An Argument of Safety vs.

Self Determination 1

An Argument of Safety vs. Self Determination:

NSG 354 Bridge to Practice Ethics Paper

V. Claire Kirchmier

James Madison University

An Argument of Safety vs. Self Determination 2

Introduction

Treatment over objection is a prevalent ethical topic in the psychiatric mental

health profession of nursing. For many psychiatric patients, mental illness can be so

overpowering that they cannot make decisions about their medical treatment. According

to a study done by the Journal of the American Academy of Psychiatry and the Law,

approximately 66% of patients in an acute care setting refused their medications, which

created the need for a treatment over objection order (Russ, 2013). When this happens, a

legal team is called to meet and proceed to court hearings to determine the treatment path

for the individual. It is a well-known fact that patients have the right to self-

determination, and according to The RCBA Journal, they not only have the right to

determine their treatment but they also have the right to receive medication when it is in

their best interest, which seem to contradict one another in many psychiatric patients. In

many cases, the physician will be required to perform an assessment to determine if the

patient is stable enough to make sound decisions about his or her treatment (Lebovits,

2016). More and more studies are being conducted involving treatment over objection,

which shows that the topic is evolving. Many health care professionals are beginning to

wonder where the line is drawn between a patient’s right to self-determination and the

right to the best medical treatment available.

Background

In a psychiatric clinical rotation this semester, I witnessed a patient receive

psychiatric medication over objection. Before this happened I did not know that any

circumstance allowed a forced treatment over a patient against his or her wishes. The

patient had clearly stated that he did not want to receive his medication for his Haldol
An Argument of Safety vs. Self Determination 3

treatment. His family had recently talked with his doctor about ways to get him to agree

to the treatment because they knew that he needed the injection to safely manage his

mental illness. The physician got a court order for treatment over objection, so the

treatment team was able to give the patient his medication because it was deemed the

safest option for him.

In this situation, I didn’t say anything or do anything because I was not part of the

patient’s treatment team. I was able to watch the process and learn about what happens

when patients are forced to receive medical treatment based on safety and necessity. I do

not think that reacting in a different manner would have been appropriate because I did

not have any knowledge about the patient or the situation, so it was better to stand aside

and watch what was happening. However, in the future I could use my knowledge to help

explain to the patient why this is happening to him. I could see that this process was

causing stress to the patient, so being able to explain that this will be beneficial in the end

would make me feel like I have done my part.

Moral distress occurs when the individual knows what the right option in a

dilemma is, but they do not feel they can pursue the right course of action. This situation

caused me moral distress because I did not feel that I could do anything at that moment to

help the patient. I knew deep down in my mind that the morally right decision in a perfect

world would be to let the patient determine his right to decline medical treatment, but I

felt helpless in the situation because I could not do anything to let him keep that right.

Methods/Findings

The 8 key questions are a set of individual questions that help determine the

ethical problems at hand when an individual faces a moral or ethical dilemma. These
An Argument of Safety vs. Self Determination 4

questions will be used in this section to further delve into the dilemma at hand. The

content of the 8 key questions includes the following: outcomes, fairness, authority,

liberty, rights, responsibilities, empathy, and character. Each topic has an associated

question that is asked to the individual to help guide their decision-making process and

find the option that is the most justifiable.

When looking at outcomes, short term and long term outcomes should be noted.

In my situation, one short-term outcome was negative because the patient was very

aggravated and upset that he was being forced to accept an injection even against his

wishes. However, another long-term outcome far outweighed the short term because the

medication that was given to the patient would greatly help his condition and make both

the patient and his surroundings safe. In this situation, it was difficult to balance all

interests when it came to fairness. For the patient, it was not deemed fair to force not only

a painful injection on the patient, while at the same time it was not fair for the family to

be ignored when they clearly could say that the medication was needed. In addition to the

family, the people in the patient’s surrounding area needed to be considered due to the

safety of their well being when the patient receives the medication. Authority in this

situation does not apply because I was not actively participating in the treatment over

objection. It does not seem appropriate to evaluate what my superiors expect from me

because I was a passive part of the process. The question regarding liberty is the most

applicable question for this situation because the patient’s autonomy was affected. The

patient was not able to have autonomy over his care because the court was able to order a

treatment over objection. This jeopardized the patient’s freedom in addition to his self-

determination. The patient’s rights were also severely affected from this situation because
An Argument of Safety vs. Self Determination 5

the court took away his legal rights over his own treatment. The question regarding

responsibilities could be applied in many different aspects. The responsibility of the

family was to ensure the safety and wellbeing of the patient and his surroundings. The

treatment team’s responsibilities included safety in addition to ensuring the patient still

maintains his personal rights during his stay at the hospital. In the end, the court’s

responsibility of maintaining the safety of everyone affected by the patient’s condition

outweighs the other responsibilities. As a nurse, empathy is an essential tool to have

while practicing medicine. Thinking about the situation from an empathetic view allowed

me to consider what I would do if my loved one was in this position. I decided that I

would agree with the family in this situation because the safety and wellbeing of my

loved one will always be my priority. Character is also an important feature of a

successful nurse. In this situation, the actions that would let me be my most ideal self

would be to use this situation to actively learn about the process of treatment over

objection after the patient has been excused from the conference room. As a nursing

student, every situation is a learning possibility, so it is important to act on each (James

Madison University, n.d.).

The American Nurse’s Association Code of Ethics is another useful tool when

evaluating ethical dilemmas and moral distress. In this situation, provision 5.2 is the most

applicable because it dives into the “Promotion of Personal Health, Safety, and Well-

Being” (National Student Nurses’ Association, Inc, 2009). This provision can help guide

the action in this situation because according to Maslow’s Hierarchy, a patient’s safety

and physiological wellbeing are a nursing priority.

An Argument of Safety vs. Self Determination 6

Conclusion

The concept of treatment over objection was a brand new idea for me. As stated

before, I did not know that a patient could be forced to accept treatment based on a court

order after the risks and benefits have been analyzed. With this being said, by evaluating

the situation using many different tools and references, I was able to gain a better insight

to the situation and its technicalities. After using the 8 key questions and the Code of

Ethics, I decided that I would not have acted in a different manner. I believe that since I

was not directly part of the patient’s treatment team it was appropriate to watch and

evaluate the dilemma in my head. In the future, if I am part of the treatment team I will

be sure to voice my thoughts and opinions regarding the treatment of a patient and to

actively participate in the decision-making process. In addition, since this situation

caused me moral distress, I will now be able to handle similar situations in which I feel

there is nothing that I can do.

An Argument of Safety vs. Self Determination 7

References

James Madison University. (n.d.). The Madison collaborative: Ethical reasoning in

action. Retrieved from http://www.jmu.edu/mc/8-key-questions.shtml

Lebovits, G. (2016). Mental hygiene hearings in New York for retention, release,

treatment over objection, and assisted outpatient treatment. The Richmond County

Bar Association Journal, 16 (1), 9-10. Retrieved from:

https://works.bepress.com/gerald_lebovits/289/

National Student Nurses’ Association, Inc. (2009). Code of Ethics: Part II, Code of

academic and clinical conduct and interpretative statements. Available from

http://www.nsna.org

Russ, M., & John, M. (2013). Outcomes associated with court-ordered treatment over

objection in an acute psychiatric hospital. The Journal of the American Academy

of Psychiatry and the Law, 41 (2), 236-244. Retrieved from:

http://jaapl.org/content/41/2/236