Chapter 9: Legal and Ethical Issues

Chapter 9: Legal and
Ethical Issues
Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Rights of Clients
Mental health clients with all civil rights

afforded to all people
Except right to leave hospital in case of
involuntary commitment
Principles for Provision of Mental Health and
Substance Abuse Treatment Services
(American Psychiatric Association [APA])
As mental health clients bill of rights (Box 9.1)

Involuntary Hospitalization
Civil commitment
Laws determined by each state
Knowledge of laws of state of practice necessary
Persons held without consent presenting with
imminent danger to self or others
Proven at hearing if person is to be committed

Involuntary Hospitalization (contd)
Detention in facility for 48 to 72 hours on

emergency basis
Then hearing to determine possible commitment
to facility

Release from the Hospital
Voluntary hospitalization: right to request

discharge at any time
Release unless danger to self or others; if such
danger present, then commitment proceedings
instituted
Clients no longer dangerous discharged from
hospital

Mandatory Outpatient Treatment
Conditional release or outpatient commitment

Continued participation in treatment on
involuntary basis after release from hospital
into community
Examples: taking prescribed medications, keeping
appointments with health care providers for
follow-up, attending specific treatment programs
or groups

Conservatorship
Legal guardianship; separate from civil

commitment for hospitalization
Grave disability
Incompetency
Inability to provide self with food, clothing,
shelter
Inability to act in own best interests
Consent to be obtained from conservator who
speaks for client
Question
Tell whether the following statement is true

or false:
Mental health clients who are hospitalized
voluntarily give up their right to leave the
hospital.

Answer
False
Mental health clients who are hospitalized
voluntarily retain all the civil rights afforded
to any person, including the right to leave
the hospital.
However, clients hospitalized involuntarily give
up this right.

Least Restrictive Environment
Right to treatment in least restrictive

environment appropriate to meet clients
needs
Free of restraint or seclusion unless
necessary
Central philosophy to deinstitutionalization of
large state hospitals, move to community-
based care and services

Least Restrictive Environment (contd)
Restraint: application of physical force to

person without permission
Human
Mechanical
Seclusion: involuntary confinement in specially
constructed, locked room equipped with
security window or camera for direct visual
monitoring
Restraint/seclusion only for shortest time
necessary

Least Restrictive Environment (contd)
Short term use of restraints and seclusion

Face-to-face evaluation in 1 hour, every 8 hours
(every 4 hours for children)
Physicians order every 4 hours (every 2 hours
for children)
Documented assessment by nurse every 1-2
hours
Close supervision of client
Debriefing session within 24 hours after release
from seclusion or restraint
Confidentiality
Health Insurance Portability and

Accountability Act (HIPAA) of 1996
Civil (fines) and criminal (prison sentences)
penalties for violation of client privacy
Duty to warn third parties: exception to
client confidentiality

Insanity Defense
Insanity
Legal meaning but no medical definition
Person unable to control his or her actions or
understand the difference between right and
wrong at time of crime (MNaghten rule)

Insanity Defense (contd)
Four states abolished insanity defense

Thirteen states with guilty, but insane verdict
Argument that verdict absolves legal system
of responsibility
People do not always receive needed psychiatric
treatment

Question

or false:
A nurse is required to maintain client
confidentiality unless the client threatens a
specifically identified individual or group.

Answer
True
In cases where a client threatens an
identifiable third party, the nurse has a duty
to warn that third party.

Nursing Liability
Responsibility for providing safe, competent,

legal, ethical care

Nursing Liability (contd)
Meeting standards of care developed from:

ANAs Code of Ethics for Nurses with Interpretive
Statements
ANAs Scope and Standards of Psychiatric-Mental
Health Nursing Practice
State nurse practice acts/federal agency
regulations
Agency policies and procedures/job descriptions
Civil, criminal laws

Torts
Wrongful act resulting in injury, loss, damage

Unintentional torts
Negligence
Malpractice
Elements to prove malpractice
Duty
Breach of duty
Injury or damage
Causation

Torts (contd)
Intentional torts
Assault
Battery
False imprisonment
3 elements to prove liability
Willful voluntary act
Intention to bring about consequences or injury
Act as substantial factor in injury or
consequences

Prevention of Liability

Question
Which of the following would be considered

an unintentional tort?
A.Malpractice
B.Assault
C.Battery
D.False imprisonment

Answer
A. Malpractice
Malpractice is an unintentional tort.
Assault, battery, and false imprisonment are
intentional torts.

Ethical Issues
Ethics: branch of philosophy dealing with

values of human conduct (rightness and
wrongness of actions) and goodness or
badness of motives and ends of such actions
Utilitarianism: theory that bases decisions on
greatest good for greatest number
Deontology: decisions based on whether
action is morally right or wrong, with no
regard for consequences
Deontological Principles
Autonomy: right to self-determination,
independence
Beneficence: duty to benefit others or
promote good
Nonmaleficence: requirement to do no harm
Justice: fairness
Veracity: honesty, truthfulness
Fidelity: obligation to honor commitments,
contracts
Ethical Dilemmas in Mental Health
Ethical dilemma
Conflict of ethical principles
No one clear course of action
Many dilemmas in mental health involving
clients right to self-determination and
independence (autonomy) and concern for
public good (utilitarianism)
ANA Code of Ethics for Nurses guides choices
about ethical actions

Ethical Decision-Making
Gathering information
Clarifying values
Identifying options
Identifying legal considerations, practical
restraints
Building consensus for decision reached
Reviewing, analyzing decision

Question

or false:
The greatest good for the greatest number
reflects the deontologic ethical theory.

Answer
False
Deontologic theory bases decisions on
whether an action is morally right or wrong,
without regard for the consequences.
Utilitarianism bases decisions on the greatest
good for the greatest number.

Self-Awareness Issues
Talk to colleagues or seek professional

supervision
Spend time thinking about ethical issues,
determine your values and beliefs regarding
situations before they occur
Be willing to discuss ethical concerns with
colleagues or managers

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Chapter 9: Legal and

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Mental health clients with all civil rights

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Detention in facility for 48 to 72 hours on

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Voluntary hospitalization: right to request

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Conditional release or outpatient commitment

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Legal guardianship; separate from civil

Tell whether the following statement is true

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Right to treatment in least restrictive

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Restraint: application of physical force to

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Short term use of restraints and seclusion

Health Insurance Portability and

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Four states abolished insanity defense

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Tell whether the following statement is true

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Responsibility for providing safe, competent,

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Meeting standards of care developed from:

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Wrongful act resulting in injury, loss, damage

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Which of the following would be considered

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Ethics: branch of philosophy dealing with

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Tell whether the following statement is true

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Talk to colleagues or seek professional

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

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