Forced Medication in Mental Health in Canada - Essay Example

? Forced Medication in Mental Health Essay Introduction Most patients are admitted voluntarily, which implies they are eager to receive medication or treatment. Still, there are patients who are not willing to be admitted and treated. Mental health care practitioners adhere to their needs and demands unless patients are a threat to others or themselves. Psychiatry has been described as “virtually the only medical specialty that includes coerced, involuntary treatment” (Shally-Jensen, 2013, 368). Scholars in the nursing professions have emphasized the inconsistency and contradiction between forced medication or involuntary treatment and components of professional ethical guidelines. Ethical codes usually require freewill or constraint in the part of clients only when threat is probable and imminent. Other scholars firmly oppose this observed contradiction between nursing principles and involuntary treatment; they refer to the right of clients to treatment, not only his/her right to say no to medication, as an essential matter (Freckelton & Lesser, 2003). Yet others argue that taking a stand in this debate draws away the attention of mental health professionals from more crucial issues about the quality of mental health services. Judgments aside, for a large number of mental health professionals, exercising involuntary treatments or forcible medications has become an essential part of their professional obligations. These professionals may frequently admit clients under involuntary directives or assist court orders for outpatient treatment and medication (Hayes et al., 2007). Numerous professionals are now confronted with the challenge of discussing complicated and problematic decisions with clients who pursue treatment under court orders. Similarly, because forced medication for mental disorder is perhaps as persistent as mental disorder itself, numerous mental health clients with severe and chronic mental disorders will undergo such medication over the course of their disorder (Freckelton & Lesser, 2003). Usually, forced mental health procedures may be given as a ‘crisis stabilization’ type of hospitalization in case of probable threat to the client or to others (Shally-Jensen, 2013, 369). Several states are increasingly implementing outpatient authorized treatment that preferably administers ‘assisted treatment’ (Shally-Jensen, 2013, 369) with additional resources and further implications if treatment procedures are not followed. Moral and Ethical Issues of Forced Medication in Mental Health Care Mental disorder can be a dreadful misfortune affecting not just the patient but family members, communities, and the society as well. Numerous mentally ill individuals do not have the capacity to take care of or protect themselves, and they could be a threat to themselves or others. In Canada, custodians or substitutes should make treatment decisions for them. Making treatment decisions for those who have mental disorders raises several moral, ethical, and legal issues (Swartz & Swanson, 2004). Several of the disturbing questions are as follows (Devettere, 2010, 111): Is it moral to place the mentally ill in institutions against their will simply because they might harm themselves or others? Is it moral to force treatment on them, most especially drugs or surgery or shock treatments, against their will? Is their informed consent for treatment truly voluntary if we have made it clear to them that they will be confined to an institution if they do not accept the treatment? Mental disorder is an ambiguously defined concept. It includes a broad array of disorder from the fairly mild to severe, and the classifications applied by the American Psychiatric Association are quite broad that health care professionals have great latitude in making a diagnosis of patients’ behavioral patterns (Devettere, 2010, 111). This makes it particularly crucial to take into account the ethical or moral repercussions of involuntary treatment or forced medication of those with mental disorders. A common misunderstanding assumes that all those who have mental disorders are helpless and have lost the ability to make decisions for themselves. This is clearly a misconception. People with mental disorders still have the ability to make decisions for themselves. Some mental disorders do not fully damage the ability to make decisions, or, if they do, this condition is just momentary, and episodes of ability remain in which the client is capable of making decisions about treatment (Hayes et al., 2007). Furthermore, a mental disorder that damages a client’s ability to make particular decisions does not automatically damage the ability to make all kinds of health care decisions. Therefore, it is ill-advised to suppose that all those who have mental disorders have lost the capacity to make decisions about their treatment. Instead, the decision-making ability of mentally ill individuals should be diagnosed accurately (Mickle, 2012). Specifically, according to Carney (2003), the health care professional will determine whether the individual is capable of understanding vital information, assessing the disorder and potential treatments, explaining the effect that the different treatment alternatives could have, and providing consent willingly. Nevertheless, it is a fact that mental disorder usually does influcent the ability to make decisions about treatment and to providing consent freely. The disorder can weaken any of the three attributes of the ability to make decisions: ‘understanding, evaluation, and reasoning’ (Devettere, 2010, 112). For instance, in several types of schizophrenia, an individual could have an unchanging assumption that medications are actually venomous or that health care professionals are trying to deceive and lock him/her up. These thoughts hamper his/her capacity to make sense of the diagnosis and the possible actual effects of different treatment alternatives (Sharav, 2005). In other types of mental disorder, like post-traumatic stress disorder (PTSD), the individual’s capacity to assess an action can be lost because the disorder damages the individual’s capacity to be concerned about any of the purposes and endeavors in life that build a foundation for value judgments. Another example is manic bipolar disorder wherein reasoning ability can be altered by creating a completely impractical idea of possible courses of action (Devettere, 2010). Given these facts, health care professionals should evaluate each client thoroughly to verify decision-making ability. What is important is to stop assuming that once an individual has been diagnosed with a mental disorder a substitute or guardian should make every health care decision from then on (Swartz & Swanson, 2004). This attitude completely marginalizes and dispossesses an individual who maintains the ability to make health care decisions. Recently the population of hospitalized mentally ill individuals has declined considerably. Numerous factors contributed to this reduction in number, such as the discovery of medications that regulate or prevent the harmful symptoms of a mental disorder and the increasing realization that patients have volitional rights and must not be admitted unless completely necessary (Mossakowski, Kaplan, & Hill, 2011). However, decisions by substitutes to hospitalize mentally ill individuals should be made, and making such decisions is both legally and morally problematic. Forced medication is a violation of one’s liberty rights. Forced treatment is actually confinement. Denying a person of his/her right to live in the outside world is a serious limit on his/her life, and health care professionals require a justifiable basis for doing it (Mossakowski et al., 2011). There are two reasons commonly used when a substitute makes a decision to hospitalize a mentally ill individual involuntarily—the patient is a threat to others, or s/he is a danger to him/herself. Definitely, some individuals who have a mental disorder are a threat to others. However the ‘danger to others’ basis for forced medication has to be thoroughly examined. It is important to bear in mind that some people who do not have a mental disorder are threat to others, but they are not detained merely because there is an indication that they could be a threat to others (Mickle, 2012). If anyone advised detaining all those who could be a threat to others, people will be alarmed at this potential violation of an individual’s liberty rights without due process. Individuals who may be a danger to others have to be left alone except if they actually harm others. But thoughts about people who have a mental disorder are usually somewhat different. Many believe that the mentally ill should be detained when there is an indication that they could be a threat to others. It is this assumption that should be challenged, in case the moral value of liberty and freedom is threatened. Furthermore, the confinement of every mentally ill individual who may be a threat to others will be unjust to some of them (Gray et al., 2010). Hence, even though it is definitely possible to defend forced detention of mentally ill individuals based on the assumption that they are a threat to others, it is not, without any criminal record, a simple case to defend. Another major reason for the involuntary treatment of mentally ill individuals is to prevent them from harming themselves. Certainly, some individuals with mental disorders are a threat to themselves, but the moral basis of forced confinement is problematic. Such basis is based on the reasonable aim to safeguard the mentally ill individual, but it is severely unsound. If a person has the ability to make health care decisions, there is no valid basis for breaking his/her liberty and hospitalizing him/her involuntarily merely because others assume that s/he is a threat to him/herself (Nagel, 2003). It would be very unfortunate if this person were not detained and afterward harmed or killed him/herself, but it would be more unfortunate if competent individuals with the ability to make decisions are forcibly confined. Involuntary confinement of mentally ill individuals who still have the ability to make decisions about their treatment is a grave abuse of their personal dignity and freedom. In brief, there is rarely a basis for the forced hospitalization of a person suffering from a mental disorder. A particular exception arises when it is known for sure that the individual is a major threat to others; another arises when the individual is actually in the process of harming him/herself or is threatened by others (Gray et al., 2010). Nevertheless, the fact that an individual could be a threat to him/herself is not itself an adequate justification to detain him/her involuntarily. And if a substitute does make a decision to confine a mentally ill individual based on his being a threat to others, it is important to bear in mind that the decision is not actually medical in nature, in spite of the fact that the individual is locked up in a hospital. The detainment of the threatening mentally ill individual is not mainly in his/her interest but for the safety of others (Pearson, 2006). However, treatment is different from confinement. The basis for confinement is generally to administer medication or treatment, but not all the time. At times individuals are detained because they are really unsafe. Making decisions about medicating a person with mental disorder can become somewhat difficult or problematic (Watson, Corrigan, & Angell, 2005). In the past, nobody questioned the forced medication of mentally ill individuals. People merely decide whether the medication is needed or not. Hence, drugs, psychosurgery, or shock treatments were frequently administered without even verifying the ability of the involuntary hospitalized patient to provide informed consent (Devettere, 2010, 115). Nevertheless, a number of legal challenges to this premise occurred several decades ago. In a Massachusetts trial—Rogers v. Okin (1979)— the Supreme Court conceded that mentally ill patients can decline medication, particularly psychotropic drugs, although they are forcibly confined, as long as they retain the capacity to make decisions for themselves (Devettere, 2010, 115). A forcibly hospitalized patient may have retained the ability to make decisions or, if s/he had lost it during the involuntary hospitalization, could have recovered it afterward. Unless it has been explicitly established that the forcibly hospitalized patient has lost the ability to make decisions about treatment, his/her right to give or refuse to give informed consent should be recognized. If the forcibly hospitalized patient who has retained a decision-making capacity refuses to give informed consent for a medication, s/he cannot be forced to receive medication unless reasonable conditions are present (Pearson, 2006). At times a debilitated patient, without prior instructions, declines medication that the guardian/substitute and health care professionals think are in his/her best interests. The initial response of the substitute to such circumstances may be to disregard the patient’s protests or resistance and to provide consent for shock treatments, psychosurgery, or psychotropic medication (Brophy, Campbell, & Healy, 2003). However, there is another aspect in such cases that is absent in majority of other substitute decisions, and it further confounds moral issues. Not like a decision made by a guardian for children or for the physically impaired, the mentally ill person will persistently resist the medication. And often the resistance is based on the personal experience of the patient; the patient may have experienced receiving the medication in the past and hence knows for sure how bad the side effects can be (Freckelton & Lesser, 2003). Forced medication on debilitated patients will only cause them further distress. Even though patients gave prior instructions for the medication but at the moment, in their debilitated condition, are persistently resisting it, their current resistance could at times be more important than then earlier instructions and demands. A particular exception to this may arise when the resisted medication is the sole alternative to resisted confinement (Marshall, 2010). Recently, an increasing number of debilitated mentally ill individuals are not detained. They are integrated into mainstream society, and several of them are undergoing treatment in spite of their resistance (Watson et al., 2005). The core moral and legal justification for medicating these patients forcibly is that the other option, which is involuntary confinement, would only generate more undesirable outcome. From an ethical perspective if the debilitated mentally ill individual is really a threat to others, this premise has several good points. Forced medication would not seem as terrible as forced hospitalization and may be rationalized if it regulates or prevents the threat to patient’s life than forced hospitalization. If it is possible to detain unsafe mentally ill people in order to safeguard others, it is also reasonable to argue that they can be treated without confining them unless, obviously, the treatment’s side effects are quite serious they overshadow the inconveniences of confinement (Graham, 2004). Nevertheless, if the debilitated mentally ill individual is not threatening, and the decision to treat or medicate him/her is not rooted in the safety of others but in the patient’s best interest, then, health care professionals have to examine thoroughly how the patient’s refusal may weaken any benefit the forced medication or involuntary confinement may bring. The central ethical argument in such cases is the acknowledgement that making decisions about treatment for the incapacitated mentally ill individual, whose earlier demands may be erratic due to the mental disorder, is not an uncomplicated case of depending on the ‘best interest’ argument (Mickle, 2012). Medication could be in the mentally ill patient’s best interests, but if the patient refuses to take them, these refusals should be considered thoroughly. Forcing medication on an individual, even an incapacitated mentally ill individual, is an act that violates his/her human dignity and can simply violate the human dignity of health care professionals (Lunsky & Gracey, 2009). What, then, is the ethical implication of medicating or treating competent mentally ill individuals when they resist? Only that the scenario is confusing and that the ethical issues in such cases necessitate most cautious and thorough assessment. Substitutes or guardians should be always aware that the refusal of the patient could reduce the potential benefits of the treatment and that forced medication brings in a situation that can effectively damage the self-respect of patients and of health care providers as well. Interpersonal Nursing Theory and Forced Medication Hildegard Peplau (1932 as cited in Elder, Evans, & Nizette, 2012, 134) recognized that human beings dwell in interpersonal domains; hence, the nurse can effectively help the patient recover by addressing his/her interpersonal needs. Within this theoretical perspective, the most important purpose of the nurse is to facilitate the prompt and proper recovery of the patient. A particular challenge of interpersonal nursing is the fragile balance needed in the division of the therapeutic and controlling roles (Elder et al., 2012, 134). Nurses tackle this issue persistently. Medication can be a serious challenge to nurses, especially if it is involuntary medication. Nurses have a duty in administering required medication. Hostile episodes may take place as the nurse forces medication. Medication is forced, as the nurse should try to administer medication even despite obvious resistance from the patient. From the perspective of a least restrictive option, which tries to balance the rights of patients as human beings and their medication needs, forced medication and confinement can severely endanger the relationship between patients and nurses (Brophy et al., 2003). The nurse can only deal with this issue within the restrictions specified by the law and the general treatment plan. The responsibility of the nurse is to strengthen the purpose of involvement and create a therapeutic relationship in the state of having to use coercive methods over the patient. These forms of contacts are hard to understand for hesitant patients and may have the impact of proving their doubts (Brophy et al., 2003). If the patient is an involuntary one the right to give informed consent has been removed. Decisions will have to be made about how to settle forced medication. The nurse has to think about his/her involvement in this situation, and whether choices are rooted in this perceived role. Neilson and Brennan stress that the therapeutic abilities of nurses could be challenged by patients’ refusal to receive medication, and nursing abilities in the therapeutic alliance strongly influence the preservation of a secure environment and the continuous risk evaluation process (Elder et al., 2012, 135). Therefore, the nurse should invest substantial time and effort into thinking about how to build a strong interpersonal relationship with the resistive patient. Mainstream social standards cannot be exercised to assess the rationality of a patient’s behavior and thoughts. Prior to these contacts the objectives for care have to be definite, as do the limitations. This can only happen if there is open communication and strong support between all health care providers and if sufficient opportunities are present for the progress of medical abilities and self-knowledge. Conclusions The conflict between liberty or freewill and the safety of other members of the community determine the episodic ebbing and flowing of mental health treatment in Canada and elsewhere. Forced medication has been a historical phenomenon, and it remains widespread today. It is hence vital that nurses and other health care professionals have an accurate understanding of the forms of involuntary treatments so as to develop appropriate and ethical care plans. Beyond merely being aware of different forms of involuntary treatment, it is essential for health care professionals to also be capable of communicating and negotiating the ethical and moral concerns that are provoked in circumstances where forced medication is used. Being exposed to circumstances that may be rough for nurses because of the incompatibility between professional or personal judgments and job responsibilities may lead nurses to suffer from an unfavorable feeling of confusion and ‘professional dissonance’. Therefore, further studies on nursing and forced medication are required. References Brophy, L., Campbell, J., & Healy, B. (2003) ‘Dilemmas in the Case Manager’s Role: Implementing Involuntary Treatment in the Community’, Psychiatry, Psychology and Law 10(1), 154+ Carney, T. (2003) ‘Mental Health Law in Postmodern Society: Time for New Paradigms?’ Psychiatry, Psychology and Law 10(1), 12+ Devettere, R. (2010) Practical Decision Making in Health Care Ethics: Cases and Concepts. Washington, DC: Georgetown University Press. Elder, R., Evans, K., & Nizette, D. (2012) Psychiatric and Mental Health Nursing. Chatswood, NSW: Elsevier Australia. Freckelton, I. & Lesser, J. (2003) ‘Detention, Decisions and Dilemmas: Reviewing Involuntary Detention and Treatment into the 21st Century’, Psychiatry, Psychology and Law 10(1), iv+ Graham, S.D. 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