Ethical and legal issues in acting as a client advocate

¶ … Ethical and Legal Issues in Acting as a Client Advocate" focuses on issues facing the psychiatric nurse in his or her dealing not only with patients, but also with family members of patients as well as wider social and political issues. The article emphasizes the complexity of the ethical issues surrounding the psychiatric profession, not only because of the nature of the afflictions of patients, but also because of the integrated factors and variety of beliefs surrounding these afflictions. In general, the article provides and excellent overview of the issues that nurses might expect to encounter, although it might have done better by providing a more inclusive introduction.

The article provides only a brief introduction that sets the stage for a discussion of the issues facing psychiatric nurses. The introduction does make a good point in terms of focusing on the importance of ethics in terms of the psychiatric nurse's dealings with clients.

One element about the article that surprised me is the many definitions that takes up about half of the full volume of the article. This somewhat detracted from the central point of the paper. On the other hand, as one works through the definitions, their central theme does become clear: the ethics surrounding a psychiatric nurse's work with clients are an integrated and complex topic.

What particularly brought this home ot me was the distinction of ethics from other elements in the daily work with these clients, including legal law, the code of conduct and ethics, hospital etiquette, hospital policy, public opinion, superior orders, and the "gut response" to what appears to be the best course of action at any given time.

The complexity of the issues surrounding psychiatric nursing can be compared to opinions such as those of Schaler (p. 23), who compares the current premise of the psychiatric profession to burning heretics in the past. The basis of this opinion is that involuntary psychiatric treatment is based upon the general public conception, or indeed belief, in what constitutes insanity. If a "heretic" is identified in terms of the sanity paradigm, he or she is "punished" by means of involuntary treatment, either by means of psychiatric institutionalization or by medication. The publication of such literature indicates that this is an opinion held by a significant sector of the public.

On the other hand, the article under review also indicates that psychiatric treatment should be voluntary in most cases. Problems arise, however, when the client in question poses a danger to him- or herself or to other members of the family or public. In such a case, the professional is under legal obligation to protect the public from preventable harm by either incarcerating or medicating the individual who suffers from mental illness.

This issue in itself indicates the complexity of issues facing the psychiatric nurse. In this way, the article's many definitions also serve to bring home to the reader the necessity of definition in order to provide a clear paradigm for navigating the ethical, legal and other issues facing the profession.

In this light, the most significant part of the article is the length of the section dealing with clients. After the definitions, the article moves to more specific considerations, such as the psychiatric nurse's work in the context of the client, the family context, the social context, and the context of workplace issues. What is significant here, is the fact that the section that focuses on the client is the longest of all the sections in the article, even the one concerning the psychiatric nurse.

The implication here is that the client is the most important component in psychiatric nursing, which almost directly opposes the opinion raised by Schaler, as mentioned above. Indeed, whereas Schaler's claim is that the psychiatric client is treated as little better than a woman to be burned as a witch in the times of heresy, the article focuses on the fact that the client's autonomy should be retained as far as possible without causing needless harm. In this, Raines (p. 11) seems to more closely resemble the current practice of psychiatric nursing. This author focuses on the accountability of the psychiatric nurse not only in terms of social morality and institutional rules, but also in his or her work in service to the client.

This appears to be the central premise of the article under review. All the definitions in the first half of the article focus on the fact that psychiatric nursing should be an integrated decision-making process to provide for the greatest good in terms of institutional ethics, the social good, legal issues, and the well-being of the client. This central premise then provides a very good platform for the second half of the article, which provides a more specific consideration of the individuals directly and indirectly involved in the psychiatric nursing process. While the client is the most important of these, there is no neglect of the other stakeholders, including the family, society in general, and the professionals involved.

Finally, the article ends with the author's suggestion of a five-step decision-making model for use by psychiatric nurses. Importantly, this model does not dictate any specific rules that can be applied universally to all cases. Instead, it is a generic model that nurses must use according to their discretion when assessing the needs of individual clients in specific situations.

This is also reminiscent of critical work such as that by Keatings (p. 13), which acknowledges that the ethical decision-making process is never homogeneous across times and cultures. Indeed, each situation is assessed based upon very specific issues such as the case involved, experiences with similar cases in the past, the social rules, norms and ethics of any particular time, and the nurse's particular set of ethics as informed not only by individual ethics, but also the accepted set of ethics by the professional institution with which the nurse is associated. The issue is therefore far more complex than authors such as Schaler appear willing to accept. Indeed, the fundamental flaw in Schaler's view is the lack of critical assessment when considering the issues surrounding mental illness and its treatment. Schaler does not appear to recognize that current psychiatric nursing practice requires, as far as possible, the right of the client to integrated decision-making when it comes to treatment. This author also appears to fail in the recognition that, at times, these clients need to be treated involuntarily to prevent harm to the patient him- or herself or to the society within which the client is released. This is very far removed from the treatment of perceived heretics in the past. The mentally ill are no longer regarded as the heretics of modern society; although this was the case in the past. Instead, their treatment is now required to follow the principle of least harm and greatest benefit. This is the central premise of the article under review.