ETHICAL AND LEGAL ISSUES

Ethical Principles and Mental Crises

Ethical principles are fundamental concepts by which people make decisions. Healthcare professionals follow ethical standards of care at all times, whether or not a patient is in crisis. Ethics is the branch of philosophy concerned with the rightness or wrongness of human behavior and the goodness or badness of its effects. However, in emergency circumstances in which there is a need to intervene rapidly, caregivers may sometimes be challenged to remember the importance of such principles.

Ethical principles serve as general guides for behavior. Bioethical principles in particular are described below:

Respect for autonomy means respecting every individual’s right of self-determination, independence, and freedom to make their own choices. In healthcare, this concept is most concerned with the ethical obligation of the practitioner to respect a person’s right to make decisions about their own health.

This is the principle underlying the practice of “informed consent,” wherein the provider gives factual, scientific, and relevant information about treatment, including benefits and risks. The issue of veracity, or truth-telling, is closely related to that of informed consent, as it involves weighing paternalistic concerns against the autonomy interests of the patient.

When applied to mental health crises, autonomy means caregivers:

• Inform patients about treatment options and risks, making sure they understand
• Respect and accept decisions made by patients about their personal care
• Implement and evaluate interventions chosen by patients
• Hold in confidence all personal information, divulging it only when patients or their legal guardians give permission

Nonmaleficence means to do no harm, or to inflict the least harm possible, to reach a beneficial outcome. The pertinent ethical issue is whether the benefits of treatment or intervention outweigh the risks or burdens. The potential benefits of any treatment or intervention must outweigh the risks in order for the action to be ethical.

Beneficence means that healthcare providers have a duty to be of benefit to the patient. The principle implies that a patient can enter into a relationship with a person that society has licensed or certified as competent to provide healthcare and that actions taken by such a person will help prevent or remove harm or simply improve that patient’s situation.

When applied to mental health crises, beneficence means caregivers:

• Relate to patients professionally and objectively
• In consultation with other clinicians, follow treatment plans
• Choose and offer the option that will do good and avoid harm
• Recognize that under certain conditions beneficence overrides autonomy and that compulsory treatment may be justified

Justice implies fairness and equality, requiring impartial treatment of patients. Like other ethical principles, justice is based on respect for human life and dignity The historic image of justice is a blindfolded woman with a scale, weighing an issue on the basis of objective evidence and judicial precepts. Justice means that scarce resources will be distributed equally, using the same criteria for everyone.

Fidelity means maintaining loyalty, faithfulness, and commitment to the patient, doing no wrong, and maintaining expertise through continuing education.

Veracity is the duty to communicate in a truthful and non-misleading way (Halter, 2022; Patel 2023).

Laws and Mental Health Crises

Laws flow from ethical principles and consist of rules about specific situations. These rules are enforced by an authority with the power to see that they are obeyed. There currently are many state, federal, and case laws that affect the treatment of people with psychiatric disorders. Of special interest to those who care for people in crisis are laws concerning civil rights, confidentiality, patient rights, treatment decisions, restraints, seclusion, and hospital confinement.

CIVIL RIGHTS

Under federal and state laws, people with mental illness are guaranteed the same civil rights as every other citizen in the land. These laws guarantee the rights of all people to humane care, to interact socially, to press charges against others, to vote, to speak, to enter into contractual relationships, to make purchases, to obtain a license to drive an automobile, to follow religious practices, to participate in legal activities, and to travel within the United States. Some laws that address these rights include:

• Americans with Disabilities Act
• Fair Housing Amendments Act
• Civil Rights of Institutionalized Persons Act
• Individuals with Disabilities Education Act
  (Casarella, 2020)

CONFIDENTIALITY

In 1996, to protect the privacy of individuals and the confidentiality of patient records at the dawn of the age of electronic data collection, the U.S. Congress passed the Health Insurance Portability and Accountability Act (HIPAA). Phased in between 2000 and 2003, HIPAA provides that without the prior consent of patients or their legal guardian, medical records may not be read or copied. The act affirms the right to privacy and supports the concept of respect for all human beings.

PATIENT RIGHTS

Patient rights refers to a general statement adopted by most healthcare professionals that covers matters including access to care, patient dignity, confidentiality, and consent to treatment. These basic rights include:

• The right to open and honest communication between the patient and the healthcare provider
• The right to informed consent based on the moral and legal premise of patient autonomy
• The right to confidentiality, subject to certain exceptions because of legal, ethical, and social considerations (e.g., risk of harm to self or others)
• The right to healthcare (although the right to healthcare in the United States is open to debate, the Consolidated Omnibus Budget Reconciliation Act [COBRA] and the Emergency Medical Treatment and Active Labor Act [EMTALA] mandate an evaluation for patients seeking attention at emergency facilities regardless of ability to pay)
• The right to not be abandoned by a healthcare provider unless the patient is referred, transferred, or no longer requires treatment and is discharged
• The right to refuse care (exceptions occur for those without the ability to make a competent decision)
  (Davis, 2020)

TREATMENT DECISIONS

The Hospitalization of the Mentally Ill Act of 1964 requires that all patients in public hospitals have a right to treatment. Prior to that time, patients could be hospitalized for indefinite periods of time without undergoing any form of treatment. Since then, the courts have ruled that patients must be cared for in a humane environment by sufficient numbers of qualified clinicians according to individualized care plans.

In other rulings, both federal and state courts have ruled that patients have the right to refuse electroconvulsive therapy and antipsychotic medications. Furthermore, according to the Federal Patient Self-Determination Act of 1990, patients have the right to prepare a psychiatric advance directive (PAD), a legal document that puts forth a person’s preferences for future mental health treatment if unable to make decisions during a mental health crisis and allows appointment of a health proxy to interpret those preferences during a crisis. A psychiatric advance directive may be drafted when a person is well enough to consider preferences for future mental health treatment and is used when a person becomes unable to make decisions during a mental health crisis (NRCPAD, 2023).

RESTRAINT/SECLUSION

To prevent injury in mental health crises, clinicians may need to restrain patients, administer tranquilizing drugs, or place patients in seclusion against their will. Similarly, when a patient is a danger to self or others, as with the patient who hears voices telling them to hurt themself, it may be necessary to call the authorities for emergency involuntary commitment. The individual is then restrained and taken to a locked facility for evaluation and treatment. These situations raise both legal and ethical issues, including the ethical dilemma created by the conflict of the ethical principles of autonomy and beneficence.

The Code of Federal Regulations (2023a) states that restraints and seclusion may be used only when absolutely necessary or when patients request seclusion to reduce sensory stimulation. Restraints are to be applied only by healthcare professionals who are adequately trained in correct techniques and in protecting patient rights and safety. Orders for restraint or seclusion must be given by a physician or other licensed practitioner permitted by the state and the facility and who is trained in their use. The Code also states that their use be limited to no longer than the duration of the emergency safety situation.

Because history is replete with accounts of the excessive use of restraints and seclusion, current state laws and recent court decisions affirm that least-restrictive measures must be used. A stated principle of mental health law, the doctrine of “least restrictive alternative” is an important concept that applies to the care of patients. This doctrine affirms that caregivers must use the least restrictive means to achieve a specific end.

HOSPITAL CONFINEMENT

Admission to the hospital related to a mental health crisis or emergency may be either voluntary or involuntary.

• Voluntary means the patient is in control and decides when to enter the facility and when to leave.
• Involuntary means the patient does not have to agree to admission.

Discharge from the hospital depends on the status of the patient at the time they were admitted. In general, those who entered voluntarily have the right to be released voluntarily unless their condition changes significantly during their hospitalization. Some states provide a conditional release of people who were admitted voluntarily. Such a provision allows physicians or administrators to arrange for ongoing treatment on an outpatient basis.

Emergency hospitalization for evaluation is a crisis response in which a patient is admitted to a treatment facility for psychiatric evaluation, typically for a short period of fixed time (e.g., 72 hours). This is often referred to as a psychiatric hold. In general, emergency hospitalization is permitted when people are a danger to themselves, a danger to others, or severely disabled (unable to provide for their basic human needs such as food, clothing, shelter, health, or safety).

Inpatient civil commitment is a process in which a judge orders hospital treatment for a person who continues to meet the state’s civil commitment criteria after the emergency evaluation period. Inpatient commitment is practiced in all states, but the standards that qualify an individual vary from state to state. Involuntary hospitalization is another term used to describe the process.

Outpatient civil commitment is a treatment option in which a judge orders a qualifying person with symptoms of mental illness to adhere to a mental health treatment plan while living in the community. Standards and laws vary from state to state. Other terms to describe this process include outpatient commitment, involuntary outpatient commitment, or mandated outpatient treatment.

In order to secure treatment during or following a mental health crisis, it is important to know the civil commitment laws and standards that determine eligibility for intervention in the state in which the person resides. The United States has 50 different approaches to this issue, with no two states taking the same approach. As a result, whether or not an individual receives timely, appropriate treatment for an acute mental health crisis or chronic psychiatric disease is entirely dependent on which state the person resides in when the crisis arises (TAC, 2020).