Ethics are moral values that govern us as individuals and a group on the appropriate conduct in society. Ethics lay down the foundations of how we should live our lives, treat others and ourselves; giving everyone an understanding of what is morally right and wrong in society. Ethics give us a baseline for understanding the concept of right and wrong. Help us to have a ready understanding of how to react to a certain situation before it has happened.
As individuals we learn about ethics growing up from our home, school and social interaction. More often than not ethics don’t give us a definitive answer to ethical questions, sometimes ethics give multiple choices leaving an individual to choose the correct path to take. In essence they provide us with a system for attempting to come to a morally right decision. Ethics are applied to all aspects of our lives and society, and there are a number of ethical approaches. Medical ethics are ethical models, which are more specific or more applicable to medical situations.
Medical ethics have evolved overtime, however the oldest form of medical ethics still in use to day s the ‘ Hippocratic Oath’, recited still by many graduating Doctors. Hippocrates was a Greek Philosopher and Physician, and the oath has been seen as the basics of medical ethics. (Patient, 2011). Approaches to Medical ethics are many, but commonly include Utilitarianism, Demonology (Kant), (ODL Ethics information pack 2011), and the more modern ‘ Four Principles plus scope’ approach to ethics (BMW, 1994). The Four principles introduces the concepts of Beneficence, Non – Maleficent, Autonomy and Justice. BMW, 1994). All medical professions have their own governing bodies, outlining codes of reactive to which they are expected to adhere to. These vary slightly from profession to profession, however the above ethical approaches are over arching guidelines for medical professions in the UK today. For example, Doctors in the UK are governed by the General Medical Council (the GM), who outline their codes of practice in the ‘ Good Medical Practice’ (General Medical Council, 2013). Midwives and Nurses are guided by the Nursing and Midwifery Council’s (the NC) code of practice, (Nursing & midwife Council, 2010).
Many ethical theories cross over with one another, which is a reflection of how these models have evolved over time. Utilitarianism, aka consequentiality. This ethical theory is based around the principle that the out come Of a decision should have the ‘ greatest good for the greatest number’ (Advanced Nursing Practice Toolkit, 2012). There are two types of Utilitarianism, ‘ Rule’ and ‘ Act’. Both have their limitations and benefits. ‘ Act Utilitarianism’ has a main goal of desiring the greatest amount of pleasure for the largest majority (ODL Ethics information pack 201 1), however, the consequences of this are not always predictable.
This approach does allow for a flexible approach to decision making given the situation. It works on the understanding that consequences are more important than motivation. ‘ Rule utilitarianism’, does not have the same flexibility. It states that we must abide by the rules of the society / law that we live in. This means that rules / laws take priority and the consequences are governed by this. (ODL Ethics information pack 201 1). To relate Utilitarianism to a general health care context, imagine if the rights of one individual were to be compromised, but the gain were to benefit broader society?
This would be an Act Utilitarianism approach. Kant based ethics is also known as Demonology, meaning ‘ duty’ (Seven Pillars institute, n. D). Kant was a Prussian Philosopher, mathematician and scientist in the eighteenth century. He believed we should base our decisions on what is ‘ right, using reason and rationality (ODL Ethics information pack 201 1). Demonology is easily compared to Utilitarianism. Demonology respects the rights of individuals and it places values on the desires and wants of individuals (Advance Nursing Practice Toolkit, 2012).
It requires a level of reasoning, and an understanding of what and who ones duty is to. With these thoughts in mind, we have the introduction of the concept of ‘ Autonomy. Autonomy is the freedom of an individual will (ODL Ethics information pack 2014). Again, to put this into a health care setting, by allowing a patient to act with autonomy allows them to have an opinion about their health care and to be proactively involved in making informed decisions for themselves. This is an interesting point if we are to think about patients in mental health care who may have had, by law some of these rights taken away from them.
The ‘ Four principles’ approach is an approach used often in modern healthcare, developed by Beachhead and Childless in 2008 (Advance Nursing Practice Toolkit, 2012). It has four key principles, which are, Beneficence, non maleficent, Autonomy and Justice. Beneficence requires us to do good in our actions. We must seek the best outcome for our patients. This can sometimes however leave us with a conflict between non-maleficent and Autonomy. Non-maleficent means that we must first ‘ do no harm’. Whether this is to not maim or injure someone, or to not increase the potential harm to someone.
If we combined beneficence and non- maleficent, each action must produce more good than harm. Justice, we have an obligation to treat al people equally, fairly and impartially (Theodore Craggy, 2012). It aims to reach a balance of what is deserved to an individual in regards to entitlement and fairness. After looking at Kant approach to ethics, Utilitarianism, and all of the Four Principles, it is easy to see how these have become molded into modern society, but also how they do not give us clear answers as to how to deal with an ethical issue.
They do however provide us with guidelines to help one find a balanced, informed decision. Human right first came to recognition internationally by the ‘ Universal Declaration on Human Rights’ (Liberty 80, n. D). Becoming legally recognizable n the LIKE by 2000 when the ‘ Human Rights Act 1998’ became part of domestic law. (Mind, 2013). From the moment you are born you become subject to Human Rights, every human being inherits these rights regardless of SeX, race, nationality ethnic origin or any other status.
These rights are regarded internationally as universal and lay down obligations expected of governments to promote groups or individuals freedoms. (Office of the High Commissioner for Human Rights, 2014). The World Health Organization defines mental health as “ a state of well-being in which every individual realizes his or her own potential, can cope with the aroma stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community”(World Health Organization, 2014). It’s all about how we think and feel.
A mental disorder is defined as ‘ any disorder of disability of the mind’. There are many potential ethical issues surrounding people with mental health problems. These range from the use of restraints on patients, which often occurs in psychiatric institutions, the degrading and harmful care and treatment of patients as well as unsanitary living conditions. Under the ‘ Mental Health Act’ people in mental health care do not have their sights restricted unless it is for their own protection. The ‘ Mental Health Act’ was introduced for the protection of patients with mental health issues.
Enabling them to be detained and treated involuntarily should there be any concern for the safety of themselves or others. (Mental health care, 2013). Patients in mental health care units are sometimes restrained by health care staff. This is particularly controversial topic, due to the not only the degrading nature of ‘ face down’ restraining, but also due to a number of deaths occurring whilst patients are restrained. According to the ‘ Mental Health Act’ patient that has been detained can be restrained providing the caregivers feel the patient is a threat to themselves or others or is necessary for the purpose of treatment.
In a recent article in the Guardian, it was reported that in one year almost 40, 000 incidents of mental health patients being physically restrained were recorded; over 3000 of these were in the facedown position which according to the charity MIND is potentially a life-threatening position. (The Guardian, 2013). The Northumberland NASH Tone and Wear Foundations ‘ said it only used the safest and most proportionate response when patients posed a risk to themselves or others’. BBC, 2013). It’s report that in 201 2 almost 1000 injuries and 13 deaths were sustained through the use of the face down restraint. Nursing in practice, 2013). The most well documented case of a death occurring due to being held in this face down prone position is that of David ‘ Rocky’ Bennett. There are a number of documented cases of deaths by restraint of mental health patients whilst in custody, but there is no governing body responsible for the investigation of these types of deaths in physicality units (Inquest, 2013). David Bennett was a patient in a Physicality unit in Norfolk and had been buffering with schizophrenia for a number of years.
Details taken from a report in the Guardian (The Guardian, 2004), explain that an argument broke out between Mr. Bennett and another patient, resulting in the other patient being punched by Mr. Bennett. The staff decided to move Mr. Bennett to another ward to calm him. This was perceived by Mr. Bennett as a racist decision, and anger and frustration soon built up in Mr. Bennett. A nurse on this second ward told Mr. Bennett that he would be staying on the ward for the night and he hit this nurse three times on the side of the face. This is when the staff stepped in and restrained him.
This restraint was in the form of the prone position, and he was initially held by five nurses. An inquest carried out in conjunction with INQUEST, gave a verdict of being “ due to prolonged restraint and long-term anti- psychotic drug therapy and returned a verdict of Accidental Death aggravated by Neglect on 17 May 2001” (Inquest, 2004). This report goes on to explain that the bruises on Mr. Bonnet’s body were the result of excessive force having being used, which would not have happened if an approved restraint method had been used. It is indisputable that the preventable death of any individual is shocking and unacceptable.
If we look at how medical ethics should be applied to this case, it is clear to see how Act Utilitarianism could be applied, revealing its weaknesses also. ‘ Act’ would say that the consequences are to be of most benefit for the larger number. So Mr. Bennett, who was acting violently, and the staff restringing him, could be justified as they were trying to make the situation safer for more people (patients and staff) than just one individual, IEEE Mr. Bennett. Clearly, as stated earlier, the results of these consequences are sometimes unpredictable and unknown; in this case they were catastrophic.
Consequences are seen to be more important than motivation, so if the intended consequence were to calm and control a violent patient, the motivation for this would not be of importance. ‘ Rule’ would expect the laws / rules be followed – were the correct procedures followed in restraining Mr. Bennett? The INQUEST inquiry reported that restraint was not carried out in an approved manner. Kant approach, which encompasses patient Autonomy is a little more complicated in application given the mental health setting.
It has to be considered who the ‘ duty of the staff involved should have been to. If this is applied to Mr. Bennett and considering the notion of what is ‘ right’ and ‘ reasonable’, he was frustrated and vulnerable, so more care should have been taken in his handling. However, if it is viewed that in the given situation of Mr. Bennett being violent, perhaps the duty was to protect staff and to calm Mr. Bennett for his own safety. From a strictly deontological view, Mr. Bennett opinions and desires should have been taken into account.
However, this is where a solely Kant approach is difficult to apply given Mr. Bennett mental health and the apparent violent Outburst. The four principles approach is perhaps easier to see in it s application. Beneficence, to do good and the best for the care of the patient. If it was that Mr. Bennett needed restraining for his own safety, it should still have been carried out in such a way that he was safe and the justification for this act was to benefit him. Non-maleficent, first, do no harm. To apply this, Mr. Bonnet’s restraint would have been very different, even before it resulted in his death.
This harm could be perceived as the mental and emotional effects of being held face down by five nurses, not least the physical effects. Autonomy we have discussed with Cant’s approach. Lastly, ‘ justice’. Was a balanced decision made about what was fair to Mr. Bennett? Was he treated equally and with fairness? Justice would perhaps suggest not. After applying different ethical approaches to the controversial topic of face down restraint in mental health care. It clear to see how no one approach will ever give clear cut guidelines. They do however give us a way to make a balanced and rational decision.
The very sad case of Mr. Bennett shows how if staff and institutions don’t have thorough training, policies and procedures human rights certainly can be infringed. A strong emphasis on the medical ethics and human rights should e ingrained into standard western medicine, but it would seem that within mental health care settings, these are sometimes lacking.
