Running head: CONSIDERING ETHICAL CONCEPTS
Consideration of Major Ethical Theories and Principles in Psychiatric Nursing
Trina Skinner
Stenberg College
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CONSIDERING ETHICAL CONCEPTS
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Consideration of Major Ethical Theories and Principles in Psychiatric Nursing
In 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
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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).
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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”
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(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
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(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
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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.
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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.
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References
Butts, 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
http://stenbergcollege.mrooms3.net/pluginfile.php/29192/mod_resource/content/0/ethics_
nurs_104_session_10_rf1.pdf
Finnis, John, "Natural Law Theories", The Stanford Encyclopedia of Philosophy (Fall 2011
Edition), Edward N. Zalta (ed.), Retrieved from
http://plato.stanford.edu/archives/fall2011/entries/natural-law-theories/>.
Mayo, D. J. (1986). The Concept of Rational Suicide. The journal of medicine and philosophy.
Oxford Journals. 11(2), 143-155.Retrieved from
http://jmp.oxfordjournals.org/content/11/2/143.abstract
Registered Psychiatric Nurses of Canada. (2010). The code of ethics. In Code of ethics and
standards of psychiatric nursing practice (p. 3) Edmonton, AB: Author.