Ethics & Law Reflective Journal



Ethics & Law Reflective JournalTrina SkinnerStenberg CollegeEthics & Law Reflective JournalFrom the beginning of our clinical journey in the Acute Psychiatric setting throughout the duration of the semester, I have been eager to construct this assignment as my peers and I were fortunate enough to have the opportunity to observe and consider a plethora of major ethical dilemmas that were presented throughout our clinical experience. Based on the theoretical knowledge gained throughout our Ethics & Law in Health Care course, when such critical situations in which there was no simplified solution arose I was able to reflect on my newfound understanding of major ethical theories and principles. Based on the nature of the ethical dilemmas my peers and I were subject to during our clinical placement I was able to firmly establish the causal relationship between the necessities of exploring ethical considerations in regards to psychiatric nursing practice and provision of care.One notable ethical dilemma that was ongoing throughout our clinical experience on the unit relates to a dire situation in which a woman in her mid-thirties diagnosed with paranoid schizophrenia was involuntarily committed during the third trimester of her pregnancy. This particular patient who we will refer to as TS, was 38 weeks into her pregnancy, had a serious disconnect between mind and body (due to her diagnosis), and was therefore placed on close observation toward the end of her pregnancy in order to assure her and the baby’s safety. The concern was that she would be unaware or make no effort to communicate the fact that she was going into labor to the nursing staff. It was interesting to sit in on the roundtable discussions each week in which the psychiatrists, community health workers, RPN’s, and case managers reviewed each patient’s individual circumstances and determined the next course of action that was deemed most suitable to the individual situation. The ethically charged issue of whether or not TS should be sterilized following the birth of this child became a cantankerous issue rooted in ethical and legal discourse. Due to the fact that TS had given birth to a child previously whom she is deemed unable to care for and is in currently in the custody of her former partner, has custody of her child and one of his own, and has had the children removed by the ministry in the past; it was decided that if TS was in agreeance the most logical solution would be to have her sterilized once she recovered from the birth of the baby. In the days leading up to her induction it was clear there was absolutely no plan on behalf of the ministry in regards to placement of the infant after birth. When TS was confronted with the option of sterilization shortly before giving birth she was adamant that this was not an option and she would not consent to the procedure, her reasoning being that she had yet to have a child with a man whom she was married and that was a goal she was very intent on achieving. After some serious ethical consideration heavily influenced by the principle of autonomy and human rights, it was established that it was unethical to forcibly seize her from giving birth to future children, after much debate she did eventually agree to the depo provera shot which was to commence sometime in the future. The last our group was informed of in regards to TS situation was that she was recommitted to the Acute Psych unit for a short time following the birth of her child and that child is now in the custody of her former partner with her other child. The major ethical implications that struck me in this case are the theories of Kantianism, utilitarianism, and the bioethical principles of autonomy and justice in relation to human rights considerations. Kant has stated that “where moral actions are concerned, duties and laws are absolute, unconditional, and universal” (Butts & Rich, 2005, p. 8). In considering the implications of Kantianism in reference to TS and the ethical dilemma of whether or not she should be sterilized, this act would be considered unethical. Kant rationalizes that “no action can be judged as right…if the action cannot have the potential to become a binding law for all people” (Butts & Rich, 2005, p. 8). Well under these circumstances Kant would assert that in order to justify compromising TS right to bear children, society must be willing to reflect this notion in regards to whether or not it would stand true for the universal population, meaning that in the interest of upholding Kant’s ethical values, it is wrong to sterilize TS because society cannot rationally will that sterilization become compulsory for all members of the universe.However, when we consider the theory of utilitarianism it is interesting to note that utilitarians believe that we as human beings should strive for “achievement of the greatest happiness possible – not for oneself, but for everyone” (Hospers, 1997, p. 263). From a utilitarian perspective, one should not perform an act that “produces less total good if [by some other action they] could produce more” (Hospers, 1997, p. 263). In considering TS sterilization dilemma it is arguable from a utilitarian stance that enforced sterilization would indeed serve the greater good considering the specifics of the situation. This woman is incapable of caring for the children she produces, has been involuntarily committed to the Acute Psychiatric unit on numerous occasions which means she has met the stipulations for which one is legally subject to involuntary commission under the Canada Mental Health Act, which declares a person eligible for such if they meet the following criteria, these criteria are that the patient:“ is suffering from a mental disorder that seriously impairs the person’s ability to react appropriately to his or her environment or to associate with others; requires psychiatric treatment in or through a designated facility; requires care, supervision and control in or through a designated facility to prevent the person’s substantial mental or physical deterioration or for the person’s own protection or the protection of others; and is not suitable as a voluntary patient.” (Mental Health Act, 2005, p. 9).Under the circumstances presented above, it is clear that although TS autonomy and basic human rights would be compromised, utilitarianism functions to serve the greater good, promoting the most happiness possible, in which the ministry of children and families, the community, the children/potential future children, and inevitably society at large would benefit from this woman’s sterilization much more than she herself would benefit from carrying on with no method of permanent contraception. In contrast, by enforcing the sterilization procedure against the wishes of TS, her autonomy (freedom and self-determination) and basic human right to bear children is being compromised, a situation that is hardly ethically or moral satisfying. I feel truly blessed to have been present to experience the pivotal role that ethics in healthcare play in such a controversial situation, so early on in my journey to becoming a future psychiatric nurse. A second example of an ethical dilemma that left a profound effect on both myself, as well as some of my peers during our clinical practice relates to a young man whom had been involuntary committed to the Acute Psychiatric unit two years earlier after being suspected of murdering three family dogs my way of strangulation and although the family did not wish to press charges, they were supportive of his psychiatric treatment. This young man, TC, was diagnosed with Asperger’s syndrome, severe OCD, and homicidal ideation. TC’s 2012 admission to the unit was a result of various correspondence produced by his family stating that he was in serious need of help and was fantasizing about torturing and murdering human beings and that he felt he no longer had control over these impulses or his intense bouts of anger and frustration. TC was compliant with the committal and regularly expressed his concerns that if he did not receive proper treatment in the form of extensive therapy it was not a matter of if he would harm people, but rather when. On this second admission TC admits to murdering the family dogs and describes it as a possible cry for help, though asserting that he felt no emotion in committing the murders and feels uncomfortable as far as human emotion is concerned. Originally, the first roundtable session we sat in on, TC’s psychiatrist was planning on working to have him charged with the murder of the three dogs in order to have him transferred to the forensic psychiatric facility in Burnaby, B.C. The next week we sat in on the weekly meeting once again, eager to learn what sort of progress had been made in TC’s case and whether he would be transferred to forensics, unfortunately two years had passed since the murder of the dogs and apparently it was too late to formally charge him. The plan, which shocked our group to the point we needed to debrief afterwards, discharge with no recommendation for community support. TC was as concerned with this situation as the rest of us. I understand that as first year RPN students we are newly exposed to the system and do not have all of the information as to how and why protocol is in place but I cannot help but feel that we had witnessed what is commonly referred to as a person in desperation slipping through the proverbial cracks in the system. The reasoning we were given behind not being eligible as a forensic patient, he was not charged or convicted of a crime. The reason he was discharged from the unit with no community supports in place, it was determined that there was nothing more that could be done on the unit and that the community supports TC and his family requested were unavailable to a to a lack of resources and the belief that was available would not be beneficial to a person in his situation.Two ethical principles that are particularly relevant to me in the case of TC are non-maleficence and justice. In considering non-maleficence as a principle in bioethics, let’s first recall the literal meaning of this principle, which is ‘do no harm’ , according to Butts & Rich (2005), “Best practice and due-care standards are adopted by various regulatory agencies to ensure that providers of care maintain a competency level of skill needed to care for patients” (p. 13). I personally do not understand how the principle of non-maleficence was upheld in this ethical dilemma regarding TC. I believe based only on the objective and subjective evidence I have studied and considered regarding TC that the course of action taken, unless there is some pertinent information that I am unaware of or ignorant to, may well prove potentially harmful to TC and society at large. I also find that the duty-based theory and principle of justice was not upheld in this case. I believe this is due to a flaw in our justice system, it makes me incredibly uncomfortable to conclude that a person who has shown high propensity for violence and is stating his desire to seriously harm people and desperately stressing his need for help is not deserving of treatment in the forensic psychiatry setting. This is an extremely interesting example of justice or injustice depending on one’s point of view, it could be considered unjust if TC were committed to the forensic psychiatric setting without being charged or convicted of a crime, I personally find the injustice in the fact that TC is not eligible for proper treatment if or until he commits a violent crime. Denying TC proper treatment is in my opinion a gross misconduct of justice which refers to “the right and the demand to be treated justly, fairly, and equally” (Butts & Rich, 2005, p. 13). In conclusion, it is clear to see that ethical theories, principles and conduct are far reaching and extremely relevant in the practice of healthcare and specifically psychiatric nursing. In a discipline built on the proverbial ‘grey area’ it is imperative that we as RPN students and future RPN’s seriously focus on comprehension and development of our own personal code of morals and ethics in considering all major ethical theories and principles available to us. ReferencesButts, J. B., & Rich, K. L. (2005). Nursing ethics: Across the curriculum and into practice. Sudbury, MA: Jones and Bartlett publishers.Hospers, J. (1997). An introduction to Philosophical analysis (4th ed.). Upper Saddle River, NJ: Prentice hall.Guide to the Mental Health Act. (2005, April, 4). British Columbia Ministry of Health. Retrieved from ................
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