become a danger to him/herself or others, the decision is made to exile the individual from the general population in order to protect the safety of other patients, staff and visitors on the unit. Thus, “Utilitarians place great emphasis on what is best for groups, not individual people”; the focus then being sacrificing one’s autonomy in order to protect the general population (Butts & Rich, 2005, p. 10). According to Butts & Rich (2005), “utilitarianism is related to real-life, common-sense actions and their consequences, not aristocratic privilege, religious faith, or tradition” (p. 10). The RPNC Code of Ethics (2010), reflects a utilitarian stance in stating that the registered psychiatric nurse “Ensures that one neither initiates nor participates in any practice that is considered harmful to the welfare of others” (p. 4).To further this discussion, one must now examine the bioethical framework known as principlism, which envelopes four guiding principles- autonomy, beneficence, nonmaleficence, and justice (Beauchamp & Childress, 2004, as cited in Butts & Rich, 2005, p. 11). Each of these principles heavily influences the ethical model of healthcare in general. A brief introduction detailing definitions and clinical examples of each principle will highlight the relevance in mental health care.Autonomy can be defined as “the right of a rational person to self-rule and to generate personal decisions independently (Beauchamp & Childress, 2001 as cited in Butts & Rich, 2005, p. 12). Self-determination and freedom of choice are major considerations in regards to autonomy. Obtaining informed consent, the right to refuse treatment, and “disclosure by the provider of personal medical information, diagnoses, and treatment options to the involved patient…” are all critical concerns in regards to preserving the principle of autonomy. Involuntary commission of a patient to a psychiatric clinical setting is a large scale example of an ethical dilemma infringing on a person’s right to autonomy. A prudent psychiatric nurse is expected to uphold the value of “respect for the inherent worth, right of choice, and dignity of persons…” (RPNC, 2010, p. 3)Beneficence “means taking action to promote the welfare of other people” (Butts & Rich, 2005, p. 13). The RPNC Code of Ethics asserts that the effective psychiatric nurse “strives to ensure evidence-based practice while ensuring continuing competence throughout one’s professional career” (RPNC, 2010, P. 4). The preceding expectation represents beneficence as it focuses on promotion of a patient’s best interests and well-being (Butts & Rich, 2005, p. 13).Nonmaleficence literally translates to “do no harm and is considered to be an overriding principle for everyone who undertakes the care of a patient (Munson, 2004, p. 772, as cited in Butts & Rich, 2005, p. 13). This principle is clearly stated in the RPNC Code of Ethics 7) the RPN “ensures that one neither initiates nor participates in any practice that is considered harmful to the welfare of others” (RPNC, 2010, p. 4): performing ‘the seven rights’ of safe medication administration is an example of taking precautions to prevent harmful action as a practicing RPN. The final principle to consider in this paper is justice. Justice “refers to the right and the demand to be treated justly, fairly, and equally” (Butts & Rich, 2005, p. 13). Justice is unique in the sense that it is considered a fundamental principle in regards to ethics in health care as well as the foundation of a duty-based (deontological theory), therefore “the concept of justice is all encompassing in the field of ethics” (Beauchamp & Childress, 2001 as cited in Butts and Rich, 2005, p. 13). Most often justice in health care refers to “distributive justice, which pertains to the distribution of scarce health care resources” (Butts & Rich, 2005, p. 14). Ethical dilemmas in regards to justice often revolve around the rationality of whether or not a person who leads a self-destructive high risk lifestyle deserve equal access and allocation of limited resources in healthcare as those of their more health conscious, proactive counterparts. In my personal opinion, such a controversial subject matter could be averted if our government reevaluated the distribution of resources and devoted more of our tax dollars to health care services in which everyone could share equal rights in the context of healthcare. In conclusion, it is extremely evident that the multitude of ethical theories and principles considered relate directly to psychiatric nursing practice. Ethical theories in health care can be expanded on considerably as ethics falls under the ambiguous discipline of philosophy in which there is never any concrete answers, merely a plethora of questions and contexts to consider; therefore the competent and effective psychiatric nurse must obtain a basic understanding of such ethical theories and principles in order to develop the critical thinking skills and uphold the moral standards expected and outlined in the governing bodies of psychiatric/mental health nursing abroad.ReferencesButts, J. B., & Rich, K. L. (2005). Nursing ethics: Across the curriculum and into practice. Sudbury, MA: Jones and Bartlett publishers.Cutliffe, J. (2005, February). Seclusion rooms, fascism and social control: are there alternatives out there? p. 14-17. Retrieved from , John, "Natural Law Theories", The Stanford Encyclopedia of Philosophy (Fall 2011 Edition), Edward N. Zalta (ed.), Retrieved from , D. J. (1986). The Concept of Rational Suicide. The journal of medicine and philosophy. Oxford Journals. 11(2), 143-155.Retrieved from Psychiatric Nurses of Canada. (2010). The code of ethics. In Code of ethics and standards of psychiatric nursing practice (p. 3) Edmonton, AB: Author. ................
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